Internal Whitening Protocols Pt1 (Non Vital Bleaching) – PDP146

Non-vital bleaching or internal whitening comes in many forms, but it’s often confusing which exact protocol to adopt. When you learn this technique you can make a HUGE difference to a patient’s smile in a minimally invasive manner.

Restorative Specialist Dr. AJ Ray-Chaudhuri covered the all-important diagnoses and indications of internal bleaching as well as how to treat tooth calcific metamorphosis (the obliterated pulp). We answer the key question: do you always need to have a root canal treatment present?

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The Protrusive Dental Pearl: When carrying out internal bleaching make sure to clean out the entire pulp chamber especially the necrotic pulp horns – clean the necrotic tissue inside using ultrasonics. Ensure the entire chamber is de-roofed – remember that these are mostly trauma cases and the pulp went necrotic in youth – hence large pulp chambers. No role for Ninja access here!

Need to Read it? Check out the Full Episode Transcript below!

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Highlights of this episode:

  • 3:03 The Protrusive Dental Pearl
  •  5:55 Dr. AJ Ray-Chaudhuri’s journey into restorative dentistry
  • 13:02 Internal Bleaching Protocol
  • 15:45 Whitening obliterated pulp (Calcific Metamorphosis)
  • 21:22 No prep veneer/Composite veneer VS Tooth Whitening
  • 22:50 Q: Best time for Internal bleaching after Endodontics?

STAY TUNED for Part 2 Next week when it gets really spicy – we have a PDF infographic to follow!

If you enjoyed this episode, check out Post Operative Pain after Endodontics – Prevention and Management

Click below for full episode transcript:

Jaz's Introduction: Non-vital bleaching or internal bleaching is something that you don't really learn or get to practice at dental school. It's something that you don't really often get to do, but when you get to do it, you get to make a huge difference to a patient smile.

Jaz’s Introduction:
But there’s lots of different ways to do it. It can get very confusing and the first time you come across a case, you end up going online and searching for all the different papers and different techniques out.

And you just end up getting confused, which is why I’ve got this killer two-part series with Dr. AJ Ray-Chaudhuri, restorative consultant. We both discuss the indications, the diagnoses, so basically it’s two parts. This first part you listen to right now is going to cover his journey as a restorative consultant.

The diagnoses that you can make, like when you have a yellow tooth, and you take a peri-apical radiograph and you observe that, ‘Hey, where’s the pulp gone? There is no canal anymore.’ That’s a calcific metamorphosis, right? That’s a sclerosed canal, and that can be a discolored tooth. Now, how do you whiten that, and how is that different to an actual non-vital tooth where you actually drill an access cavity if there isn’t one already and you whiten the tooth from within the tooth?

So your diagnosis is really important. And some of the big questions that we cover are things like, do you always need to have a root canal treatment present? Does that root canal treatment need to be perfect quality, even if the patient is asymptomatic? And then we go on to discuss about which barrier material.

Barrier material is something that you put over the gutter percha before you put the whitening gel to whiten the tooth. So these are all the nitty gritty things that we build up to. And in part two next week, wow. That’s really going to go into the full protocol for non-vital or internal bleaching.

Hello, Protruserati. I’m Jaz Gulati. Those of you who are listening, I probably sound a bit different. And those of you who are watching, yeah, I look in a different place. So, I’m actually in between Reading where I work and live and West London at the moment because my wife is heavily pregnant. And so we have a lot more family support in West London.

So kind of between two places at the moment. But the show must go on, right? Protrusive must go on. And I owe you a killer episode because I’ve been so busy with OBAB, so happy it’s been launched. As you’ll know, it’s been a really tough ride for me to actually put this occlusion course together, and I had to do it now before baby number two comes.

But I’m just so happy I’m going to read to you the first bit of feedback that I’ve got. So at the end of every module we have a video like, ‘Hey, congrats to finishing the module. What did you learn?’ And so at the end of module one, so well done to the guys who already finished module one, remember this is a 30 hour course.

