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This episode gives it all away – every micro-step on how to successfully treat white patches with Teeth Whitening and ICON Resin Infiltration. If you are an experienced clinician or new to White Spot management with ICON, you will gain something from this blockbuster.
After the success of the ‘Teeth Whitening Under-18s’ episode, Dr. Linda Greenwall is back to make resin infiltration tangible. Dr. Greenwall shares everything from assessment to troubleshooting!
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The Protrusive Dental Pearl: Download the Protrusive Treatment Guide for White Patch management Icon Resin Infiltration inspired by this episode – the Infographic that summarizes this episode with the exact micro-steps and the little nuances with helpful diagrams and tips all in one flowchart.
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Need to Read it? Check out the Full Episode Transcript below!
Highlights of this episode:
- 1:42 ICON Treatment Flowchart
- 7:39 The science behind Icon Resin Infiltration
- 16:35 Using Resin Infiltration Posteriorly for Caries
- 19:33 White Patches Anterior Resin Infiltration Protocol
- 22:08 Resin Infiltration Treatment – Air bubble Analogy
- 32:50 Patient Communication – Treatment Planning and Fees
- 34:50 Resin Infiltration Technique – after the etching process
- 40:36 Predictors of success and failure
- 45:02 Expected longevity of Resin Infiltration
- 47:02 Etiology of white spots
- 47:57 Dr. Linda’s advice when starting a white spot cases
Learn more about Molar Incisor Hypomineralization with THE D3 GROUP FOR DEVELOPMENTAL DENTAL DEFECTS
Check out the Tooth Whitening Techniques Book, a compilation of before and after photos of patients produced by Dr. Linda Greenwall
If you enjoyed this episode you will also like Teeth Whitening Secrets for Success
Click below for full episode transcript:
Jaz's Introduction: Did you know that resin infiltration was initially developed for the management of early carious lesions? But it's actually taken off hugely for the management of white spot lesions anteriorly. I've been using icon resin infiltration for a few years now, and I've had some pretty good results.Jaz’s Introduction:
And so this stuff, this resin that infiltrates into these white patches, like our guest Linda Greenwell, the way she beautifully describes it with her soothing voice is that the white patch is like an air bubble, and she explains that analogy wonderfully throughout this episode.
And it seems to be a really great, minimally invasive way to manage white patches, either after orthotics or MIH or of any origin. Hello, Protruserati. I’m Jaz Gulati and welcome back to another episode of the Protrusive Dental Podcast. That’s right. We got Linda Greenwell back again after that amazing episode about the rules around whitening for under 18.
If you haven’t seen that, do check it out because it does tie in well with this episode because one of the things that Linda will teach us is the importance of tooth whitening before doing resin infiltration. In fact, Linda leaves no stone unturned. Every single micro step and the nuances and considerations, and even the troubleshooting.
What if things don’t go to plan? It’s covered so comprehensively, so beautifully that I think DMG, the company that makes the stuff will probably host this podcast episode on their own website. We also answer burning real world questions such as, do you have to use rubber dam for this technique? And can you use any composite, like sometimes you actually have to have composite at the end of it.
Do you have to use a bond before you use the composite or is the adhesive with the icon enough? And what is the best type of composite to use at the end if required? So if you listen all the way to the end, you’ll find the answer to that one as well.
Protrusive Dental Pearl:
The Protrusive Dental Pearl for you is the best infographic or treatment guide you’ve ever seen. As you know, some of the Protrusive guides before have become pretty famous for the amount of detail and concise amount of knowledge on them. And so what we’ve done from this episode, because there is quite a lot to remember, a lot of little nuances.
I imagine if you made a flow diagram of this episode, you’ll see later what I mean. It gets a little bit complicated, but don’t worry, we’ve done all the hard work for you. We’ve mapped out the exact microsteps and the little nuances with helpful diagrams and tips all in one flow chart. That treatment guide is essentially everything you ever want to know about icon resin infiltration with our protrusive masala. Sprinkle all over it.
If you want to access this treatment guide on icon resin infiltration, then check out the Protrusive app. It’s an IOS and Android. You can also access from your browser. If you just head to protrusive.app, that will take you to the app website itself.
It’s under a section called Protrusive Vault, and you’ll find so many of the previous infographics and files, which is only accessible to the premium members. It’s thanks to the premium members that this podcast can stay alive and viable, so I thank you so much for your support. Before we joined the main episode with Dr. Linda Greenwall, I wanted to announce something really special with EVO 4.
EVO 4 is the latest generation of Enlighten Whitening. The changes with EVO 4 really make it superior, so now there’s no more in surgery stages, three weeks, all at home. They’ve also done something very clever with the tray design.
So the whitening tray, sometimes posteriorly, they sort of flap off. There’s a lack of retention sometimes. Quite often molars have small clinical crowns, you see, and that allows saliva to come in. So kind of like with the aligners, they’ve actually built in an attachment, single attachment on each side, which is optional to use, but I’ve used it and super easy.
So if it gets you better results, why not? And they’ve incorporated that as part of the EVO 4 system. The final change, which is pretty important, is that now the gel will ship to you with the tray so you don’t have the gel lying around the practice. It comes with you as a bespoke order with the patient’s whitening trays.
Now, the benefit of that is that the gel doesn’t stay lying around the practice, and the more it lies around the practice over time, the more it breaks down, the more it breaks down, the more acidic it becomes. The more acidic whitening gel becomes, the more sensitivity you have. Can you see where we’re going with this?
It’s less sensitivity. It’s fresher gel for better results to celebrate the launch of EVO 4, my buddy Payman Langroudi and Enlighten Smiles are giving away 20 free kits to the Protruserati. It’s super easy to get a kit. All you have to do is go on the Facebook group, Protrusive Dental Community. On there, I’ve started a thread, and on that thread I’ve asked, who wants a free whitening kit?
