Internal Whitening Protocols Pt2 (Non Vital Bleaching) – PDP147

Jaz’s Introduction:
Because you’ve got a patient next week who’s got a black tooth and you want to follow all the protrusive pearls shared in this full guide on how to actually carry out internal beach treatment, or you are in luck because we cover all those things today.

In the previous episode, so part one of internal bleaching we covered about getting your diagnosis right, making sure you’ve got a really good root canal treatment, and also the difference between a yellow tooth, which is more likely be like a calcific metamorphosis versus an actual non vital tooth. Now, why one will not need a root canal treatment?

So if you haven’t listened to that one yet, please go back one episode and check that one out. Now towards the end of that episode, I left you on a cliffhanger because you got really saucy. We started talking about barrier materials. Like what material, what restorative materials should you put over your gutta percha before you put your whitening gel, right?

Because the logic says that we need to put a barrier to prevent our peroxide gel from actually going into the root canal system. But you know what? I’m going to give you a spoiler now, right? What AJ actually practices is no barrier material, providing you don’t have a scope because the problem is like, imagine you don’t have a scope and you’re going to provide some sort of a barrier.

Like have you ever tried placing GIC deep down three millimeters below the CEJ? And how difficult it is not to smear that glass ionomer material all the way up the tubules. Because if you smear them, then how is that whitening gel? How is the proxide gel going to enter the tubules? And that’s when you get ineffective whitening.

That’s when most of the tooth whitenings, but you get a neck that’s still discolored. So his argument actually is really good. So we’ll listen to that first thing up. But we also talk about my protocol and what I’ve done as well. We go through every single detail and step-by-step protocol of non-vital bleaching, including tray design, how much to charge your patient, which gel to use, what do you put over the gel, but before the restorative material, yada, yada, yada.

There’s a lot of ground we cover when it comes to internal bleaching. There’s the ultimate guide you always wished you had. Hello, Protruserati. I’m Jaz Gulati and if you didn’t hear from the previous episode, I’m not in my usual recording studio. So sorry if I sound a bit different. I’m also a little bit ill at the moment, so probably sound a bit nasal, but I look different because I’m in West London where my parents and my in-laws are.

So we got a lot of family support as my wife’s heavily pregnant, expecting baby number two any day now. So that’s why I’m in a different place. But the show must go on. You’re going to love the Protrusive Dental Pearl. Not only did we summarize the both those episodes and easy to follow diagram with a flow chart just like we did for the icon one also, which is the best ceramic episode, and you can download that.

Plus AJ is very kindly donated his patient advice sheet and his lab sheet, so you get. Three PDFs. Now, if you’re Protrusive Premium, head over to the app or the web app, which is protrusive.app, and then you can actually just download it. It’s there in the Protrusive Vault section. Go ahead, download it right away.

But if you’re not Protrusive Premium, and if you want to gain from this pearl, head over to protrusive.co.uk/blacktooth, or one word that’s /blacktooth and you’ll get all three PDFs. So thanks AJ for donating yours and the protrusive team have put together this fantastic little diagram inspired by these two episodes.

There’s loads of facets to this part two is very, very clinical, it’s very geeky. But we also talk about communication, like patients often use the word ‘perfect’. They want things to be perfect and there’s lots of connotations and things to be careful when we’re talking about perfect. Because remember, beauty is in the eye of the beholder.

So AJ actually talks a lot about communication when it comes to doing this kind of treatment, which I think is absolutely golden. So please enjoy this episode, I’ll catch you in the outro.

Main Episode:
Any tips and advice you can give to the humble GDP try and do this in practice?

[AJ]
For the humble GDP who does the vast majority of the dentistry in the UK. I’ll tell you what I do. I don’t put a seal on that. And I was taught this technique by Martin Kelleher and he published that paper, the original paper, one of the original UK papers with Poiser. Peter Briggs and Martin Kelleher and he said, ‘AJ, why are you sealing it?’ Firstly, you can’t do it well.

And for the exactly the reasons you described, because this is when I was a first year registrar, I couldn’t use a microscope. I couldn’t use that microscope until much later. So he goes, ‘AJ, you’re just going to smear all of this up the walls. It’s going to look like a bird poo in there’. And the second thing is, he goes, ‘and also what you’re filling it with, we are filling this with carbamide peroxide, which is dissociating into hydrogen peroxide’.

‘ What is hydrogen peroxide, AJ? What’s Its job?’ Obviously as a 28 year registrar, I not the first idea, and Martin Kelleher is just in many ways a polymath, and we say, ‘well, AJ, let me give you a history lesson and it would be a long one’, but cycle forward, he goes, ‘well, have you heard of Vincent Angina?’

No, ANUG. We just about heard about it. Trench mouth, maybe heard about it. He goes, ‘well, actually, one of the reasons we used hydrogen peroxide was actually because it releases lots of oxygen, is very good for killing anaerobic bacteria. And that’s all they kind of had a hundred years ago to stop ANUG and ANUP occurring in the trenches’.

So one of its primary jobs as we discovered it is to kill bacteria. So you’re filling this entire chamber with a enormously hostile oxidizing product. You’re not going to get any bacteria in there, AJ. And actually-

[Jaz]
Especially for the short while that you’re working and doing this procedure, it may not be worth without a scope to make it so messy with the glass enema.