So it’s pretty killer. So, Aysha Dhanani, thanks so much. You wrote, ‘I found myself wanting to click on the next video rather than fall asleep (what’s happening to me?)’ And then Aysha goes on to write all the things that she learned from module one so far. So that kind of feedback just means so much and there’s loads more at the end of that lesson.

I’m not going to bore you with. So it’s been such a graph and so busy doing that, that it’s about time I release an episode like this. This is like my Trump card. I’ve just kept this episode on the DL for you because I knew that you’d be a little bit upset with me, that ‘Jaz, you haven’t been dropping the pearls as regularly as you used to’, but now I’m back.

Okay? I know baby number two’s coming, but I’ve got loads of content for you and you’ll love this two-part series. Very comprehensive series with Dr. AJ Ray-Chaudhuri.

Protrusive Dental Pearl
The Protrusive Dental Pearl for this episode is very relevant for internal bleaching or inside outside bleaching or non-vital bleaching. Lots of different terms for it. And the pearl is that if you ever attempt to do this treatment, I’m hoping that this, by the end of the two part series, going to give you lots of confidence to take on cases like this. Like I said, these cases can be extremely rewarding and they can really lift up a smile, and it’s a lot more intricate and more fun than just regular whitening.

So a lot more to it, a lot more hands on. But when you get to do this, you have to make sure of one thing that you clean out the entire pulp chamber. Now, usually it’s incisors that need this kind of treatment, right? Internal bleaching, and therefore the places where you might miss in terms of cleaning or your access cavity is the horns of an incisor.

So make sure those necrotic horns are completely cleared out with ultrasonics and there’s no necrotic tissue inside, which is not going to help your whitening. And also why would you want to have necrotic tissue, right? Like you don’t want that, obviously in your root canal system. Now, for those of you watching, there’s some images on the screen right now showing you how I’ve done a few cases before where when I’ve inherited it.

The root canal was good, but the access cavity was insufficient. It was too small. So all you have to do is actually remove all the old material and really assess, have we gain full access to these pulp horns? Because remember these people with dark incisors, black and yellow, and various colors, even purple I’ve seen before.

It’s usually due to trauma at a young age, right? Maybe, 12, 13, that kind of stuff. And therefore the pulp chamber of these centrals and laterals and pulp horns are very large. So it’s well worth cleaning out. There’s no place for ninja access cavity. When you’re doing this kind of treatment, ask me how I know. I’ve had a failure before many years ago, and that’s where I learned that actually you can’t do these tiny access cavities.

You need to make them big enough for a reservoir, for your whitening gel. And also just to make sure you removed all the necrotic material. So lots of pearls where that came from. From this episode and the next one. I hope you enjoy these two parts. A full protocol guide to non-vital bleaching.

Main Episode:
AJ Ray-Chaudhuri, welcome to the Protrusive Dental Podcast. How are you, my friend?

I’m very well, thank you. Thank you for the very kind invite.

This is going to be a really huge topic because I find that internal bleaching, I don’t know how you learned it, and it’d be great to hear about not only your journey into restorative dentistry and your a little bit about your career ladder and that kind of stuff.

But in terms of specifically internal bleaching, How you get into it and how your GDP friends got into it because it’s something that we don’t really learn or do very unlikely to do at Dental School. Because it’s more postgrad kind of stuff. And then when you get to DF1, you might see someone with a dark tooth and then you ask your principal, or you ask your trainer, how’d you do this?

And then they have their own version that they do it. And then you might be brave enough to try it and you try to search some literature. So it’d be cool to learn about how you got into that. And then I’ve got some cases and failures to share and I know you do as well. And we could talk about your protocol and my protocol and just discuss a few things. So it’ll be great to learn from you. But first, AJ, just tell me your journey into restorative dentistry.

Into restorative dentistry. So-

And tell us also about where you work and what kind of stuff that you do.