Of all the people who comment, we will randomly select using one of those random apps that you see online. 20 winners. So you can start using either on your patients or your staff or your family with the new EVO 4 system. So the Facebook group again is Protrusive Dental Community. Just search it on Facebook.
You’ll find it. Thank you again. Enlighten and Evo 4 for supporting Protrusive Dental Podcast. Now just check out this really geeky, fantastic episode with Dr. Linda Greenwall.
Main Episode:
Linda Greenwall, welcome back to the Protrusive Dental Podcast. How are you?
[Linda]
Thank you. I’m good.
[Jaz]
It’s great to have you back. You blew us away when we talked about whitening for under 18. It’s a very controversial topic and it got a slightly controversial response on social media and email, which is fine. We kind of expected that, but in a good way that a lot of dentists were like, wow, someone’s actually standing up i.e you for the profession. So that’s wonderful. And I was actually at dinner, the weekend.
At my friend’s house. And he’s a dentist, and he asked me a question, Linda. He said, which,’ Guest have you had on the podcast whose story really inspires you?’ And it is just, like the almost like the most inspirational guest you’ve had.’ And I said, okay. It has to be Linda. Because of your background, your story, your mission, and the clarity in which you communicate your mission statement is just so you know, you are oozing passion about this in all your educational ventures and what you’re trying to . Achieve.
Through whitening and much further for the restorative dentistry. So I think it was an easy choice for me. So thank you for all that you do for our profession.
[Linda]
So just one more follow up. There’s two more things. Number one, we are really making this year to campaign for the under 18 children because MIH, which is the disease, and a lot of the kids have these white spots that we’re going to talk about.
MIH is a disease and it’s one in six children have this disease. And so whilst they need the mild cases, need icon resin infiltration, they start with whitening. So we are going to focus on the disease aspect, and I’m going to do quite a few series of lectures on the disease aspect of MIH because it’s pretty severe and there’s a whole lot of new information.
That’s the first thing. The second thing is we’ve ramped up our care for the child refugees this year through the Dental Wellness Trust charity that we are working on. And a call to anybody who wants to open their practice on a Sunday, on a weekend to help the child refugees. These children are asylum seeking families, but we only work with the children.
They are not eligible for any NHS treatment or anywhere else. So, we do this treatment for them. We are happy to do it and provide it. This next week we are going to a hotel in Paddington to screen 40 children who need to be desperate for dental care, who can’t get it. So anybody who wants to volunteer, please message me afterwards. Any of that, we’d really love some help. We need to be ready to roll up your sleeve, so thanks so much. Thanks.
[Jaz]
If you weren’t already in love with Linda, there we are guys, you know, what a beautiful, noble thing to do. And just so to make it easy that I’ll put a link in the show notes so they can directly contact you for that.
And you’ll just let me know which is the best contact afterwards so I can take them directly to be able to them to get involved in helping. So that’s amazing. So completely right with today we’re talking about icon resin infiltration, and you already touched on. You know, whitening may be a part of this, but before we get to that, I just wanted to help dentists understand, because dentists, we weren’t taught this at dental school.
Like many things. And when we come across this, you know, “New Technologies”, obviously it’s been around for a little while now. I’m sure you’ll tell us. We get a little bit skeptical about actually using it in the practice. So first thing to cover is what is the science behind icon resin infiltration? How does it actually work?
[Linda]
So the way that it works is literally as it sounds, it’s infiltrates a porous area with resin. It was originally discovered, I think it’s more than 15 years ago now. By a group of researchers in Germany. One of them was called Paris. One was called Lueckel, and one was called Pharck, P-H-A-R-C-K.
And he did a lot of research on this, and I saw this information presented in Chicago when I was lecturing and when I saw the technology, I was like, this can be applied for patients with whitening and for white spots. And this has been nearly 10 years ago. And since then, we’ve been applying the technique.
So when a patient has got white marks or white spots on their teeth, you have to think of them as an air bubble within the tooth porosity. The reason that it occurs, I don’t know, we discussed this Jaz, but we need to talk about it. One in six kids have this. Anytime a tooth is starved of oxygen, so the little embryo is starved of oxygen.
It’s creates an air bubble, there’s a defect, and it becomes porous, and that is prenatally, postnatally or perinatally, anything that occurs around the birth. So when that happens, there’s a defect in the truth. What we know now with the new research is albumin for some reason gets incorporated into the developing tooth structure.
An albumin stops the tooth structure from hardening and calcifying, so it’s soft and it peels off. It just where you get post erupted breakdown and the tooth just starts breaking down and you know, it’s a very severe, there’s about seven different categories. About 20 years ago, a pediatric dentist noticed this disease.
Up until about 20 years ago, we weren’t really seeing it much, and all of a sudden we started seeing this. The history shows that it was around 200 years ago, but it’s much more prevalent now. So it’s now one in six, it’s now globally, all countries have it. Denmark, for example, they’ve eradicated tooth decay completely and they just deal with the severe MIH cases.
So MIH means Molar Incisor Hypomineralisation. There’s a really good website if you put it on the case notes as well, on the podcast notes. It’s called www.thed3group.org. And that is for children, clinicians, parents. Everybody wants to know about MIH and white spots and white mark. So I’ve prepared a whole series of literature. I can give you some of the literature in your case notes. What is MIH? What are the treatment options? What is resin infiltration? In fact, I’ve produced a book of before and after photos for patients.
[Jaz]
Oh, wow.
[Linda]
To see what it does with a little bit, it’s all picture books rather than technical words. So again, that is available, which would soon be available on Amazon. But explaining what it is. So the kids that come to see me, they are been traumatized, they have been bullied because a lot of it is brown, white, and marks. The parents are traumatized. The parents have so much guilt. So one of our options that we want to do, we actually want to do a research study surveying the parents because the parents have lived with this guilt that this cause something that happened during the birth caused the child’s teeth to be this way and the parents feel very strongly.