So I really respect that you said that actually, if you’re in that scenario and you haven’t got access to a scope and you haven’t done this before, then maybe just to have a really good root filling root seal with the GP at the correct level, three to four millimeters below the CEJ. And then allow the proxide to get in there. Right?

[AJ]
Absolutely. And except that’s a niche, that may be a niche opinion. And if I’m doing my own whitening, which I almost always do, but if I’m returning it to a colleague, right? The colleagues that I work with in private cloud, they’re just brilliant. I’ve got no problems that they’re going to drop the ball.

I worry about the patient in between who goes floating off, and that’s when I want to seal something. So under those circumstances, I will see it. If I’m doing the endodontics of somebody else. I don’t have any strong views on what should be in there, really. I think it can be GIC. Or it can be something like IRM or kalzinol, so something zinc oxide eugenol based.

But I’ll be placing it using a microscope if you’re going to do it. It doesn’t have to be a microscope, but I think you need magnification. And the trick is not to go runny. The trick is to the opposite. You get your nurse to get it, let’s say GIC or whatever. And so it’s almost crumbly. And then you pick it up and you pack it in there.

So it should be rollable into a sausage and you pack it into and go for the tiniest amount you can. Pack it into there and as long as soon as you’ve got a seal of a millimeter or two, you’re fine. But the important thing is not to smear it up the walls, and that’s one of the reasons I quite like. Something like radio-opaque ketac chem which is a white GIC, old-fashioned GIC.

Or IRM because it’s white. So if I have submitted up the walls which you will still do, depending on how closely you look at it, then you can identify that that needs to be removed before the whitening occur.

[Jaz]
Plus you’ve got the pluggers that can reach there and do it. So if you don’t have those pluggers, how you going to reach that far below the CEJ? So you’ve got to have the right tools to be able to do that. So if you are really keen to seal it, then maybe consider, are you going to make a mess of it or not? So I think it’s a really tangible, really key gem right there actually.

[AJ]
You need a masseter, or you can plugger to do that to a high standard.

[Jaz]
Exactly. Now in that scenario, so you are tending towards, I think, based on the PDF you sent me, walking bleach technique, right? The inside, outside technique. That’s your preferred technique.

[AJ]
Yeah. And I-

[Jaz]
Can you describe this technique for young dentists and students listening? Because I stopped using that technique a while ago. I use a different technique, so I’ll be able to share mine. I’m sure you probably use it as well, but if you describe this technique, I’ll later tell you why I moved away from this one. I’m sure you’ve spaced these exact same issues as well. But your handout was much better than the advice I used to give my patients, so it’s probably something to where I dropped the ball. So please.

[AJ]
I mean, an insider. So I, again, I’d never come across this until I did registrar training, and it’s in essence, it sounds a bit obtuse, you’re leaving the access cavity open, and what the patient is doing is the patient is using the gel, the carbonide peroxide, and they’re inserting it into the access cavity, and they’re replenishing it.

They leave it overnight. And when they’re awake, they replenish it every couple of hours and at the same time, they replenish that. They use a normal whitening tray and they put a blob of it on the front of the tooth. So then they’re both bleaching the tooth from the inside, intra-coronally and extra-coronally.

[Jaz]
And do you again put a window adjacent teeth?

[AJ]
Yes. Yes, I do. Because otherwise what they’ll do is everything will change color and actually the other teeth will then go whiter quicker than the dark one. And actually they’ll get worse. And I did do that a few times. I made plenty of errors, especially as a registrar.

I was in a very safe learning environment where they’d laugh at you and then they’d help you. So yes, if you don’t cut out the adjacent teeth, they’ll whiten everything else. But what I found is this works extraordinarily quickly. The first time I heard it described, I thought, this ain’t going to work for toffee.

But anyway, I thought I’d go with it. I mean, I’ve had patients who phone you easily with like the next morning and say, this tooth is already white than the other teeth. It doesn’t always work that quickly, but you really get very excellent results within, let’s say a week, two weeks max, if it hasn’t worked within two weeks.

I’ve had a few patients in the past where it’s got two weeks and they’re like, it’s better, but not quite. And I know they’re not doing something right. Or they’re basically just misunderstood my instructions, in which case it’s my fault. But most of my patients, it has rapidly, the problem is, that level of rapidity is that actually I can’t get them back in time.

Quickly enough to do the next things. If you’re friendly up within a day or two to say, I want to see you, that’s actually a bit problematic.

[Jaz]
Yeah, I agree. That’s why actually getting them in the diary and zoning them in that way is to predict how quick that’s going to happen. Usually I agree with you, happens very quickly and let’s say you’ve got a compliant patient happens very quickly and they’ve got the gel at home in the fridge and they’re, every couple hours, they’re replenishing it, they’re washing out, replenishing. And obviously using something like a TePe brush and single tufted brush to clean out the gunk.

[AJ]
Yep. Yeah.

[Jaz]
Obviously when they’re eating and stuff from inside there. So very important to have a good compliant patient with good hand skills to do this. And then once they’ve done it and the tooth’s gone much whiter, then they come back to you. Can you just explain, can you just finish off the protocol and then we’ll talk a little bit about the mini steps within the protocol?

[AJ]
Yeah, sure. So then once I ask them to over bleach the single tooth, And objectively, I just say, so it’s visibly whiter than the, sorry. Subjectively I say, ‘look, just tell me when it’s visibly whiter than the adjacent teeth’. And objectively, I say, ‘look, if it’s 10% whiter, but I mean, look this is more arts than science, but I know there’ll be a degree of relapse’.