Well, okay. I’ll give you brief, I’ll won’t go back too far. So, born in India, move to England in 1986. Couldn’t speak a word of English and I moved to Luton where it’s not really necessary to speak English anyway. And then, secondary education.

I went to King’s College London and then kind of came out in VT went, it was in the Northampton Ski, which was just brilliant and probably quite important to know. I was got into dental school through clearing when it, I don’t know if that exists anymore. And I really was not a great student. And because I think you have some student listeners possibly. And-

Oh, yes, yes, yes.

And so not a great student. And it didn’t really ignite my passion for dentistry at dental school, and that’s not a criticism. That’s a criticism of me. My aims were simply to not get thrown out of dental school and just have the time that I could and I achieved those.

But AJ I just want to mention on that I’ve spoken to so many guests and they all say the same thing, that it’s not so much what you do during your time at dental school, it’s more about after dental school where really your sort of career trajectory can get some sort of direction, would you agree with that?

Absolutely, a hundred percent. I guess I, I’m quite removed from undergraduate education now, but the skills, the things that I needed to do to get into dental school and not get thrown outta dental school were completely different to the skills that I think you need to be a good dentist. Not well, yeah, not completely diametrically opposite, but many of those skills are not necessary.

I don’t remember much of the things I was taught as an undergraduate. And nor do I need to, but yet we’ve all got some other skills based in communication and emotional intelligence, which we now, we trade on far more than our ability to remember or not remember the krebs cycle.

Very true. And then so what lured you into the restorative pathway? Because you are restorative consultant now?

So I know I’m a consultant in restorative dentistry, so I’m the head of restorative dentistry at Brighton. And I’ve been there since 2014.

Awesome. And, how did you know that restorative was your calling? Because it can be a, not only very competitive to get into restorative training, it could be a grueling process while your friends were in private practice doing that kind of lifestyle. And then you had to sacrifice some of your best years young family. Cause then you got three kids and stuff and you were this perpetual student, if you like. How did you find that?

Well, that’s one of the things that drew me to it. I thought, I was determined not to get a proper job, so I thought, let me go with, do some postgraduate education. But that kink in the journey was quite important. I had absolutely no aspirations of doing anything like that.

And like a lot of people, these things came by chance. You could tell the story differently, but the truth is our decisions are half chance. So I did VT and I worked as a general dentist to meet. I went as into working as an associate. I used to work in BMW, in Cowley, so where the minis are made.

So that was my job. And this takes us up to, it’s kind a 2005. And that’s critical because you won’t recall, but you may know that the UDA system came in about 2006. So it was advised to me, and I think it was good advice to say, ‘look, AJ, you’re not going to make any money doing in this UDA system. You’re too slow, you talk too much, want go and do something else for a little bit and then come back and work in primary care’. And that was advice given to me by people who knew me very well and with very good intention. So I thought, let me go and hide in hospital for a bit for a year, basically.

And I’ll come back when this whole UDA business settles down and many, many years later, it hasn’t really settled down. I’ve still never earned a UDAs. Don’t really understand what it means, unfortunately. But so I did a maxfax, SHO job then of course, and then I did kind of MFTs as it was called then, and suddenly realized-

What did you know when you did your maxfax? Did you know that you wanted to go into restorative at that point? Or this is just something you took one year at a time?

Just wanted to wait for these UDA systems to settle down so I can go back to primary care and be a proper dentist. And, but then I love maxfax, but then I thought, I’m not going to be a maxfax consultant.

That’s not for me. So then I did a couple of years of SHO in Restorative in Birmingham, where I met some absolutely fantastic people, people who I’m still very, very good friends with. That’s the first time I really came across a restorative dentist, a restorative consultant. And they were just cool and they could do loads of stuff that I thought didn’t exist.

And that’s when I thought, and I went in at kind of 26, and I came out at 28 as an SHO. And by that time in that transition, I thought, that’s what’s my calling. I really want to do that. But it was very competitive then, I think it’s even more competitive now if I’m being honest.