There’s no access to dental care on the NHS for this treatment. And under 18 whitening as we discussed, but, our next little project is to interview. Often I’ve been videoing the mothers after the treatment for the kid, the mom starts crying, not because of the fees, but because of the impact for that child, and everything is about the impact of the child and the mental wellbeing.
So in my book, which was published in 2007, second Edition, tooth Whitening, I wrote an index of treatment need for children with white spots and white marks. If it’s impacting the child, then treatment. If it’s not impacting in a child, wait till later. So we would start, very rarely we would do eight or nine years old.
We wait until all the teeth are wrapping, so about 12 years old. And normally when they leave year, then year five, year six, and they’re go into high school before that time, that’s when they really want to get the treatment sorted out.
[Jaz]
Now, I just want to say Linda, it is really good you mentioned that because from the previous episode, we did, teeth whitening under their 18s. I don’t think this was the impression that was created at all, by the way, but I don’t want dentists to interpret that as when they see a 14 year old with white spot, they will say, ‘Hey, let’s treat it.’ It should be a case of need. Ie It’s actually bothering the child.
If it’s not bothering them, then that’s the conversation you could potentially ask, oh, is it bothering you? And, later time in their life, basically. But if it’s definitely bothering them and the parent, then that is a worthy conversation to have at that point.
[Linda]
That’s right. But if it’s not, then you just move on and leave it over. But there are a lot of patients and unfortunately because of the, you know, they can’t get treatment anywhere else, they do travel a lot. And that’s fine because if this is all that it needs to help their mental wellbeing, this is fine. So, you know, as dentists, we are not psychologists or psychiatrists, so we cannot diagnose depression and all those things, and that’s not our remit.
But at the same time, we can see when a child is impacted. And if a child is telling you, they don’t often initially tell you that they’re being bullied at school, but when it is, the mother will say, and often, the recent case that I saw with a kid. The child was so, he’d biten the inside of his lip and his cheek.
He was so upset about the bullying, not only so there’s an internal thing where they hold it all together, but the external thing that the teeth are brown and yellow and defects on the teeth. So the beauty about resin infiltration, is that it’s non-invasive. Generally it’s non-invasive, but there are things that can happen, which you need to be aware of, but it’s a simple non-invasive treatment.
And as you know from our previous discussion, whitening is first always whitening because you want to see what whitening can do. Because what happens is that these cases need to be widen for a prolonged period of time. So not 4 weeks, not two weeks. Most dentists think, oh, it’s all over in two weeks. It’s actually longer.
It’s about six to eight weeks, or eight to 10 weeks, because you want to see what can whitening do for this patient first before you do the resin infiltration because-
[Jaz]
Absolutely.
[Linda]
The whitening can shrink the lesion not entirely gone away, although we have seen it go entirely away with patients who’ve got tiny little white spots.
So we’ll talk about predictions later, but if it’s small, it’s easier to get rid of. If it’s pale white rather than very opaque, then it’s much harder. So those are kind of some of the things. So the science behind, basically this technique was done as a method for treating early D1, D2 carious lesions, and that’s when it was just penetrating in the enamel and on the radiographs.
And we have many patients, and I know you do as well, when you see they take their bite wing radiographs, you see these little triangles in their enamel and you go, okay, what’s my treatment decision here? Do I leave it and tell the patient to floss more and use interproximal little brushes, or do I intervene if it’s only in the enamel?
If they change the habits, we can keep this lesion just as it is for seven years. Maybe nothing will get worse, but if it’s just like sort of tiny, but in the dentin, what we do with our digital x-rays is you can sharpen the image and when you sharpen it up, there’s a little thing on software of excellence.
Some of the software, you sharpen it, you can actually see there’s a little bit more decay than on the first digital image. But anyway, when we see that those are your decisions you need to make, do I treat it? Do I intervene, do I prevent it? Do I go through the fluoride and flossing, et cetera. My opinion on those cases especially when they’re multiple lesions, is we all know that the patients don’t really change their brushing habits all.
They don’t really. As much as dentists, we work so hard at trying to get them to change a behavior. We are not always as successful as we want. And so for those patients, I do the resin filtration posterior.
[Jaz]
Which was actually going to be one of the questions I want to ask later on whereby from my understanding, the technique was initially for molars and using it for E2, D1 caries. And so it’s great to hear you are using it, but why do you, I mean, it sounds like such a great, minimally invasive way to treat these early lesions.
Why do you think the uptake amongst, cause I don’t know. I know loads of clinicians and very few that I know are actually using this for molars. I particularly, I myself have the kit, but I use it for interiors and I haven’t had the training to use at molars and I’m a little bit apprehensive and I feel like maybe I should be doing it for molars. Because it’s such a great thing to offer your patients. Why do you think uptake has been slow?
[Linda]
So just a couple of things. By the way, Jaz, with your group of listeners, we can do hands on with you and your team, whoever wants to do it as part of the podcast because we can do it online. And so then-
[Jaz]
Amazing.
[Linda]
You don’t have to go somewhere so we can do it. So there’s two different kits. So you can do, and there’s an anterior kit, which is a round sponge, and there’s a posterior kit which has a different applicator. It’s got like a matrix, it’s a green handle with a matrix which you swap around and I can send you photos of it. And it’s got little pores on the green side.
It’s got little pores. So let’s say your lesion is on the lower right six mesially. You twist the applicator and you put it just mesially. You pre wedge or you put an orthodontic wedge, an orthodontic separator through. You wedge it, you place your matrix and you do the etch, and you would etch it again for two minutes.
And then you would go straight on to the resin and the resin is on for three minutes and then a further minute. So there’s a set protocol which we can go through, but that is for posterior. My point is on these patients, nothing is going to change. And then we are eventually going to have to drill them, those lesions.
So why don’t we just try this? Only problem is that the resin is not radiopaque. So you need a good preoperative radiograph to say, this is how it is. Now you can undertake the technique. And I explain to patient, it’s like a clear fissure seal.
