Finally, Some Clarity on Teeth Whitening for Under-18s with Linda Greenwall – PDP096

Jaz’ Introduction: Protruserati. I’m Jaz Gulati and I’m not going to waste any time in this introduction. I really want you to get into the heart of this episode. This episode will really get the fire in your belly going. This is such an inspirational episode by Linda Greenwall. If you don’t know Linda Greenwall, which you should do, you should know Linda Greenwall. She is the undisputed queen of teeth whitening. What she doesn’t know about teeth whitening is just not worth knowing. And it all stemmed from a discussion on our Facebook group, the Protrusive Dental community Facebook group, which is a thriving group of dentists who are passionate about dentistry. So it’s great to have you all on there. Now, Protruserati, what happened is that someone posted about teeth whitening in under 18s. Now there are cases where you may need to do this for example, fluorosis, MIH, these are things that we’ll actually touch on in the episode. And there are some strong opinions by dentists that I really respect, really careful, really admire on the group that actually you shouldn’t do teeth whitening on under 18 in the UK, where it is technically illegal, it’s technically illegal, right? It’s against the law, because some silly European directive. So this episode, I’m hoping will give you the confidence, if you’ve got a child who’s getting bullied and they’re 14 and you feel as though you’re at a loss and you have to have no choice but to cut the teeth or plaster composite all over them and whereas all what they might need is some whitening this episode will really give you so much clarity. And I’m happy to my hands up and say I whiten for under 18s when there is disease. Okay? And that should be very much part of your protocol as well. I’m hoping you will see that after this episode. Now, so just before we joined this very contentious issue, I’m gonna give you the Protrusive Dental pearl, one of the things I found the most annoying in my own cases in the past and sometimes occasionally, because I’ve changed equipment so I see this is lighting differences in before and after photos. And I sees on social media all the time before whitening and after whitening and after whitening, not only have the teeth whiten but it’s a different patient’s gums and the skin has gone like 17 different shades whiter. So it is an annoying thing to have before and afters were not just the teeth have changed, but the gum and the skin has also changed. Therefore, what you need to learn to do if you’re not doing already is use a manual flash settings instead of ETTL. Now usually ETTL is more convenient, it’s quick, it’s a quick and dry and good thing to do for daily practice. But when it comes to teeth whitening, that’s where I’m gonna switch to the manual flash. I know that when I’m using my Canon MR-14EX II , that when I’m taking a photo on manual flash, well, when it’s a 3:1 ratio of photo, I know that I think I’m on about one 1/5 flash power. And that gives me a good photo that I’m happy with. So once the teeth whitening course has finished again, I’m at 3:1, I’m using that manual flash setting again, and no other settings have changed. Your aperture size is the same, for me, it’s 22. Your ISO should be the same, for me, it’s 200. And the shutter speed, for me is 1/125. It could be slightly different for you that’s cool, whatever produces a good consistent image. So really, if nothing’s changed, the color of the teeth should be different because you’ve whitened, but the gums and the skin should be the same providing you’ve taken at the correct angle and been as consistent as possible on your site. And that’s how you get better before and after photos. Now if this is all confusing you and you get confused by photos, and you need a bit of help to get good quality, basic dental photos, then I’m starting a challenge. I’m starting a 21-day photography challenge. So every day, you will unlock one lecture, it’s like a five minute little thing just to show you from equipment decision and choosing equipment to actually how to take your first few snaps, how to get consistent occlusal photographs, what are the settings you need to choose. So over 21 days, you will watch video after video after video. And you should be able to take from something like this like telephone style photographs or lack of consistency and framings before to something that’s better, the kind of photos that you want to be taking for your photography. So if that sounds appealing to you, jump to protrusive.co.uk/challenge and then you’ll be able to pre register so when I launched that you’ll get the email and don’t worry it’s not like a expensive course or anything. It is something that’s going to be very affordable and very quickly get you some results without having to leave your home and some of you could actually watch in the practice every day, on your lunch break and that’s very much how I’m designing it 21 days of you at work watching short little videos to get consistent and good quality photographs including whitening photographs. Anyway, let’s join Linda for this phenomenal episode. I know you’re gonna love it and I’ll catch you in the outro

Main Interview:
[Jaz] Linda Greenwall, Welcome to the Protrusive Dental podcast. How are you?

[Linda]
I’m good thank you. Thanks for inviting me.