So as long as it’s visibly whiter, then that’s the time to stop. Nowadays with social media, people are sending you lots and lots of selfies. Selfies didn’t exist. Unfortunately, or fortunately when I did this after I started doing this. So you can really get a sense of the direction of travel if they’re kind of 90% there within a day.

You can’t wait two weeks. So once they’re happy, and I’m happy I get them back in. And the first thing I do is I clean it up a little bit, something simple, clean it up a little bit and I will put some endo sponge in there or some sort of, so I don’t put any cotton wool roll, or cotton will pledges in there. I will use endo sponge or something visible, which is bright blue or bright purple. And all PTFE tape is quite reasonable.

[Jaz]
Yes.

[AJ]
And then I’ll put just a plug or something simple like IRM over the top of it. And then I’ll leave them alone for a reasonable period of time, minimum of 48 hours for me.

But, if it’s a reasonable plug of IRM they could be left alone for a week, two weeks, a month. That’s quite reasonable. And the reason I don’t go directly to the final restoration is, again, is not evidence based, but working on first principles. We know, like with resin based materials, composites, things like that, the oxygen inhibited layer is both a good thing and a bad thing.

Oxygen inhibited layer means that there is a layer on top of our, let’s say, our composite, which isn’t fully polymerized, but it means that it allows modern composites to stick to itself and you can layer on top. When I was an undergrad, we were sometimes taught to put composite down, put another layer of resin, then put another composite down, another layer of resin.

I’m showing my age here, but we don’t need to do that because you have a layer that sticks to the next layer because of the oxygen inhibited layer. However, the final layer of composite being oxygen inhibited means it’s kind of sticky and not fully polymerized, and thus people will use glycerine or some sort of barrier product to like cure through that.

Yeah, but the reason I’m drawing attention to that is if you think about what the whitening process is, that whitening process means that the tooth will cons still be releasing oxygen or free oxygen species for a period of time after the whitening stops. So if you put your composite straight in there, you’re going to have a layer of unpolymerised composite exactly where you want your coronal seal.

So what you want to do is you want to let all that oxygen be released from the inside of the tooth before you do the final restoration. Does that make sense?

[Jaz]
Which is why you go for the IRM and then at some point later, now at this point, you’re going to make them a new tray to do the whitening all around for the rest of the teeth, a new whitening tray.

[AJ]
Good question. So the answer is, it depends. So the time to do your impression for your inside, outside white training is on the consultation. Or just before you do the access cavity, because on the palatal aspects of my whitening tray, there’s no divot that goes into the access chamber.

It just completely covers over the top. So what that means, it allows the patient, let’s say, is it just a single tooth problem, right? It allows the patient to continue reusing that tray then for a very long period of time. If the tooth, let’s say, they’re not happy with the tooth or whatever gets dark after a year or two, they can use the same tray again, my tray to re-whiten that single tooth.

If they want to whiten all the other teeth, I need to know that beforehand. And even if they don’t mention whitening, I have a conversation. I say to them, ‘look, please don’t misinterpret this. I’m not in the sales business. I don’t think there’s anything wrong with the color of your teeth. And nor do I want to sell you tooth whitening. But if this is on your radar for your other teeth, you must let me know now cause I need to plan this differently’.

Because then what I need to do is I can’t get the patient to over bleach by 10%. Compared to the adjacent teeth, I need them to over bleach, so it’s 10% whiter than the final color. They want all the other teeth.

That creates a bit of unpredictability, so they sometimes have to go for a very white tooth, wait for that to relapse. Then their target tooth is white than their other teeth. Then they get their other teeth to match. When they get some degree of relapse, then they have to use two different trays.

And it takes a level of bit of sophistication for them to understand that just re whitening with a normal tray will never get them exactly the same result in the future. So there’s a level of-

[Jaz]
Yeah, it’s part of the consent process there that, look, this is, we’re going to significantly improve things, but there’s going to be a little bit of difference if someone comes up close sometimes. And we were talking earlier before we hit the record button. There’s these two really cool handouts, which you sent me, which had this addendum at the bottom, which shows patients examples of what this patient here because there was a rotation and also because this tooth was difficult to bleach in the neck area.

There is a difference, but it’s still a lot better than it started off with. So it’s not really a failure because it’s a great improvement, but so that the patient doesn’t interpret that as a failure if it happens to them. You’ve already shown them as part of your consent process, at the beginning. So I really like that.

[AJ]
And oddly, of course, this is just a matter of perception, right? If a patient has been walking on a single dark tooth, they’re like, I’ve got a single dark tooth. They don’t notice the rotations and the whites and things. They’re just obsessed about that. You get rid of that. Then they go, ‘oh, my teeth are crooked’.

I was like, ‘yeah, they were two weeks ago’. But now of course, now it’s a thing, right? So if, if it’s a cosmetic thing, I try and draw attention to it a bit earlier. If they’re not, I just say, ‘oh, just remind you, this is exactly the same as it was before. You were crooked before you’re crooked now’.

The wording we use is important, I think unfortunately, is permeated. The word perfect has permeated in our vernacular in our profession. And I don’t like that word because I can’t deliver that. And if the patient uses the word perfect, I pick them up on it. I say, ‘oh, you use an interesting word, perfect’.