[Jaz]
Got it.
[Linda]
Because we do a lot of fissure sealing in the practice, so it’s like a clear fissure seal. This is prevention. We rather intervene and prevent rather than wait for the lesion to get larger. And most parents are quite acceptable on that. And so it’s a simple technique to do, but you can’t see it working. You can do the technique, you can’t see it with an anterior, it’s all in front of your face, so you can see it working and you can see what’s going on, but it’s a good thing to know about.
And as you know, Jaz, I mean the reason for the success of your podcast. And just by the way, after we did the other one, I was stopped all over when I went to lectures and they’re all like, ‘Hey, I’ve just listened to it. I loved it.’ But so you’ve got a very impactful, very wide range of people. This is wonderful and congratulations.
[Jaz]
Well, thank you so much. Let’s make it happen because it’s a technique I want to learn. And this podcast was made for greedy reasons, in sense that I wanted to share a very specific bit about how to move to Singapore as a dentist so that I can help those people.
So I’d free up more of my time and eventually it led to me talking about things I love. And this is such a great thing, minimally invasive dentistry. And there’s loads of people who actually. Use icon resin infiltration anteriorly for those white spots. But we just lack that direction. And I think what you can give us is that direction.
So I will put a little ad in here for like, ‘Hey guys, if you want to come and join us for the HandsOn Online kind of thing.’ Is it like a HandsOn, like virtual hands online?
[Linda]
Hands on. We send you the hamper. And then we all do it together.
[Jaz]
I love how you call it a hamper. That’s so good. So great. So we can do that. So essentially the resin infiltration works by, well first whitening. Then the resin-
[Linda]
Then you wait two weeks.
[Jaz]
Infiltrates into the tooth.
[Linda]
But you must wait two weeks because you want the resin, the enamel bond strength to reestablish after whitening, it’s 20% reduction. So you complete your whitening treatment and get the patient to come back two weeks later. So you’re ready for resin infiltration. Cause you want the bond to be working really, really well.
[Jaz]
Great. And then on the day it’s rubber dam isolation.
[Linda]
Rubber dam isolation. If you can’t, we use Optragate. Some kids don’t like the intrusiveness of rubber dam. We tend not to use local, so it can be uncomfortable for children.
So if we can, and we also do it for everybody with white spots between adults and kids. It doesn’t have to be just kids, and it works just as well on adults as well. So you would isolate because you are using hydrochloric acid. So you would isolate either with a full rubber dam or you can do the Optragate with a barrier.
And the Optragate works very well and you just bury it up. Some people just barrier where the white mark is on the tip of the tooth. So there’s different types of isolation that you can do, but you must do it because the hydrochloric acid causes staining on the gingiva, does cause burning. You get chemical burns.
There’s no legislation about hydrochloric acid. You can use whatever you want, whichever concentration on whichever age. No legislation on this. Of course, as dentists, we need to do everything that’s safe and there’s product safety legislation and the beauty about icon is so much research on this and there’s ongoing research.
I traveled last month to Paris to work with Professor Jean-Pierre Attal, and they have, which is very in innovative. They’ve got a discoloration clinic at the University in Paris.
[Jaz]
Wow.
[Linda]
And I go there to consult with them, to help them. I’m what you call like the special, I don’t know, like a, the godmother. The godmother for them.
The fairy godmother, the godmother for the clinic to help them. And we look at cases together. But Jean-Pierre Attal has published so much, and if you want to look up more, look up his work. And he has PhD students all the time working on resin infiltration. And so I always go to learn with the best that I can learn.
And so I spent a wonderful day in the clinic working with him and in his research lab looking at resin infiltration under the microscope and all those things. And so we working with them and producing more papers on this as the new information is coming along.
[Jaz]
So, what does it look like? Cause you likened the porosity or the white spots like an air bubble. I love that sort of likening into an air bubble. It’s a great visual image. And essentially once you infiltrate it, can you go over that analogy? What happens to that air bubble?
[Linda]
So then what happens, there’s a few more things about that. It depends. Little about the white mark. It depends where the white mark is located. If the anatomy of the white mark is also really important, so if the white mark is like a thin crescent on the cervical area, because it’s been poor oral hygiene, those are really super easy to do the resin infiltration. Really easy cause they’re tiny demoralization areas where the white markers on the incisal tip or in the body of the tooth and there is a depth and there is, it’s very, very opaque.
And on the severe cases, there’s actually enamel missing on their labial enamel because their enamel’s so weak. There’s a divot, like a, from a, I don’t know if you play golf, but there’s a piece missing out of the enamel. And so you need to do whitening resin infiltration. Plus you need to do a composite bond and you need to be ready to do a composite bond as part of the treatment plan.
And often some people find it difficult to work out. Is it a amelogenesis imperfecta or was it MIH. Or is it, you know, there’s many different type of things that it could be, or fluorosis, for example. But, so you need to look at the location, where is it? And then if it’s severe, it needs to have a composite bond.
So when we go with the analogy of the air bubble, the first step is you would clean the tooth. I use pumice and Hibiscrub with a little tiny micro brush, not a normal prophy brush, but the pumice and Hibiscrub. Then I would use my aqua care and I use it on the sylc mode, so the sylc is like, it’s got Novamin inside with vanilla flavor, we tell the kids it’s going to be like a vanilla ice cream on your tooth and we jetted and clean it. So you’ve got that, which starts the abrasive. Very mild. Abrasive, but it’s jetting in, so the conditioner, because the problem with MIH children is they are super sensitive. So just rewinding a little bit.
And many, many cases need sensitivity management treatment. That’s really important. And but this is the whitening. But that’s part of how we diagnose that it’s this. There’s not only MIH, it’s for all white marks and white spots and white specks and flex and all kinds of things that you would do the resin infiltration.