[Jaz]
I am so pumped today’s episode Linda like for those very few people who don’t know you like you know you are the undisputed queen of whitening there’s not even a king of whitening, you are just the single monarch of whitening, like even last night, in the middle of night I like woke up and I thought, oh my god, I’m seeing Linda and I haven’t whiten my teeth for two months. You know how like patients apologize at dentist for not brushing their teeth? That’s how I felt last last night. If you think of teeth whitening, you think of Linda Greenwall. So tell us a little bit about yourself. And how did that come to be? How did you single handedly come to dominate anything and everything teeth whitening in a good way? I mean, like, wow, what I’ve been to your lectures and stuff. You’re so passionate about it, you’re oozing so many brilliant about it. Tell us about your journey with that.

[Linda]
So thanks. The journey is that I was doing my master’s degree at Guys. And I needed to find a research topic. Right? I love to learn about contemporary controversial issues as right been right from the beginning, just by the way. And I was interested in this whole debate about mercury toxicity. And patients complaining that their fillings were toxic, and they were being poisoned. And they were losing their memories and all those things. And at the time, dentists were ripping out amalgams to place composite restorations, because that was in their best interest. And this every life was going to be healed. The lives were healed not only their dentistry, but their lives because their amalgam fillings were removed. So I asked to do this research study and I said spent six months researching this to discover, what is it? What’s the real truth? And what’s the science behind it? Where’s the evidence that these patients are seriously ill and get cancer because of their amalgam fillings? And I spent a long time doing this and my conclusions were in case you wanted to know, my conclusions were that those patients who were complaining about their amalgam fillings, it was a really big study in Sweden, really big. These patients who were complaining about amalgam fillings and toxicity etc. were unemployed, were unhappy with their lives. And you know, there were other issues associated with amalgam fillings. What we did find, and this is really relevant clinically to this day, but if you have an amalgam on a buccal surface, you can there’s much more chance that you can get lichen planus. So if you have lichen planus associated with amalgam filling, or let’s say, on a lower seven buccal, then that’s a reason to take it out. And so, and then, and I’ve found from that research they’re doing that actually makes a difference for lichen planus, and can clear it up. So that clinically that was relevant. And then I was about to do my research study where you had to do you know, long research study, and my professor whose name was B.G.N. Smith said, No Linda, we’re not going to do the study. Because we know what you’re going to find and so was I, So you mean? I’ve spent, six months of my life researching this topic, and he goes, No, find something else. So I went off to the library. And I saw this paper, I saw this photograph of on the front cover of Quintessence. So this isn’t, I was started my master’s in 1990-92. And the first publication on why thing as we know, it was in 1989. And I saw in Quintessence this photograph, upper teeth were white, and the lower teeth were yellow. And I go, what’s going on here? How can this be? And so I read the article. And I took the Quintessence publications to the professor. And I said, Please, I think I’d like to research this. He goes, Really? So I said, Yeah, I’d like to do that. And so I started one of the very early studies. And what we did is we spun blood into teeth, we [created a whole lot of wisdom teeth], we spun blood into the teeth, we discolor them artificially, I then section them. And then we tested all the whitening products that were available at that time, because I was very skeptical. And I didn’t actually think that it worked myself. I wasn’t so sure. And so we tested and we found and then we created our own shade guide. And we found actually, that it did make a significant difference. And then I had to put the teeth into saliva while we weren’t bleaching and then I had to photograph them. It was a very intense study, a very long study. And I just become a new mother with my first baby. And I was stuck on Mother’s Day in the lab at Guys on the Sunday, taking photos when I should have been at home with my little baby. And so I did regret that a little bit. But anyway, and so we conducted the research study, I got a master’s for the research study. I got a distinction, like an award for the I don’t know, but the thing was that I read every single study in 1990-92 to see if it was relevant. How does it affect, for everything was we knew nothing about the subject. So how does it affect glass ionomer cement? How does it affect our IRM? How does it affect amalgam? You know, all the [effect] on existing dental materials, and then I went into it. And then a few years later, I was approached by a publishing house to write to do a book on it. Like it will be so easy, Linda, just take a couple of photos. And that’s all it is. And you know, like, seriously? And then I had a few more kids along the way. And so the first publication came out of that one was a 2001.

[Jaz]
Wow. So quite a few years after your research project.