Because perfect means it’s a categorical, it’s perfect. And it’s really important that you realize I absolutely cannot deliver perfect. And if you want a perfect result, you need someone better than me, because I can’t do that. What I can do is I can make it significantly better. But I can’t make it perfect. And I try and again, some people being a bit more objective, I say, ‘well, what would you describe the cosmetics of your teeth being?’

And they’re like, out of 10. Oh, is it three? Is it four? They’re like, ‘oh, it’s five’. I say, ‘okay, fine’. So as I’ve told you, I can’t get you to 10 out of 10, because 10 out of 10’s perfect. But what number, if I got you two, would make you happy. And a lot of patients go, ‘oh, if it going to seven, I’d be happy. Or if an eight or a nine’.

If someone’s a nine, you’ve got to think, okay, can I get there? But if someone says 10, you need to get out. That is a big.

[Jaz]
This is such good advice. Like if those listening, just rewind the whole minute. Listen again to the conversations that AJ has with patients because as a young dentist like you hear your patient use the word ‘perfect’ and you may not think anything of it because just like you said, the word is banded around so much, perfect dental, spa, whatever, all these names of practices they’re calling themselves perfect smile. How do you set those expectations?

So I think it’s a great thing you mentioned to pick up on your patients and actually just pause a moment. Okay. You use interesting word. Let’s talk about this and certainly this can sometimes bite you in the ass. So definitely pick up these terms and make sure that you set realistic expectations.

[AJ]
Always. And one of my things is with my team always, I’m saying, look, I want to under promise and overdeliver. If they’re expecting a 7 out of 10 result, I’m not going to get a 7 out of 10 result. I’m going to do better than that. I know that. I’m going to tell them that, but I know that. Under promised, over-deliver.

[Jaz]
Amazing. So now let’s say you’ve got the full tray. Now you’ve now whitened everything, the patient’s happy, you’re then going to replace the IRM with some composite.

[AJ]
No, because if you-

[Jaz]
GIC?

[AJ]
Sorry, I’m being a pedant here. If you replace it with some sort of anything, you’re going to have a problem. So I think you’ve already realized I am a bit of a pedant, and this is not a simple, quick, cheap process.

This has going to be done to exacting standards. If you whack a bit of composite in there, it’s going to fail. So, as you can imagine, I have a proper protocol for it. So this patient needs to be booked in for a long appointment, alright, a reasonable appointment rather than just me cramming some IRM there, rubber dam isolation back on.

Of course, IRM comes out really easily, you get a bit of a poke or an ultrasonic, something like that. I’ve got bright blue or purple endo sponge, which I take out. Pretty easy. I’ve got a really quite a long access cavity so your standard composite, if you just put some composite in there, you will absolutely get a void 100% of the time.

So that ain’t going to work. So the next thing I do is I irrigate it with some hypochlorite, simple hypochlorite, dryer. And then I use some isopropyl alcohol. Yeah, and this bit, again, it’s maybe a bit controversial, maybe not that controversial because you can buy it in the UK for endodontic purposes. But one of the isopropyl alcohol is brilliant at is getting rid of all the bits of eugenol.

Some of our colleagues will be concerned that actually I’ve introduced eugenol into that area with IRM or kalzinol, which is a zinc oxide eugenol, that’s fine. But actually the way to get rid of Eugenol is isopropyl alcohol. But it’s just another way to get rid of all the other crud that’s developed in that area.

So you have a meticulously clean endo chamber. Then you go back to your bonding. Okay. So this is, in my opinion, like using a one step or bond, et cetera, is not going to work. I go back to a very, old-fashioned, boring, three-step bonding protocol, etch prime bond. I personally use Opti Bond fl, but there’s lots of-

[Jaz]
And I knew you’d say that. Yes. Good man.

[AJ]
Predictable, but optibond FL has been ED before I went to dental school, so it’s mid 90’s, so we got nearly 30 years of data on it. So, but the first mistake I used to make, I’d get all of it really good. I’m really happy. But actually if you get pooling of your, even though it’s 48% filled, if you get pooling of your primer or your resin, you get this little layer.

Now, in the old days when I graduated and an x-ray was that big, you couldn’t see it. Nowadays the x-rays are that big and it drives you a bit potty having this light. So the trick is you do the etch, you get it immaculate, isopropyl alcohol, sorry, then etch. Then you put your number one, which is, let’s say your primer.

[Jaz]
Primer.

[AJ]
You try and put the smallest amount you in and you’ll still put in too much. Then you’ve got to spend the rest of the time rubbing it all out, really rubbing it over those areas, over the dentine, but not the enamel. So you’re taking it out more than you put in. You air dry it and don’t blow some air in it.

Like no matter how good quality your three and one tip is, you’re going to blow some water in there. So you either use high volume suction or you blow the air onto your mirror and then you use your mirror to blow the air into there. You get that spotless. Then you introduce your resin.

And then again, you’ll have a pool of it at the bottom. It always happens. Then you’re going to spend the rest of your time getting it back out. It’s really important. Then, because the cavity depth is so low for me, I can’t put a standard composite in there. I mean, it’s all I can, but it doesn’t look that good.