So you’ve got a nice clean tooth. Now you decide. Is this a basic lesion? Is this an intermediate lesion or is this an advanced lesion? A basic lesion is orthodontic demoralization, poor oral hygiene with those white lesions. One isolated little flick, tiny little, tiny little thing. That’s step one. The intermediate lesion would be, again, one lesion, quite diffused, a jagged edge, quite diffused within the middle. So it’s like a spider shape lesion. It’s not clearly demarcated.
OBAB:
Occlusion is just so confusing. Does occlusion even matter? Wait, don’t you just grind away all the blue marks, right? You mean like plant it low, let it grow or leave it high and let them cry. Listen, what are these interferences even interfering with?
Is it safe to lengthened teeth? How much can I raise my patient’s bite? How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs? Is canine guidance always better than. Why can’t I just use the DAHL technique on all my wear cases? Can I stop my patience from grinding?
What the bloody hell is crossover? What should the occlusion look like after orthodontics? How and why do you check for fremitus? What on earth is a custom suicidal guide table? How do you use a leaf gauge? Do you always need to use a facebow? Does everyone really need a perfect occlusion? What is the difference between edge wear and pathway wear?
Is it naughty to adjust the opposing tooth? What the is centric? Occlusion is coming. One does not simply just open the bite. May the force mitigation be with you.
[Jaz]
To make sure you don’t miss the crucial update about the launch of our occlusion course, OBAB head over to occlusion.wtf. That’s right. It’s actually occlusion.wtf. It’s almost released and you’re going to love it.
[Linda]
An advanced lesion is multiple lesions on many, many teeth upper 4 to 4. Large deep lesions plus a central incisor with a whole piece of enamel missing, or it’s brown or yellow because there’s a defect. So those are your lesions. So you would start with the basic-
[Jaz]
One little trick. I learned Linda, and I just want some validation from you. Is that, is this a good thing to do? Is this something that you practice as well? Is that to shine a light cure behind that central incisor with the big white patch and see, can you still see the outline of that white patch.
And that gives me a clue as to, okay, what are we up against here? Because if you can’t, if you see the outline the white patch, that tells me that, okay, it’s potentially going to be quite deep and more of an intermediate to advance. Is that something that you practice as well?
[Linda]
Yes. So that’s called transillumination and the way that we do it, we take a photo with it as well. We use, instead of the curing light, you can use a curing light, but SDI make a really good diagnostic light. So instead of the white, instead of the blue light, it’s a white light. So we take a photo with no flash with the light behind.
And then you’ve got the photo of the transillumination before this. There’s a researcher whose name is Omar Marouane. Not marijuana, but Marouane. From the University of Tunisia and David Manton. They’ve published on this. And he’s done a whole, a series of transillumination as before he starts.
And then as the treatment is completed and with the transillumination, you can see how the lesion shrinks and you can see how the lesion is penetrated with the resin. So going back again, then we need to assess, what am I dealing with, with the transillumination? Then you will etch the tooth. So the etching, it’s called Icon Etch, and that’s for two minutes.
Now, we are not used to etching for two minutes. We are used to our 15 second quick flash, flash. So this, you need a timer, you need to time it out. Exactly. And the way that you do it is you place the etch all the way into the lesion. But what happens, because it’s an air bubble, it’s very porous, so it just sucks in all the etch like that.
And so you need to, during those two minutes, you need to keep replenishing. So you twist, it’s a special syringe, which is a twist sponge, so that you twisting and you keep replenishing as you go along and you massaging in gently not tickling the tooth, but more like massaging the etch into the tooth and you keep going and going and going for two minutes.
If you’re doing a lesion with sixth teeth, what you would do is you place the etch after isolation all the other techniques. We said go with the etch on all sixth teeth, and you start, you set your timer for two minutes, and you start massaging all the way for two minutes on all those teeth.
[Jaz]
On that point, the surface area that you’re etching, Linda, would you just do the, imagine you got quite, well demarcated white patches, 3 to 3, let’s say canines, canines. Would you want to do just the white patch only or do you want to extend it a border beyond the white patch? And if so, what is that border that you’re aiming for?
[Linda]
You don’t want to extend it too far. You don’t want to extend it too far, so you can just go over the little white area. So there’s a margin, but coming back to the air bubble analogy, what you’re doing is you’re opening up the top, the lid of the air bubble with your etching.
So you would then use the alcohol not for drinking. We taught in Croatia when you and the guy just, he lost it at the alcohol and so we couldn’t carry on with, he couldn’t get it out. It’s not for drinking. The alcohol is a test. It’s the test because alcohol replicates the refractory index of enamel.
[Jaz]
Of the result that, you know, if you were to resin infiltrate at that point, it was like a preview, right?
[Linda]
It’s a preview, it’s a test. So you put the alcohol on and you drip feed it for 30 seconds. Very, very, you drip and you watch, so you just drip it and check. If when you drip it on the tooth, the white spot’s completely gone. You know that you can go on just on your basic step etch alcohol resin infiltration. That’s a basic case.
But if when you drip it on the tooth, you think, I’m not really sure on this, it’s not looking fab, because you can still see the whole extent of the white lesion. You go back again, then you start again. So you do more micro abrasion so you can then you’ve got a few more abrasion options. You can sandblast with a MicroEtcher from Danville, you can sandblast it.
[Jaz]
How many microns? Because that’s the next question my Protruserati are thinking right now.
[Linda]
Honestly, you guys 30 or 50. I don’t think it really, maybe we’ll go on and on about.
[Jaz]
That’s what I think too, but that’s the next question that they’re going to be thinking.
[Linda] Our dentists just keep, you know, I know we anal, but this is like, it is what it is. Whatever it is. 30 or 50. It doesn’t matter guys. Don’t lose sleep over it. You know, whatever you’ve got, you will then. So you sandblast. So you go sandblast etch alcohol, and you do that up to seven times. If you have availability, micro abrasion paste, that is-
[Jaz]
Opaustre?