So I wasn’t really sure I was going to get in and I was already dabbling in a few other things, my masters at that time. But that was nonclinical. It was in medical law. So I felt a bit behind the curve. But next thing you know. I’ve got a registrar job at Kings with some amazing, amazing consultants, who are still very now friends of mine and are still amazing consultants. So, that’s how I got in.

And what’s your split like now in terms of how many days in hostel doing the, I mean, are you doing the cancer kind stuff? Trauma, tell me a bit about that and then the rest of the week private practice, but, what’s your split like?

So, head and neck cancer was the big thing that I did up until very recently. So my primary job in Brighton was to sit on the head and neck cancer MDT and be the only restorative consultant there to do oral rehabilitation. So obturators and implants and that kind of stuff. But, covid changed lots, children changes lots.

So now I work one days a week as a consultant and I spend four days a week in private practice where I work as an associate one day a week, and the rest of the time I’m in my own practice. My own referral practice in Hassocks, which I co-own with my wife, Emma.

Awesome. And AJ I mean, just your story. I, unlike you, when I qualified, I really wanted to be a restorative consultant. I really wanted to follow that pathway. That’s why I specifically did, DCT1, these two, both in restorative, but when I did them, I realized that the training pathway wasn’t for me. For me, hospital was very slow pace and stuff, but, I knew that I wanted to upskill, so I went about the other way.

I just did lots and lots and lots of courses, and now I’m in private practice. I’m happy. I’m getting to practice the kind dentistry I wanted to practice minus the head and neck cancer stuff, I guess. So I got the fun bits and stuff, and I guess at the time it was very attractive to be a specialist in, this is way before they made you choose like a mono speck before it was like, you’re a specialist in perio, you’re a specialist endo, you’re a specialist in a prostho.

You’re like this hotshot, right? And I was like, wow, I want to be this awesome dentist and whatnot. But then just the way I experienced training, I thought, okay, this is not the most effective learning for me. And that’s why I went the way I did. And it’s great to hear that you are very wet fingered, very much a restorative practitioner.

And so that goes in very handy with the topic we’re discussing today of internal bleaching. So, thanks so much for that intro. So let’s dive in straight away. This is the kind of stuff, as I was telling you before I hit the record button, that when you come across it, you don’t relearn it in dental school.

And when you see your first case with someone with a black tooth or a yellow tooth, and you think, hang on a minute, I think we can whiten these, but I don’t know how to whiten something from inside. And they end up speaking your trainer or your principal and then they give you their version and then you end up looking at a few papers and yet confused, wait.

There’s a lot of different ways to do it. And then you get worried about internal resorption and relapse and stuff. So why don’t we all bring it together and talk about your protocol, then I’ll share with you my protocol because I think I know which protocol you like to use. And tell me, do you ever switch protocols as well?

So we’ll get into that. But what is your standard protocol, but maybe even before then? I think I’m jumping the gun here is just describe the process and when it is an appropriate option to go for internal bleaching, just for students who might be listening.

Okay, sure. So, yeah, absolutely. This didn’t exist, this wasn’t on my radar until a Beckham registrar actually, so I’m not surprised. Some people haven’t come across it. So, as part of this process, I see there’s three people involved I think. So there’s me as the dentist. There’s a patient and there’s a lab technician, and if we bring our A game, we’re going to be fine.

And if one of us drops the ball, this is not going to work. So part of my job is diagnosis, so I’ve got to work out this, let’s say, single discolored tooth. Is it because there’s extrinsic staining? Is it because there’s intrinsic staining? Or is it because there’s internalized staining? Most people kind of split things up into extrinsic, so stuff on the outside, in which case they need maybe a good scale and polish or something like that, or drink less tea and there’s no place or inside outside whitening, or is it that there is an internal issue, an intrinsic issue?

And if it’s an intrinsic issue, is it a systemic issue or for example, a metabolic issue where they’ve got like liver disorders or kidney disorders, but generally that tends not to present as a single discolored tooth, or is it something that we have done. For example, it’s fundamentally, it’s a dead tooth, which is not root-filled, or it is a dead tooth, which is root-filled. And that’s kind of, I think, the focus of our conversation today that single tooth, which is discolored.