You have to do it in really small increments. So one of the changes in my protocol is I use SDR. And I get it right to the bottom of it, and I basically jiggle it around, make sure I get rid of any of the voids, and then I slowly backfill it. And then, right. But I don’t leave my SDR exposed, so I still cap it with some normal composite, something radiopaque like gradia PA one.

[Jaz]
Is that because that’s part of the protocol with SDR? I don’t use SDR much. I used to use it. Or does a dentsply claim that you can leave it exposed?

[AJ]
So, good question. So I think certainly it was described that it shouldn’t be used in occlusal loaded areas. So I think they would probably say that it’s quite reasonable to leave it on the palatal aspect of a central incisor.

But I don’t fill the entire access cavity, and it’s the same way I do endodontics outside of the aesthetic zone. I will fill the base layer with SDR. And then I’ll put a capping composite. It’s still quite recognized to do a normal capping composite for occlusal areas. And I ideally that want that.

You should have that radio opaque because again, that last bit of composite is radio lucent. Again, it’ll drive you, it won’t annoy anybody else, but it’ll annoy you. So, that’s my protocol. So can you see actually though, that’s why I was thinking it’s very different to actually just whacking in some composite, because you whack in some composite, you’re going to go around in circles.

[Jaz]
On that note, one thing I tend to do and please let me know your opinion and if you disagree, that’s totally cool. Something that Ian Harris taught me, if you know, from Sheffield where I did my DCT is Phil, I actually do the seal next to the GP, if you like, with, GIC. So let’s say you’ve done your internal beaching.

Everything’s gone well. And you now you’ve got this large and long access cavity. About 70% of it will be with a glass ionomer cement and then the final 30% with composite, because of the predictable of the chemical bond to GIC, is that a bit outdated you think?

[AJ]
No, not at all. And in fact, when I was taught depending on which consultant would supervised me, some of them would say fill the entire lot with GIC, it’s completely fine. that’s chemically bonded. Others would say, do it that way. Actually no one taught, but SDR didn’t exist. You know these back then, if it was like a highly flowable composite with just lots of resin and not much filler. So actually you didn’t want that.

And that’s very, that’s different to SDR, even though it might look similar. So it was always GIC either the whole lot or with capped with composite, and I think that’s still very reasonable. I don’t think something, if you were to inject some GIC into that in my hands, that would just put lots of voids in it.

So if you’re going to use GIC, you kind of want to do the opposite. You want it so it’s quite thick. Again, like a sausage, take a little bit of powder onto your plugger, and then plug that GIC so you’ve got a really nice densed GIC layer. And then either leave it exposed or put a small amount of composite over the top of it.

[Jaz]
Okay. Just in case anyone’s not got SDR and they have, so, GRC composite is a valid way to do it. I appreciate that. And then one thing that we didn’t actually discuss, which I found to be quite significant is the access, a proper access cavity and making sure that you remove the horns of the pulp chamber.

Because a few times where I’ve had a slow start and I’ve actually gone back in and checking the modification after actually, there’s so much of the pulp chamber that I haven’t removed or has not been removed properly. And even especially as endodontist, we all make mistakes stuff. Previously I got one back from them and I thought, ‘whoa, hang on a minute’.

And I’ve got photos of me having to open it up and exposing the pulp chambers. And now this was amenable to good whitening. So the mistake I made in the past is actually making these tiny access cavities. Well, actually you want to make them full form because a lot of these people are young when they have the trauma and then you get intrinsic bleeding into a tooth and a black tooth and whatnot. And quite a lot of these patients are quite young. Any comments on getting the correct form of the access cavity?

[AJ]
But I’m glad you actually, I’d forgotten that, but that is a common error I used to make because you take the history of where the patient rocks up, right? But really you’re treating a 10 year old tooth, a 10 year old’s tooth on a 40 year old’s patient.

So yeah, you’re used to access cavities getting smaller and smaller, but so yes. The mistake that I used to make was exactly that. So if we take a step back, really what you’re describing is that they would bleed their hemolytic products from the pulp. They break down, they create iron. The iron gets stained and that causes that red staining, right?

So your access cavity needs to be appropriate for, let’s say a 10 year old or whatever they were. Ultrasonics, I think make quite a difference to me. So ultrasound’s a very important part of my access plan and what other things do I do? So, yeah, so I mean, taking up those pulp horns and like an Endo Z bur can be quite reasonable.

But on that theme, actually, as you know, rightly, access cavities are getting smaller because of armamentarium and things. And endodontists rightly are obsessed about saving peri-cervical dentine.

[Jaz]
Ninja. Ninja, access cavities.

[AJ]
But that, that is very good from an end Doty point of view, but in the aesthetic zone that if I had a ninja access, that would actually completely compromise my endodontic treatment. So under those circumstances, I still like, as part of my access to use something I guess would be considered a bit old-fashioned, like a Protaper SX bur, which will flare the coronal access much more. It’s got a little bit like maybe a Eiffel tower shaped and making sure that actually that that’s flared quite nicely.

And sometimes I flare, if the demographics I treat sometimes are older patients who still knock their tooth earlier. I take my access cavity might be larger than you would even think because some of them, especially in the laterals, have had amalgam in there. Now that’s quite an important subtle thing because actually even if the amalgam is now gone, the staining for the amalgam is still there.

And unfortunately I’ve seen one or two that the tooth has gone a bit green. And one of them was properly green and I had a panicked friend and colleague telling me about it. And actually it is actually at that stage, it’s a bit tricky to to deal with. But the history of that is what they would’ve had is an old amalgam with high copper content and-

Have you been to the United States, been to New York?