[Linda]
Opalustre™, and you’ve got 6% hydrochloric acid. Then I will micro abrade, so often I know it’s going to be a complex case, it’s a deep lesion. I go straight onto the micro abrasion before I do anything else because again, that roughens up the surface.
So you, if you go onto the advanced lesion, you can do only etch alcohol sandblast, sandblast etch alcohol, sandblast etch alcohol. Now, there is a new step, which I saw at the University of Paris. Professor Jean-Pierre Attal has taught his students to take a scalpel and where it’s really, really chalk. After you’ve etched it, you opening the lid again of the air bubble and you gently shave off the very opaque, like chalk you gently, gently so that you’re not using a handpiece unless you need to.
You gently shaving off some of that chalk dust and then you go back and you go etch alcohol, etch alcohol, and then you test it as you go along, but that way-
[Jaz]
Up to seven times.
[Linda]
Yes, up to seven times. But that way, you committed. If you start with your handpiece or your scalpel, you committed to a composite bond so often.
Actually, I would say like 80% of time, I would always add the composite bond onto the treatment plan anyway. If you don’t need to do it, you don’t, but you don’t want to do it as an excuse afterwards because, you know, so you just added on.
[Jaz]
You’ve answered one of my queries, and actually a question that I discussed with a dentist before is that when they’re communicating and they’re treatment planning for patients, the way I, and I’d love to know, I’m sure you got much better automated version than what I do, but essentially, I charge the patient or the parent or whatever for I will manage this white spot, how, I will manage it.
There’s a range of things that I might do. I will manage it. It may go up to removing some enamel and doing some composite at the end. It may stop short of that, but I will. So, because one lady dentist, she messages me saying is that, I don’t know how to charge this case. I don’t know how to communicate it because, I want to tell them, okay, it might be, it’ll be whitening.
And then it might be icon, but then if it’s a composite, I’m going to charge you this much more. And if it’s this much more I’m not, I’ll be like, don’t do that. Just charge it as a package and just do what you need to do. What are your thoughts on that?
[Linda]
I think that’s good, but often, so as we discussed, sometimes whitening does the trick honestly, in a 5% of the cases.
That’s it. So then you don’t have to have anything else, which, so that’s why I think you need to charge properly for the whitening and then the management of the white spot. And then you can go into the package, the resin infiltration or removing enamel and then with a composite bond. But if you know it’s going to be, then you were, if you know that there’s already a defect, you’re going to do it anyway.
So I like your idea. I think that’s great. That’s a very important to choose which composite you’re going to place over that. But coming back to the actual technique, you need to warn the patients that you may need to remove a little bit of the enamel. So that, yes, it’s minimal invasive. And the other thing, one of my students messaged me afterwards said, the tooth goes very flat.
It does go flat if you’re massaging and etching and all that, and sandblasting. And then again, you need to pre-warn the patient. The tooth number one may become more translucent because you’re taking off a tiny layer. So you see the little mamelons, you know, you see that little blue translucent area.
More often it goes more flat and it’s got a horrible taste during it. So even though it can feel rough at the back, and again with kids, you need to just warn them. So just coming back to the technique, so we’ve done the etching process. Then once you see, okay, the alcohol is really removed, I can see it’s working.
Then you go in with your infiltration. And the infiltration is done twice. So there’s two schools of thought. This is the classic thought is that you go in for three minutes. Again, if you’ve got six lesions, you place it on, it’s still the air bubble, it’s still porous. So to get, it just keeps being absorbed. So you keep replenishing as you massaging in for those three minutes, replenish, replenish, keep replenishing.
So you’re twisting and holding and massaging and checking. All that. Remember, really, really important, to floss through because the resin, it’s a clear resin. It’s called TEGDMA resin. It will adhere between the two teeth, and its difficult after it ends approximately. So you must floss through before you go. Then you will do your light. Your light, it’s 40 seconds, not a quick flash of 20 seconds.
So the way I do it, if I’m doing six lesions, is I will flash it across all of them just to get started for 20 seconds. Then I go back individually. And do 40 seconds each lesion as we are going along each lesion like that. Just checking. Again, some research says, but we don’t recommend it at the moment cause we need more research.
Why don’t you do it for longer? Why don’t you just etch for 11 minutes and place the resin for that amount of time? But there’s not enough research. Again, we go with Professor Jean-Pierre Attal, who’s done the research with these PhD students on it and published a lot. So you will do all your infiltration for three minutes.
It’s a long three minutes, and you keep going and going and going. Massaging, massaging, massage it, then floss through. Then you go back again. At that stage you can transilluminate and look and see what the resin has done the first line of resin. And then you go again with one minute. Et cetera, floss through.
Then you need to look and see how it’s looking and make sure there’s not too much excess. You know how resin is. The TEGDMA resin is quite flowy anyway, so just have a look and if you need to remove any excess, you take your soflex disc, not the black one, but like a medium blue, not the navy, the medium one, smooth over and use a rubber wheel.
And also those lovely composite polishing burs, the EVEs and the Astropols and all that purple and cream, you just polish. You just polish it up nicely. Remind your patients not to go and have anything with food staining. Immediately afterwards, one of my students sent me a photo where her patient made to have ramen 10 days later and the teeth became orange.
I think it’s because, number one, that maybe there’s a couple of things. Maybe the risen wasn’t cured enough, so you need to really do those 40 seconds of cure and then make sure it’s smooth enough so that it’s a nice labial contour is nice and smooth, not a big blob of resin.
[Jaz]
Hence why you use the polishers in a sequence to make sure it’s resin. So you are polishing the resin as you would do for a composite.
[Linda]
Like a composite. Yes. And then afterwards, in terms of maintenance, It’s a really good technique. What we also learned from working with it is that the resin keeps going. It keeps infiltrating. So just on the first occasion, you think, I’m not really sure if it’s fab, you go back again.