[Linda]
So that was three then it was actually three years, three babies later, actually. And then yeah, so we published it in 2001. And then had another baby the next year, four sons, but what we, first of all, writing a book is really intense, it means a lot of hours. I used to do it at 10 o’clock on a Saturday night, when the babies were sleeping. And then I’d go 10 till 2 and I could sleep late on a Sunday, because, you know, doing dentistry, you have to be highly focused, you know, can’t have a bad night with no sleep. So yeah. So then, in terms of looking at every single research study, and trying to understand I then went to the original researchers, like Van Haywood, and I messaged him, and we became very good friends. And he’s a really, really kind man. So your readers should go onto his website, which is vanhaywood.com. And you can download all his articles, he’s published on whitening, which is over 250. And by the way, go on to my website, which is lindagreenwall.com. And All my publications are there as well. So please, please look at that. And so he was very willing to share his knowledge. So I traveled to Chicago to the midwinter meeting to meet with him. And we’ve stayed friends ever since. And then all those people who published those early research studies, I contacted them all. And I connected with them, and I went to meet with them. So Elon Rothstein, who published on the effect of amalgam and whitening, so there’s another, there was a link there. And he also published on the drop in your bond strength, 20% reduction in bond strength after bleaching. So that’s relevant to the state. So I’ve traveled to Paris. He lives in Southern California. So I traveled to Paris to meet with him to quiz him and pick his brain and ask him all those questions to try and find. But at the same time, what was happening, Jaz, was that the academics in the UK were very skeptical. And they would like push it to the side. So it was like considered a sideline, and they didn’t want to get involved. And it’s almost to this day, that they think, Oh, well, it’s just cosmetic. So they don’t want to get involved. So that’s when you say, single handedly, I’d had to do that, because people were not willing to listen, because it was considered cosmetic, and so therefore trivial.

[Jaz]
They can just say even within the undergraduate scheme of things at Sheffield, I felt as though we were taught very little on teeth whitening, and actually remember being a DCT at Sheffield, and I seen this young lady for non vital bleaching of upper lateral incisor. So I did the re-RCT. I did the whitening of that lateral incisor. And then now this lateral incisor was a beautiful shade of a B1+ you know, like B0. But all the other teeth were obviously darkened. And then we had to discharge the patient because we didn’t do cosmetic procedures. How crazy is that, Linda? That I whitened this one tooth, because that was pathology. And I couldn’t then give her more bleach or more whitening job to do the rest. That for me was an eye awakening moment in 2014. That’s when I sort of discovered you and all the message that you sent. So listening to your story there. Firstly, kudos to you. Well done for grabbing these opportunities by the horns and going for it traveling to US and then France to make these things happen. You know, get the wheels in motion about this, and you’re just such an inspirational woman and your work ethic is just amazing.

[Linda]
Thank you. So in terms of controversies, because the academics didn’t want to listen, they therefore didn’t make it a serious subject in which you teach the subject. So now it’s bee, so that publications 1989. So now it’s like 32 years, where we have a body of evidence of scientific literature, of efficacy, of safety, of effectiveness, of, you know, impact and all those things and quality of life improvement. And you know, we’ve got all that evidence just from this one technique, the home bleaching technique, so you know, so you can’t ignore the research and the science. And what I find is that most dentists have actually never done a proper training on whitening. So yesterday we did a whole online training with ICON and whitening and it was training mainly the dentist in Scotland. And we went through and discussed all that. But most dentists, they make it up as they go along whitening. Nobody’s trained them, they just see what does the principal do, they don’t know. So they use the wrong concentration. And they just wing it.

[Jaz]
Can I share my experiences, Linda, with that? So as it as a DF one, I didn’t know how to whiten at that point at that stage. Because I wasn’t taught as an undergraduate. I didn’t know about tray designs, I didn’t know about which gel to use. And so the classic way is just like you suggested, I asked, my principal said, Hey, I think I need to go in some sort of whitening course. And he said to me, you don’t need to go on a course I just write your prescription and you know, just do it, it’s fine. And Linda, I had to learn the hard way. Like, you know, firstly, you learned the importance of medical legally to take photographs then had to take good photographs that are consistent before and after, then I went some of your lectures and I learned about the importance of motivating these patients, seeing them two weeks later, and see how they’re doing. So you gave me so many gems and tips and even things like which I’m happy to share with everyone something that you teach is if you have someone, you start teeth whitening, and you taught me that if they suddenly come back with severe pain, then that could be because there’s a non vital tooth in there. And then someone posted on Facebook around about four months ago saying, Hey, guys, I whiten these teeth and the show it with some intraoral photos. And then she’s complaining of severe pain from the lower incisor. And I said, Hey, Linda taught me that this could be non vital, take a PA. So then he took a PA and lo and behold, had apical infection. And that was all thanks to you. So these are the little fine details. And there’s so much more to it, obviously, that we miss out because we think that whitening is just this little procedure that is easy to do. You’re so right.