[Jaz]
Yep.

[AJ]
Do you see the Statue of Liberty?

[Jaz]
Yes.

[AJ]
What color was she?

[Jaz]
Yes. Yeah. Very, very green.

[AJ]
Green. Right. So here’s a fun fact for you. She was not green when she was delivered. She was actually a lovely golden bronze colored copper. It was height she had covered in lots and lots of copper. When there’s a guy called Bardi, who designed her, and it was made by George Eiffel, Eiffel Tower fame. And over these many years, she’s become greener and greener because the copper in here has become oxidized. And with the old high copper amalgam, it’s the same process that causes the teeth to go green.

But the problem, that’s not just the amalgam, that’s all the bits that have actually gone into the dental tubules. So I’m afraid you’re going to have to drill quite a lot of that out because you can’t actually get those amalgam products out of these lateral incisor kind of the pit.

[Jaz]
I’ve never actually seen that, but I can imagine it’s not a pretty scene and I don’t want to ever see it.

[AJ]
I look like a Hulk.

[Jaz]
Yeah, fine. That’s very interesting. I’d never heard of that, but it’s a good point to make sure you get all the amalgam out those just because of time and stuff. I want to talk about an issue I had using this technique, which I used for some years, is that, some patients were just hopeless.

Have you met a hopeless patient that you’re constantly having to pick bread or something out of the access cavity and they’re just progressing slowly and because they’re just not able to clean, even though you made this perfect access cavity, you’ve rehearsed it. And in your handout I said that you given a little mirror to see and stuff, but some patients just can’t do it. Have you experienced that?

[AJ]
More recently, no. But I guess it’s part of case selection, but certainly in the past, because I didn’t really understand. This is for an educated patient. I don’t mean someone with lots of letters often though. They’re seeming to be deadly educated, and they need to be dextrous.

So under those, if they cannot do that, this is where we talk about failure. These are the patients who, to be honest, they will still get in my hands. They’ll still get a very good result, but they won’t maximize their result. It’ll be good, but they’ll never get to excellent.

So that’s where you got to work it out. If it’s a patient who’s completely uncompliant, then this technique won’t work. So in between, if I was to come across that in the future, I think then that’s where like some of the walking bleaching techniques would be appropriate.

[Jaz]
So that’s what I use. Maybe if we’ll talk about that, if I’ll just describe to you my technique. What I do now, nowadays is patient comes in for consultation. Make sure you get your diagnosis correct. Make sure that everything we said before that the tooth is ready to go with the lovely seal. So usually, Caesar would see them and do the endodontics and bring up this perfect plug of resin or GIC, whatever it is. And I can see beautifully inside there. So at that appointment, I would scan their teeth ready for whitening trays. I would then actually put rubber dam on, gain access, and place my carbamide peroxide inside there, followed by a bit of a PTFE and followed by some IRM.

Okay, I just leave that on. And then a few weeks later, when they come for their whitening tray fit, the tooth a lot of time is significantly whiter already. I would then reaccess the tooth. Wash it out, replace the carbamide peroxide gel, make my seal again with IRM, and then now give them the whitening tray and then they’ll be doing and then sometimes I do it where they have the adjacent teeth cut out and sometimes I’ve been brave enough because it’s going well just to give them the full tray.

And then they come back a few weeks later and now everything’s whiter and the tooth is whiter. So you got to pick your cases. I guess. I have been burnt before where all the other rest teeth whiten and there’s one lags behind. So you got to just pick and choose carefully. And then when they come back for the final time, I’m then happy to wash it out, my GIC all the way, and in the future checkup, I’ll then replace that last bit with composite.

So that seems to work well in my hands at the moment. And that’s my preferred way at the moment, just because to get someone in a few days later is a nightmare. And so sequencing wise, I like that. Have you experienced this technique? Anything that you think that we should be careful with when doing this technique?

[AJ]
No, I think actually that’s for a less compliant patient that is, or someone, I think that’s a far, when I say safer technique, as in like your results will be, they’ll be slow, but they’ll be predictable. The walking technique. There’s a degree of unpredictability about it. I think it will always work.

I don’t know how quickly my technique works. So under those circumstances, yes, I’ll happily seal it in. But with that technique that described and my technique, have you thought about how time consuming this is? This is not a quick solution to something. The very little data there tells us this is five to six hours that we’ll be spending.

[Jaz]
Wow. Okay. So I’m spending way less and like typically I charge around about 900 to a thousand pounds for a single tooth. This is after they’ve got their root canal and they’ve paid, yeah. After endodontics they come and see me and all I’m doing is the whitening, the access, two times the bleaching, and then the restorative.

So we’re spending in total about one to two hours. So, that’s my fees. But I think, I guess if you include the consultation appointment and the root canal and the follow up review, then yes. That they can add up to that much.

[AJ]
You’ve got to charge for the review. You’ve got to factor that in and that’s fine. So really what you do is you take your hourly rate, you multiply it by how long it takes you, you add your laboratory fees. You include the review equipments. That’s how much you-

[Jaz]
I mean, the lesson there, the great lesson you shared there, AJ, and it could have been missed, is that, when you’re doing these internal bleaching techniques, don’t charge for just a little bit more than your normal whitening. This should be significantly more than your normal whitening by multiple fold because you are re-accessing in the tooth, you are placing rubber dam, but you’re doing all these things which are time consuming. Very good point mate.