You know, that’s the end of the appointment. It’s been your hour. You’ve done this. You’ve gotten, you know, because between the photos and the consent and the explanation and the technique, it’s a good hour. A good hour means another 10 minutes as well. Anyway, and so after that you bring the patient back and you would review the patient about three weeks or a month later because one of the very first times I did this technique, I didn’t do any whitening for a patient who was about 64 years old.
I wasn’t even sure if could work. At the end, when I finished, I was like, this is not bad. When she came back, it was even more stunning, but it’ll completely eradicated. So it keeps working, which is why you say to the patient expectations, manage the expectations. The other thing is when you’ve got a rubber dam on, you’re going to get more white spots visible than within the first place.
So often on those kinds of cases, I will actually draw with a pencil the white spot, the extent of that white spot. It’s there. Because I don’t have to do that one, that one and that one because-
[Jaz]
That’s genius. I didn’t consider that before. That’s so clever.
[Linda]
Just, but you just write, you just kind of draw that and you work on that part of the tooth first. Then you rehab the patient, rebates come back and you review the situation. Now the next common question is, what happens if you’ve done the resin infiltration? Will the whitening work? And the answer is yes. So because the way whitening works, it works in multi directions the same way. This is a new hot topic. We can discuss it another time. Whitening and Invisalign, hot topic number three. Very, very hot.
[Jaz]
Mm-hmm.
[Linda]
And the same way when you’ve got the buttons on the teeth for the Invisalign, they think, well, don’t do the whitening now. Wait till the end. Absolutely not. After a few weeks, you get on and do it. And the whitening goes underneath, through the enamel, through that way from the pulp dentin into the enamel, it goes that direction. So it’s absolutely fine to do the whitening at a later stage if you want to rewrite it.
[Jaz]
That’s a real gem. And I didn’t even think of that question to ask you, but you’re, I’m so glad you covered it, that a lot of people are concerned that once they do the icon resin infiltration, that’s it.
They’re done, they can’t whiten. But you just answered that really well. And there’s a few other questions I have, but you know what? I’m going to save those for our hands-on session, so there’ll be lots of goodness there. So I think you’ve described the protocol beautifully, and you’ve also talked about about transillumination stuff.
What are the predictors of success and failure? Are there any cases that you see that you think, oh, this might not work so well. Or equally an opposite to that. Cases that come in and say, yes, this, I’m going to nail this. Because a lot of dentists, when they’re first starting out with this technique, they’re always like, oh, let me ask a mentor. Cause I’m really not sure.
[Linda]
Let’s just say there’s just one more thing. I just wanted to mention this.
[Jaz]
Sure.
[Linda]
In terms of the predictors, if you don’t infiltrate completely and when you finish the infiltration, at the end of the point or the end, the first resin, the first time you kind of do it, you go, ‘Hey, but there’s a white halo around this lesion.’
That means you haven’t completely infiltrated with resin properly. Okay? So at that stage, if there’s a halo effect, it means it’s not infiltrated deeply enough or correctly. So you need to then go back a step or two. You would take your black soflex disc, remove the resin, go back and sandblast and go back again so that you can go deeper with it. Otherwise, it’s incomplete infiltration. Even-
[Jaz]
So this is like a repeat icon resin infiltration. Like a few weeks after to fix a halo that because you know, you missed it, whatever. We’re human whatever. Yeah.
[Linda]
So, that can happen as well, just so that you know that you can go back and remove it. But it’s always, that’s why you can go up to seven times, you’ve got all this time to make sure that you completely infiltrated and the use of the scalpel to take the chalk dust off also helps you to go deeper. So.
[Jaz]
Amazing.
[Linda]
That’s good. And in terms of predictors of success, we spoke about the size of the lesion, the color of the lesion, and the opacity of the lesion.
Super duper opaque will probably need. Mega abrasion, which you might want to take a handpiece a little bit and take the lid off more of the air bubble so that you can go deeper with the resin. If you see that it’s not great, you go deeper again and you’re going to score art with a little round bur a little bit there.
So then it comes back to a really important thing, which composite do you use? Over the icon over the, because there’s a whole lot. And the recommendation from Professor Jean-Pierre Attal is not to use an enamel composite. Cause enamel composite is translucent and you’ve got a white lesion, opaque lesion. You would use a body composite.
So look for a, like a dentin composite that’s ultra white. So that’s why we do the whitening to blend in to the opaque, to blend the white to the surface around. So you want to do that and then you choose your composite. We would use a bleach to shade composite, but not a translucent. Always. There’s a Tokuyama, A1 body, which Jean-Pierre Attal uses.
There’s a brilliant composite from DMG where they’ve got a bleach shade composite, which is fabulous. There’s another one from SDI, which is called Bleach Shade. Bleach dentin, which blends over. So you need to, again, like you’re doing, you know if you’re going to do the technique. Now, what we didn’t discuss was that, you don’t, after you’ve done your resin infiltration and you’re going straight onto your next step composite, you don’t have to re-etch and you don’t have to rebond because you’ve used the TEGDMA bond. The TEGDMA is an unfold resin. You go straight on and you put the composite straight over and you scotch it.
[Jaz]
But you can cure though, right? You can cure it to see where you are or don’t even cure it. You put the concept over the uncured, TEGDMA.
[Linda]
No, no. So, you cure it and you do your three minutes of resin curing. But then you go straight with your composite. So before you even start the case, before you’ve even isolated, before the rubber dam, I’ll just put some cotton wools in and work on your composite shade. Just check your shade if you’re going to go on with a bond. Check your shade before you even start where that white lesion as is.
Look at enamel shades, look at body shades, look at dentin shades, and just choose which composite is going to be the one. Because there is a defect, you have to do it and then you go back. Cause otherwise it’s going to mess you up in terms of the color afterwards.
[Jaz]
Brilliant. I think that’s so many real world tips here, including the actual, that was a question I was going to say for the hands on. I was like, okay, which composite? And also how do I put the composite on? Do I use Universal Bond afterwards? But you’ve answered that brilliantly. We don’t need to do anything, we just add the composite on.