[Linda]
The thing is that on a patient’s journey, patients want to have whitening because they want the benefits of it and they want to look good. But on a patient’s journey, whitening is the beginning of the treatment plan. So therefore, and the legislation in the UK is very strict. It says, first treatment cycle, first examination to exclude pathology. And that means that every discolored tooth needs periapical radiograph for exactly what you’re describing. Because even though there’s a tiny color difference between two central incisors that could have had a cosmic metamorphosis or something, but there are other things that go on. And you know, dentists, there’s a whole debate another controversial issue, should you be taking radiographs? And I saw a whole debate on Facebook where the American dentists take radiographs, post cleaning, to check for palque. [Jaz] Post cementation of crown [Linda] Post cementation, and almost again we don’t, but preoperatively when you, you need to know what you’re dealing with on a new patient. So yes, it’s my experience that I’m a prosthodontist training. And so we take periapical radiographs on new patients on all the teeth. If we don’t then take again, that they may know what we’re dealing with, because whitening becomes the first part of the treatment plan. Then, as you know, 85% of patients opt for further aesthetic or necessary or restorative because they’re motivated from that. So you need a baseline on which to start. And we also teach that most dentist because they think it’s trivial. They don’t do comprehensive treatment planning. And so to do comprehensive treatment planning, it means the patient has to be away, patient goes away, you have the data, you have the X rays, the notes, the photos, the microscopic, I take the little intraoral microscopic photos, and I sit at my desk and I do you can’t see what it just here. But I’ve had three screens, I have that at home now I’ve installed that since lockdown, where things were like chaos at home. We’ve installed three screens. So on one screen, I have my patient photos. On the next screen, I have the X rays, and I have clinical notes on the third screen. And I sit and I dedicate time every week to just doing treatment planning because then when you’ve got clear time, you know we are so busy as dentist and we doing a lot of diagnosis on the go every three seconds when the patient comes in to diagnose etc. Medics don’t do that you have to wait for hours in the hospital to get your X ray to find out what the story is, you know, we just making instant decisions. But when we talk about a new patient who has hopes and aspirations, we need clear thinking time where nobody disturbs us and we can look at those x rays and see what we need to see and work out a clear defined comprehensive treatment planning. And in terms of dentists, if more dentists would do that take an hour out of their day. They’re not doing dentistry, but planning treatment, things would be much easier, you do better dentistry, comprehensive dentistry, your patients appreciate the value of that more and you get you know, you get to enjoy doing your dentistry because you get to do the dentistry that you love.

[Jaz]
I love everything about that and it reminded me very much if I think about episode 48 we had Zak Kara and what you described there about you know we are diagnosing on the spot and then we are splurging these treatments on the spot without giving it much thought unlike our medical colleagues and that’s what Zak termed as a shotgun treatment planning so we need to move away from that and move towards comprehensive dentistry. Linda, thanks so much for that amazing inspirational introduction. I feel like I know you a lot better now as well. I’ve been to so many lectures, but I really liked that insight you gave. This episode is about a very controversial topic. Now there are so many controversies in whitening and maybe at the end, I might just ask you about how we’re going to combat all these beauticians and non dentist doing whitening, maybe you can say that might be a whole another episode. But this episode is about the contentious issue of whitening under 18s. Now, the reason this came about Linda, the reason reason I reached out to you as the authority in my opinion for this is I have had experience in the past where like many dentists, you see a child that’s being bullied at school, maybe 12, 13, 14 I just find it ludicrous that nothing can stop me from placing composite veneers or ceramic veneers or whatever. But I can’t do whitening because

[Linda]
or cutting them down

[Jaz]
Or cutting them down or doing something additive, which you still know when you know that you will get a predictable and good result with teeth whitening. So I will put my hand up and I say I do illegal teeth whitening. So I do it. Okay? Because technically, I’m breaking the law because under 18. But in my eyes, I think the patient’s best interest and the moral interest patient is beyond that of some silly honestly, I think it’s a silly law. Personally, I’d love to hear your opinions on it. Now I do take it very slowly. So the child has to be you know, bullied or has to be bad enough. If it’s really mild, a couple of white spots, I’ll wait till 18 just because practicing defensive dentistry, but I’m happy to whiten for a you know, 12, 13, 14, 15 year old in the right cases, if they’re being bullied, if it was my own child, I would. However, when I posted this on the Protrusive Dental Community Facebook group, some dentists I really love and respect, they were like, I don’t care, don’t do it, you’re going to get into trouble because the law, if something happens, then you’re breaking the law. And this is illegal. So then this is open a can of worms. So my first question to you, Linda, is how have we ended up in this situation? How what’s the Genesis and a couple of minutes in terms of how do we end up in a situation where we could do this whitening treatment before and now we can’t or supposedly we can’t, in a quotation, we’ll come on to what you actually recommend.