[AJ]
So, and ultimately, look, we are here talking about this because it’s the right thing to do, right? So why charge less for doing the right thing? What we don’t want these patients to do is wander off and have a veneer or a crown or things like that if that’s not indicated on these teeth. So, we’re going to charge well for doing the right thing.

[Jaz]
Yeah. Very very good point mate. Any final considerations or tips that you want to pass on to the young dentists listening who may be coming up to trying it for the first time and looking into which techniques they can use to maximize success? Or any mistakes that you’ve made in the past that you just remembered that you want to share? Anything that you could share with us?

[AJ]
Yeah. Well, I mean, yeah. All of this, I’m telling you is based on my own mistakes. So, I mean, I’ve given you the way I do it. So having an educated patient is quite important. Them really understanding and just from a legality point of view, that you’ve going to remember that the currently we’re in the first course of whitening needs to be done by the dentist. So what that means to me is, I want to load the gel in there and I want to put some on their own. Start them off as they leave. And then I’ve fulfilled my responsibilities as doing the first course of whitening this is in the UK regarding cleaning. Go on. Tell me.

[Jaz]
Cause two things I actually just sent my notes now that I want to discuss and I forgoing to mention. So let’s just also touch on what do you tell the patient regarding relapse and also what do you tell the patient and do you worry about internal resorption?

When I started to do this techniques many years ago, My principal said, ‘oh, but make sure you’re warned by internal resorption’. And so I’ve never experienced it so far with any of my patients. I believe and you’ll know the history of this way better than me, is that this used to be from times when we used to use much stronger chemicals to whiten the tooth and also heated techniques.

I believe they used to get a ball burnisher and put flame to make go red hot and then stick it inside, which we don’t do anymore. So, is internal resorption a as big of a concern now than it used to be? And then also just talk about relapse. That’ll cover all bases.

[AJ]
Fair enough. So firstly, we are looking at survivor bias here, right? These are often traumatized teeth and traumatized teeth get resorption. You just didn’t realize it before, and someone did whitening and then there’s a resorption. Then two must come together. It’s a classic post-hoc fallacy, right? So actually now I do kcts and I see there’s plenty of preexisting resorption for a start. So that’s one thing.

And secondly, that was one of the real concerns. You will probably be too young to remember, certainly when like, so tooth whitening was illegal when I graduated. It’s illegal by the letter of the law and only became legal not that long ago. Let’s say probably legal in the last 10 years, something like that.

[Jaz]
I think it was 2010.

[AJ] Something in that region. Yeah. And one of the problems was there were questions about safety. Now, because people were mixing up all these techniques. Yes. So the classics sort of, is it spazzer, I think. And then there was the nutting and poe techniques from the early sixties where they used these sodium poborate and heated them and they’ve released enormous amounts of hydrogen peroxide, what would now be illegal amounts of hydrogen peroxide, and it’s one of the reasons that the European laws came in for this particular thing is to actually, to stop these like very large productions of hydrogen peroxide.

So that’s why we are limited to 6%. So carbonide peroxide kind of, there’s different kind of ways that it dissociates, but fundamentally it splits up into urea and hydrogen peroxide, and then the hydrogen peroxide usually disassociates into water and free oxygen species, right?

And that’s what caught the whitening. So even though we are buying high carbonide peroxide, really we are, the law relates to the hydrogen peroxide. So 10% carbamide peroxide, 16% carbamide peroxide is fine because it disassociates to less than 6% hydrogen peroxide.

[Jaz]
By about three to one. So the maximum would be about 18%. Carbon peroxide would be-

[AJ]
But interesting if you’ve got to be careful because you can certainly buy a lot more than that in the UK. So if you went on the internet, you can get, let’s say po. 22%, which is completely fine, but actually is not designed for the European markets.

And is, you can buy it, but you can’t give it to your patients because it’s illegal, unfortunately. So just be a bit careful of that. But these old-fashioned techniques used to disassociate the massive hydrogen peroxide, which were heated and would cause resorption because fundamentally they’d kill bits of the cement blasts and the periodontal ligaments, the sharpeys fibers, and they would lead to resorption.

But that is very different to the carbamide peroxide that we use now, which disassociates it to very small amounts of hydrogen peroxide. And that’s part of the basis that we have a legal limit to what we can provide for our patients. So do I worry about internal resorption or external resorption? Well, internal resorption, no.

Cause it’s a pulpless tooth. External resorption, no, I don’t worry about it in as much that I know I’m not going to cause it. But it’s preexisting in more patients than you think. And you’ll realize that the more cone beam CT scans you take.

[Jaz]
I mean, that really aids us in terms of making sure that when in doubt, a CBCT scan, like you said, really has its value. So that’s, that’s a real gem that you shared there. And regarding relapse, I always find that even just for success rate, I find that the black teeth whiten super well to white teeth in my experience, but sometimes the dark yellow, orange ones, That, maybe still leave a tinge of yellow brown.

And then someone once told me that, I don’t know if it’s evidence based or not, that perhaps those orangey ones are also the troublesome ones when it comes to relapse, but I have no scientific basis or data on that. But in terms of relapse, what have you observed and what do you tell your patients?