I mean let’s go with that specifically. That one tooth with the black or the dark yellow tooth. And then let’s assume that they come to you for the first time and you find that, oh, it’s non-vital.

It hasn’t gotten access cavity. So you find that okay, it hasn’t been root filled. And then the first step is take a PA and then I guess who’s got to put your end it on his hat on and make a diagnosis. And think, okay, we need to obviously do I say obviously, but there might be scenarios where you may not need to do a root canal treatment.

Now, specifically what I’m thinking of is that scenario where it’s calcific metamorphosis, right? Where the pulp is completely obliterated. And therefore the tooth has a yellowish appearance in that scenario. Obviously to do a root canal, there’s no canal to obturate. So in those scenarios, is it safe to just go ahead and whiten?

So here’s a good question. So I’m glad you talked about that because I think that’s one of the things that is one of the subtle but important academic points that could really get people in trouble in the UK. And that is fundamentally, does that tooth need root filling or not?

And so this, and how do you make that decision? So in the scenario you’ve described there, in my opinion, in my very strong opinion, actually one of those teeth does not need a root filling and should not be root-filled and the other one does. So how do we discriminate? So if we go back to diagnosis, I split up my endodontic diagnosis.

Now this is with my specialist Endo hat on, you’re right. I split up my diagnosis into two parts. I’ve got a Pulpal diagnosis and I’ve got an Apical diagnosis. So let’s say a patient comes in with a history of trauma to a tooth classically, for example, if you’re in middle class, sort of Sussex. They were standing in slip, they missed a catch, they took a whack 20 years ago, and the tooth has started to get a bit darker, right?

Maybe they get some odd pain, maybe they don’t. Then someone does vitality testing on them. Primary care practitioner rightly does the things, does vital testing on them, and it’s negative. So what does that mean? So you put that information together just from a history point of view, and that would be pretty much all of the discriminators you need to say, this is a dead tooth, right. But you take a radiograph and what you see is, let’s say calcific metamorphosis, sclerosis, whatever you want to call it.

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So just as for students, you take this radiograph and you do not see, a pop, you don’t see that radiolucent line going across. It’s all dentine.

So that to me means that tooth is, or certainly was for a very long time, vital, because you can’t create the secondary and tertiary dentine in a non-vital tooth. So, does that make sense? So actually what you are almost certainly looking at is a vital tooth, or certainly a tooth, which is vital for some time.

That tooth will still give a negative response to cold thermal testing. So I use something like Endo Frost, which is like minus 45, minus 50 degrees, and it does give a negative response often to electric pulp testing. So can you see? That’s a very confusing picture, but diagnostically that is not a necrotic pulp and diag.

So if you talk about the end, the pulpal diagnosis, that’s not necrotic. Apical diagnosis, you’re not going to have an apical area. So is a healthy periapex. So diagnostically, what are you telling me? You’ve got a healthy pulp and you’ve got a healthy periapex. No root filling. And I do, let’s say once a year, maybe a bit more, maybe a bit less, get referred or at least ask an opinion on it.

Say, AJ, how am I going to root refill this tooth? Because the tooth patient wants tooth whitening. And the first thing, that’s one of the things I dropped what I’m doing, said, don’t take a birth of this tooth. This tooth does not need a root filling unless proven otherwise. The final question is how many of those teeth go on to develop necrosis and actually then become non-vital because they call strangulation of pulp and things like that.

The data, there’s a positive of data on that. But actually the vast minority of those teeth ever go on to need a root filling. Depending on Andre’s old data was less than 10%. Some of the more modern data will say maybe it’s up to 25%, but the standard answer is less 10% or less will go on to ever need a root filling. Does that makes sense?