[Linda]
So here’s the story. The story is that we’ve been lobbying, you know, we used to be in Europe. So we used to comply with European legislation. And the story is that we lobbied for change, because before that the law was even more draconian, where it says all tooth whitening was illegal and you couldn’t do it. You couldn’t use more than 0.1% and you’d be locked up in jail for six months if you did whitening. That was until 2011. And in 2011, they made changes to the law, which came out in 2012. So we lobbied in Europe for changes and I went to Europe to meet with the European Council of Dentists, you see, I do travel to meet and to make, you know to make these decisions. So we went, we arrived in Brussels.

[Jaz]
Linda, I’m so sorry had to stop you, I’m just going to ask because it’s playing our mind now, that context of we couldn’t use more than 0.1% that specifically for under 18, right?

[Linda]
This was for all of UK.

[Jaz]
So you’re telling me that any dentist who had whiten before 2011, technically was breaking the law? [Linda] Yeah. [Jaz] That’s hilarious.

[Linda]
I know. So that’s why, in 2008, we established the British Dental Bleaching Society. I was lecturing one day. And so Paul Barrett’s furred who’s a dentist and an MP. He said, Linda, I understand your South African accent, don’t worry, and I understand your humor not everybody understands your humor. But I get the message that you’re trying to explain. And that is that we need to make some change in the UK law, we do need to make changes, this is wrong. So we established the British Dental Bleaching Society with the basis of educating dentists in competency and clinical skills in whitening and also in trying to explain, create awareness of the situation will things can be changed. And so then there was also controversy. The other controversy was that there was, Do you remember when we shut down the whole of the UK was shut down for bleach? There was a patient complaint and the patient complaint was given this is before the sub. Over the counter, she was given 10% Hydrogen Peroxide as a take home, which damaged her clothes. And she wanted compensation for her clothes for the damage that the bleach had on her clothes. And then the dentist asked another controversy, the dentist said Well, let me see your clothes a bit [like long and Monica Lewinsky] but like let’s see that evidence. And then instead of just saying, Sure, settle. What happened it went to the Trading Standards. And so the Trading Standards took this matter up and actually managed to shut down all the supplies of whitening.

[Jaz]
I had no idea. When was this?

[Linda]
This was about just before that also. And that was another controversy. But coming back to the under the 18 win, so when they change the law, there’s two really good studies to look at. It’s called that SCCNFP. If you Google SCCNFP, hydrogen peroxide,

[Jaz]
I will put these links on the on the show notes, Linda, so I’ll put it all there for everyone.

[Linda]
Thank you. SCCNFP, 2008 and 2005. They did a comprehensive study of hydrogen peroxide. And they looked at how toxic was hydrogen peroxide if a baby should get hold of a bottle of hydrogen peroxide and drink it, how toxic would it be? And so they gathered evidence for hydrogen peroxide to check the safety. Because there’s always a question on safety, which shouldn’t be, it shouldn’t be. And so these particular papers were commissioned by the European Council of dentists to be able to present this evidence it as we said, the law was changed in 2012. And that we comply with that. So this is nearly 10 years, but because of safety and lobbying from other countries in Europe, and they thought, well, let’s just only have it available to adults. There was no reason to not permit, I’ll just go slowly on this. There was no reason to not permit under 18. The European Council at the time said We don’t know. And we haven’t seen enough evidence, not that we don’t think it’s safe. And so we presented a lot of evidence. So then we went back, the UK commission to Europe and that included Kathy Holly, Dr. Kathy Holly, who’s a pediatrician consultant, pediatric dentist, myself, Paddy Fleming, and Paddy Fleming was head of the European Association of Pediatric dentists. The reason I’m telling you this is that Paddy Fleming said, it’s against a child’s human rights to deny them the right to health. So you cannot do this in the UK, deny these children the right to tooth whitening, because it’s in the UN Charter. So you know, stop all this nonsense. Every single child has a basic human right, which is the right to health.