[AJ]
Okay, so they all relapse in my hands. They all relapse. And that’s part of my consent process to say, ‘look, I can’t do any dentistry that lasts forever’, but we have failures. There are good failures and there are bad failures. If you do a full mouth of a full arch of implants and they fail, that is a bad failure.

If you have a single tooth, which you have done a root filling on, and you’ve whitened that, it gets slightly less white. That is a different level of failure. So I kind of talking about it early, that’s just part of the consequences.

[Jaz]
AJ, I think the true failure would be to not talk about failure when you’re doing this time trip. That’s the true failure, right?

[AJ]
If you miss your future, talk about failure at the beginning, that’s when you get yourself in hot water. So the orange, so personally, I haven’t noticed that subtle distinction, but can I go back to diagnosis? Diagnostically, they’re usually different if you’ve got a tooth which has not been root-filled.

And has got blood products in there and they go that brownie, black color purplely sometimes, they white in fantastically well and equally so do the ones which have discovered cause of endodontic products fantastically well. Cause you can solve the problem if, but you mustn’t confuse that with the patients who actually have, let’s say, have a vital tooth and have orangey brown discoloration, which you often see when they get sclerosis because really what they’re doing is building more and more and more dentine.

So those two are not comparable because the one with more and more dentine on a vital tooth will be harder to whiten and will relapse more because they still grow more dentine, whereas the ones you do the proper internal external whitening on will, again relapse, but will not relapse at the same rate.

And just because they’ve relapsed, my patients have unfortunately been standing still long enough to see plenty of my own failures. It’s actually very easy because often you could just reuse their same tray. You don’t need to do internal whitening again. All you do is use that same bleaching tray that I’ve given them to just target that one tooth.

And what they need is just some more gel. And that could be from me, that could be from their general dentist. As long as it’s from a regulated healthcare professional, it doesn’t matter. So as failures go, that is a real good failure.

[Jaz]
When you put it like that, in that perspective, that is really good to hit. And I think those who are considering to do this technique, don’t be scared. As long as you get your diagnosis right and you have a plan and you want to use one of the protocols that we discussed. AJ, this was immensely valuable. I’ve been getting asked about this kind of topic and I’ve been looking for the right guest.

So I really appreciate you coming on and discussing this, I think your experience and your handouts. Do I have permission to share your handouts with the Protruserati?

[AJ]
Absolutely. And any of the papers and stuff like that. I can certainly give them to you. I don’t know if, if you’re allowed to distribute them or not, but no, look, we’re standing on the shoulders of giants. I’ve quoted lots of names, but not to name drop, but I’m just, I’m really just reusing what I’ve learned from them. And as, as you do so, no, please-

[Jaz]
Always, always, absolutely that’s the name of the game and that’s how we just share what we’ve learned before and improve one day at a time. So, AJ this has been absolutely amazing. Just tell everyone where you work and someone who has a tricky case maybe near you and whereabouts, exactly. What’s the name of your practice they might want to refer patients to? Also any educational content that you have. Any courses that you run?

Perhaps, you involved in teaching? Cause I know you said you did a BDA webinar recently. So tell us about those kind of activities.

[AJ]
So my practice is in Hasek, which is just north of Brighton. About our catchment area, because we’re a purely specialist referral practice, we have, there’s about 10 or 11 of us all specialists and consultants.

So we see patients from all over Kent Surrey and Sussex. We do a lot of children’s dentistry and things like that. And I don’t do much national lecturing or anything like that, firstly, cause I don’t have timers. I’ve got three daughters, but also because we just do our in-house CPD evenings, they’re free.

We have dentists which come over from all over kent Surrey and Sussex just come and hang out. You’ve seen how I lecture. Most of my lectures will be about the things that I’ve messed up and what I’ve done to get myself out the c

[Jaz]
I love it. I love it.

[AJ]
So they’re free evening lectures at Greystone Referral Center. And then I do a few some of the national talks. I do the BDA cone beam Masterclass, and I teach on the BDA restoring implants masterclass. And that’s pretty much and the rest of the time I’m just in private practice doing lots and lots of dentistry and making lots and lots of failures. And having a laugh about the woodwind makers and learning more, and then doing the best I can.

[Jaz]
I really appreciate your humility and your humble attitude. It’s really nice to hear. And AJ, thanks from Protruserati for coming to making this complex topic a little bit more easier to manage and breaking down really nicely for us.

So, thanks so much and it’d be great to have you on again one day. I think I really like your style and the way that you brought in some stories and we end up talking about the Statue of Liberty, so that’s pretty cool. So thanks again for your time.

[AJ]
Pleasure.

Jaz’s Outro:
Well there we have it guys. Hope you enjoy that very detailed guide into internal bleaching and all you have to do if your protrusive premium is answer a few questions and yet again, you can get another verified CPD or CE certificate and a chance to validate your learning, what’s not to love about that. Don’t forget in the Protrusive Vault section to download those three PDFs that we’re giving away at the end of this episode.

And if you ever have a colleague who’s stuck on internal bleaching protocols, you better direct them to this episode. So thank you once again for listening all the way to the end. I’ll catch you in the next one. I don’t know exactly when the next one might be. Might be in four days time, might be in eight days time.

It depends on when baby number two lands. It may have landed already by the time you listen to this, or I might be patiently waiting for baby number two. We’re super excited. Thanks for all your love and support guys, and I’ll catch you in the next one.