So something you should warn the patient, but in this case, you don’t need to do a root filling. Obviously you’d struggle very much even if you tried. ‘

Then you walk course, and then you do all these other bits. And then you actually, you really end up in the chocolate, don’t you? Because then someone rightly after the event going, yes, you went of course, but this is not a tooth that needs a root filling because what’s the diagnosis doc? The diagnosis is healthy periapex.

Yeah. Yeah. And so in that scenario, just are normal whitening protocols, would you say? Or would you say that to have a special type of tray whereby the adjacent tooth, let’s say it’s an upper left one or upper left central incisor.

The adjacent teeth, the upper right central and the upper left lateral are cut out from the tray and they’re just whitening that one tooth only. Would you adopt that protocol or just go normally?

No. So a normal whitening tray will not work. What you described there is, I have a modification of that, but yes, fundamentally, so what I do is I make a normal tray. Let’s say it’s upper left central incisor, which I want to do, we call that the target tooth. Then I’m going to cut out windows in three of the adjacent teeth, either side of them. Because if you don’t. The patient will whiten the other teeth accidentally or on purpose. They’ll whiten the other teeth. So you wanted targeted tooth whitening on that one tooth.

But be in no doubt, that is a much slower and less predictable protocol than when you root fill the tooth. Yep. And some, and these are the patients that sometimes do need some top up treatment, but what, in my opinion, what you mustn’t do is then go immediately to a veneer. Because if you think about it, you’re taking off the translucent white enamel and you’re going back down to the further bulk of dentine, which has got primary, secondary, and tertiary dentine. So actually the first thing you’re going to do is make the tooth darker.

And in those cases, I guess, every case is different. And I would say from experience that if you have such a tooth, which is a bit yellower because it’s grossed. And you are thinking that, okay, it’s going to be a very slow process with teeth widening and the patient’s after a quicker result.

If that tooth is now slightly in standing and you can get away without prepping, then just go for a minimal prep. No prep veneer or composite vene or something to, rather than doing the dance of the whitening and then also then going into relapse surgery in the future. What do you think about that kind of a approach?

I mean, if you were in the, so a long time ago, wrote a paper on the class two div to patient with Martin Keller and Richard Porter, and that’s one of the things we talk about. I said actually, if we’ve got a retro client tooth, if it’s a purely additive approach, fantastic. I probably would still favor direct dentistry because I do, but on that patient, the first thing I’m going to do is I’m going to mock it up chairside and I’ll probably try the first appointment to mock it up with, because the shade of composite may need to be more opaque than you would normally expect.

So in the gradient system, you might need to go for like an A02, an a opaque 2 rather than an A2. But if you can do that without the whitening bit, that makes perfect sense.

And of course it’s instant orthodontics not in the old classic way of drilling away all the crowd into little pegs, but in a way that’s purely additive.

And I’m very comfortable with that approach. Yeah. Additive approach. Yeah, absolutely. I mean, but even with that, if you think about it, that’s a great quick fix, and it may be cost effective, but that needs to be maintained. There is no dentistry that you and I, Jaz will, that will do, will last forever.

Unless it’s the patient who expires on the patients that we do who are living longer and longer, they have to factor in a maintenance cycle, and let’s say for a composite, that’s going to include repolishing and replenishing and eventually replacement. At the patient’s cost. Not at our.

Well, let’s dive into the same tooth, upper left, central incisor. This time it’s a black tooth. It’s that patient who’s been walking around with a black tooth. I’ve got lots of good cases. I’ve actually done the past some good success rates, with this type of patient. Let’s assume they have a successful root filling.

Healthy periapical structures now because of this successful root filling. Obviously if you’ve got disease, then yeah, no, it goes about saying, treat the disease first. Send it to your endodontist, get the re-RCT done, and then wait for that to heal. Now, any guidelines in terms of how long we should wait? That’d be a good question to ask in terms of you are waiting for post endodontic, when is there a time that you have to wait before starting whitening?