[Linda]
But you need to sculpt it nicely.
[Jaz]
Sure. I like to use like some of the brushes from cosmedent and whatever, just to get a nice blend. And then obviously the full polishing protocol, amazing. What is this common question again? What’s the expected longevity of this? So some dentists say, I’m a little bit concerned, do we have enough data or how it’s going to look like in five years and 10 years? What is the evidence suggest or clinical experience?
[Linda]
The research has shown that it’s predictable with the following discussions that we’ve had with all the different basic case, intermediate case, advanced case. Longevity, it doesn’t come back unless incomplete infiltration. In terms of stain, you know, some patient with poor oral hygiene, if you’ve done a beautiful composite bun, you get a black line or a brown line where the joint is, you don’t get that, but you may, which I’ve been doing it for the last nine years.
Now you make it like a tea stain, a very light tea stain over where the resin is, and all you do is just polish it with your rubber wheels and that’s that you don’t need to redo it. Don’t need to redo it. So that’s-
[Jaz]
Do we have, I imagine success rates are a difficult one to gather because every lesion is unique in terms of depth. So do we have enough sort of success rate data based on the how variable it is?
[Linda]
When I first learned the technique and saw teaching the technique, one of my students came up and said, no, it doesn’t work. But now we know there’s modifications. Every lesion is different. And they said, because MIH has got different chemicals, it doesn’t really work on MIH.
So we’ve modified the technique, and by modifying the technique, you get a much more predictability, and you’ve also got the predictability of doing a composite bond. So with all that, the success rate is high on it.
[Jaz]
Amazing. I mean, you’ve answered all my questions and now I’m really excited for this, this hands-on session, to do molars and anteriors for those who haven’t done it before. Are there any other messages that you want to pass on to dentists who are maybe learning about icon resin infiltration for the first time?
I feel like we’ve covered the assessment of the lesion, the actual clinical technique itself, and you’ve gone way well and above and beyond in terms of the nitty gritty details. Any other messages you want to pass on to dentist while you have the microphone?
[Linda]
I think that also from our point of view, the etiology, which is unusual that you’ve gotta ask patients or their parents their birth history. So you want to know, for example, were you born early? Were you on time? Were you late?
Because early preterm babies, they’re premature more likely to get white spots. Another interesting thing is celiac disease, for example, celiac disease also results in white spots, again, because there’s calcium absorption deficiencies, right? From an early age. So medical history is important, is relevant, and you want to show that you’re a caring practitioner and that’s really important.
But basically the technique is, you know, whitening resin infiltration, composite bond. But you still want to get a more understanding of the medical history because from our point of view, we also scientists as well as clinicians, and we also need an empathy factor that’s really a very important, the care factor.
A patient is a human being and so we need to modify, communicate really well. Expectations, pre-op assessments, paperwork, really key Jaz. You must have your paperwork, you must have explanations, and then you can build up your photo library. That’s why I created these books.
Again, it’s available if you want me to send for you to see. It’s nice as a clinician, when you starting, start on basic cases, start on an orthodontic demineralization case. You know, one tiny flick. Just get used to the technique. Also younger kids, the younger patients can be a little bit easier, just depends.
And then you build up a library of cases, in your experience so that you’ve got a whole library. And that’s why I show my patients this case looks like this little boy and we, for this little boy, we did X, Y, and Z. Yours looks like this. It’s not so severe. Then you can show them. Some of the severe, you know, because some patients are so distraught that they’ve just got a one tiny little white flick on the tooth that when they see other cases that is really much more severe than, it’s not so bad, but communication, paperwork, financial planning in terms of the costing, the signed consent form.
In terms of consent, patients always have to have a 24 hour cooling off period. All the risks and benefit all the options. And the whole beauty about resin infiltration is that the option is veneer or a crown, I mean it’s very severe. It’s like so minimal invasive. That’s why for me it’s like why wouldn’t you? If this is, if it would you do it for your daughter.
Absolutely. So, you know those kind of things, but you must explain the ramifications. Some dentists charge per arch for the whole lot or some dentist charge per tooth, whatever works for you. But sign the consent form, sign the financial arrangement. Make sure at your treatment planning discussion, a financial arrangement has been made with a parent and they understand the five different options in your practice of how you take care of fees, et cetera, so that it’s all run smoothly and that’s taken care of it. The admin’s taken care, and then you just go onto the cilinc.
[Jaz]
Amazing. Linda, thanks so much for, I know you’re such a busy woman, and I really appreciate your time and giving so much information. I’ll be in touch with yourself and Rachel to get find a date. We’ll do this. It’s going to be great to do a Zoom session.
I’m actually excited. I’ve done fair few anterior cases with great success with Icon Resin Infiltration, but I’ve never done a posterior and I’m actually really excited to learn that and be able to offer that to my patient, so we’ll be in touch guys. Stay tuned for that. Linda, thank you so much.
[Linda]
Thanks so much. Thanks, Jaz.
Jaz’s Outro:
Wow, there we had it. Was that absolutely mind blowing? This woman is just so full of knowledge and the little nuances that she covers is why she’s number one at what she does. Guys, I’m a huge fan of Linda Greenwall and so if you want to do some hands-on training, DM us on @protrusivedental on Instagram and let us know.
And so if there’s enough interest, I will get in touch with Linda and we will make it happen. Just like we made the Portugal trip happen, we can easily make this happen. Do you remember if you’re a Protrusive premium member, not only can you claim CPD for this full episode, which was full of educational gems, but you can also head to the Protrusive Vault to download the treatment guide with all our Protrusive masala.
Just like I said before, It is phenomenal. I hope you love it. I hope you use it. I hope you’ll be extremely practical. You should print it, laminate it, keep it the surgery so that you can successfully assess and treat any type of white patch. Thanks to that document. Listen, if you found this episode useful, do send it to a colleague and I look forward to catching you in the next episode. Thank you again.