In my opinion, well, no, I don’t. If I’m redoing that endo, which I do myself, then my plan is on that appointment where I obturate, I’m starting the, so this is, we’re talking about inside outside whitening. I’ll be starting that obturation on that appointment. But perhaps we take a step back and say, because we’ve kind of talked about the spectrum endodontics, and you are talking about, let’s say asymptomatic tooth or with a poor root filling and there won’t be much controversy by saying that needs endodontic revision. That’s fine.

And even did you say symptomatic or asymptomatic? Sorry.

So asymptomatic tooth there, there’s not going to be anything. But now here’s the tricky bit. What if the patient because the vast majority of the failures that I see and the failures that I’ve had in the past is actually not of the three people involved.

It’s not the dental technician. It’s not the patient. The person who’s got it wrong or drop the ball is me, and it’s at the diagnostic phase because this patient may have a reasonable root filling, which has served them well, but the root filling is often part of the problem. So have they got reasonable root filling?

Yes, but I don’t need them to have a root filling that a reasonable root filling to me, I’m afraid is not acceptable under for this particular circumstances. They need to have an excellent root filling. I’ll tell you a little bit about when I look at I, as you may or may not know, I’m not a much of a consumer of social media, and I certainly don’t put much on there, but I do look at other people, but my job isn’t to take pop shots at them.

But if you look at things when people put up root fillings, everyone is obsessed with the apical third. Lovely ramifications. I’ve got a sealer spurt. It’s on purpose. It’s not, okay, fine. I’m always looking at the other end of the radiograph. I’m always looking at the coronal bit. Because we know that coronal seal is as important.

Some of the data tells us more important, let’s say let’s forget the Ray and Trope studies and things like that. But let’s say it’s just as important, okay? But in the aesthetic zone, not only can it, it can’t just be enough to seal it. That gutter percha has to be sealed miles above where people think they are.

And the first thing that I look at, these root fillings in outside of the aesthetic zone, I can see gutter percha into the pulp chamber of the molar tooth that is compromising the seal. Right? But if you put a crown on top of it, you’ll probably get away with it. And if it does become dark underneath, you can’t tell.

You cannot get away with that in the aesthetic zone. So I’m really asking myself the question, is this tooth, which has a reasonable root filling and is asymptomatic, does that need endodontic revision? And almost always for me and my patients, the answer is yes. And not only do I have, I think the periapical is a minimum standard that you need, I almost, if it’s de novo endodontics, peral is fine.

But if it’s not denova endodontics, if it’s endodontic revision, then I will have a code beam ct, a small field of UN cone beam CT scan, and I pick up far more pathology than you would think. Let me ask you the question, Jaz. Why is this patient got a single discolored tooth? It’s almost always trauma, right?


So you’d be amazed how many undisplaced root fractures that I see on that tooth. Or the adjacent teeth. Awesome resorption. Now it might be surface resorption, it might be replacement resorption on the palatal aspect of this tooth. It then I’ve seen a few times when they’ve had re really decent palatal resorption on these teeth.

Now this tooth, no matter how much I changed the color of it, actually isn’t going to last this patient’s lifetime. It might not last that long at all. So really then what I’m saying, this patient needs to spend a significant amount of their resources making a tooth pretty accepting that this is a short to medium term option because I cannot stop that replacement root resorption if it’s progressing.

So can you see diagnostically, I think actually. Even as dentists, we focus on the outcome, which is a nice white tooth, which looks like the one next door, but I think that’s the wrong question. I’ve dropped the ball if I haven’t done a proper endodontic diagnosis. And my root filling needs to be of a very high standard, and it needs to be, and this is where there’ll be many people who disagree and that’s cool.

And if you’re an, if you’re a student, please don’t quote this because for an undergraduate level exam, this is definitely wrong. You need to be minimum three millimeters below the CEJ or the gingival margin, whichever is higher. And for my patients, it’s often four millimeters or more than that. Right?

Now if you just do the maths here, let’s say an upper central incisor, how long are you going to call an upper central incisor? Top to bottom. What would you say?


Perfect. 22 mils. Right? So how big is my root filling? 6, 7, 8 millimeters long? Hardly anything. Actually, if you think about it, you’d look at my root fillings and think he’s well short of the CEJ and the reason is the maths 22 millimeters, right? That’s the entire length of the tooth. Now do you want to filter the radiographic apex or do you not Jaz?

Me personally, gosh, you probably don’t want to because the anatomical apex is before the radiograph.

Absolutely right. Yeah. Because the data tells us if you look at the lots of the data, including the Mitani study from 1992, the radiographic apex is not coincident with the apical term.

That’s right. So your actual root filling is probably going to be, let’s say, what, 21 mil from the edge of the tooth, right?


Okay. How long’s the actual tooth, how long’s an upper central incisor? 10, 11 millimeters, right? So now often 22 millimeters, you’ve taken one off the top that leaves 21 millimeters.

You’ve taken 10 off the bottom that it leaves 11 millimeters, right? And I want my root filling to be four millimeters short of that CEJ. So that leaves a seven millimeter root filling.

Seven millimeters of gutta percha.

Of gutta percha. Now, okay, now that for me is very easy because I use a warm vertical compaction technique and then I back fill. If you’re actually using a lateral condensation technique, which the majority of our colleagues are, or you’re using a single cone with a bioceramic sealer, actually that’s quite a lot of effort and I think Serax Ferguson would say squeaky bum time, right? When you’re trying to now with a gates glidden bur trying to go back through and cut out the vast majority of this mohican of gutter percha that you’ve got.

But if that bit is not done correctly inside, outside whitening, as I would describe it, is not a predictable process. But people jump ahead of that bit too much, you see, because without that bit, the primary curvature of the tubules, I’m sure you may remember that I just about remember that the dental students will remember that the primary curvature of the tubules means that there’s a sign of pseudo process, which means that the tubules actually are three millis of other CEJ, right?

So any discoloration you get of your endodontic gutter perker, or the sealer, three or four millimeters above the CEJ will eventually present as late color changes the neck of the tooth. You have to leave room for the the GIC plug, if you place one.

That’s exactly what I was coming to. So the relevance here for those young dentists may be unfamiliar with this, is that you want to leave that three to four millimeters of space below the gingival margin of CEJ because if you don’t, and if you finish at the CEJ, the neck of the tooth will still remain dark, right?

Yeah, absolutely. Or it will get whiter and then it’ll slowly darker.

Yeah. And so, let’s talk about because this is a pain point for dentist in terms of the technique involved. Now you are probably using a scope, you got a lot experience in this, it can be quite tough to do to get right in this.

So some of the best results I’ve actually had have been from the endodontist Caesar to work with Richmond. He’d do you under scope and he’d make this lovely seal for me. Perfect position, three millimeters below, including after the GIC seal there and he’d sent it back to me and I just have the easiest job ever and I get really great results because the seal was fantastic.

But in the times in the past, I remember six, seven years ago doing something like this and with GIC, without a microscope, it can get very messy. And then if you get some up on the sort of the outer wall, then obviously you’re compromising your peroxide actually penetrating into those tubules. So any tips and advice you can give to the humble GDP, try and do this in practice.

For the humble GDP, who does the vast majority of the dentistry in the UK.

Jaz’s Outro:
Okay guys, I’ve done it again. I’ve left you on a cliffhanger. So in part two, make sure you tune in to find out what is Dr. AJ’s preferred barrier material. Actually might surprise you, so definitely tune in for that.

Hope you enjoyed this introductory episode so far. And episode two is going to have so much meat that we’re going to make a famous protrusive infographic with step by step with all the information from this one and the next one, but the next one really is the meat and potatoes of it all. If you’ve listened to watch as far and your Protrusive Premium member, you’re in luck.

You get your full listening and watching time allocated as CE or CPD certificate. You just have to answer a few questions as you scroll down on the app. And as you know, protrusive premium. I’m adding premium content as I go along. I really appreciate you watching or listening all the way to the end, and I catch you in that killer next episode, you’ll absolutely love it.

Hosted by
Jaz Gulati

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