[Jaz]
Amazing.

[Linda]
Okay? So that’s why, all this chitter chatter and all this, you know, nonsense, in the end of the day, every child has a right to health, and that includes mental well being and includes the whitening. So we’ve got actually no leg to stand on. And all this fuss is actually puts it into perspective, when it’s the human rights of a child under 18, to have the right to health.

[Jaz]
So it’s safe to say that, Linda, your own opinions and views and what you practice is that as long as there is a case to improve, some a child’s health that you will advocate, teach and do yourself teeth whitening on under 18s, is that fair to say?

[Linda]
Correct. But also, the General Dental Council were very clear in the direction. And they said, if this treatment of disease for under 18s, then it’s appropriate to treat for whitening. And so we’ve produced a paper with Kathy Holly, my son Joseph Greenwall Cohen and Van Haywood and underlying the 10 reasons why it’s appropriate and when it’s appropriate to treat under 18 children, not just because they’re going to the school prom and they want to look super stunning or be a love Island contestant. It’s because they want to, they are suffering because they’ve been teased at school. So what’s happened is that there is a now a you know, we in COVID at the moment, but there’s a bigger pandemic, which is the problems with MIH, Molar Incisor Hypomineralization. It’s one in eight, children’s teeth erupting have white spots, white marks and discolorations on teeth. You know, we never used to be like that 20 years ago, we were dealing with a little bit of fluorosis but now we’re dealing with a major pandemic, a global pandemic of MIH

[Jaz]
I certainly see it loads, Linda and actually we have it very international audience here we have dentist from Canada, part of Taiwan, all over the world. Now, when I was doing my elective in Vietnam, I was with a group of Canadian dentists and they were, you know, 25 years my senior at that point, they were celebrating 25 years out of dental school at that point. And when I told them about MHI, so I was this back in 2011, I recently learned about it, I was documenting it, they had no idea and a lot of my international colleagues had never heard about MHI. So it just if you spend a minute just telling dentists, who maybe our international audience, I feel like in the UK, we have a better grip on this, but what is MIH?

[Linda]
It stands for Molar Incisor Hypomineralization. And the reason that we have this is that there’s basically there’s 100 reasons why. So anything that occurs when the cell is developing , the tooth cell, the enamel cell. The tooth cell is developing in utero, Anytime there’s oxygen starvation, there is likely to be a defect and white spot, but also, this affects the enamel, the dentin and erupting tooth occurs at the time when the sixes are developing, and the central incisor tips. And so anything prenatally, perinatally or postnatally, anything that happens, mother is ill, mother is exposed to antibiotics, mother has a hospital admission, the baby, this affects the baby. And so anytime oxygen is starved from this in that developing enamel cell, the ameloblast will result possibly in wide spots. For example, twins, twins are more likely to get it premature birth you likely to get it anytime any antibiotic is administered and any childhood fever and illness. Those are the basics. Celiac disease, for example, Vitamin D deficiency, all those times is when something affects, so there’s a medical situation that affects the baby or the mother, and the baby’s teeth are born with it. We live I think, we live in a more toxic society, more polluted society. So there was a story in Sweden which was reported there was dioxin in the rivers in Sweden, and they found dioxin in the breast milk of these babies, and the babies were developing later on, they were developing these white spots on teeth. So it’s hypomineralization, the enamel is not forming properly. And it can result in white marks, brown marks, yellow marks, a breakdown when the tooth post eruptive break down. But the main thing is that there’s a wide variety, from minimal to extreme. And extreme cases, the children are so sensitive, they call them cheese like molars, the child is holding their hand in front of their mouth because when they breathe in, it’s so sensitive. They’re not faking it. We think it’s overdramatic, but they’re not faking it, they have super sensitive teeth, the teeth have post eruptive break down, they just like cheese peeling off. And extreme cases, those children at age nine have to have the molar teeth extracted, because they’re in so much pain,

[Jaz]
Very classically difficult to numb up and also misdiagnosed as caries. And the whole spiel about you know, diet advice, and that’s wrongly directed to that child who just had a genuine, you know, Oh, does my child have weak teeth? Like no, they don’t. But in this case, this child generally did have weaken teeth in those more moderate severe cases.

[Linda]
Absolutely. There’s, again, there’s a really good Facebook site, an MIH Facebook site, which publishes articles, research that any publication related to MIH, which is really nice is shared on that site. And there’s a really good website, which is called thed3group.org. That’s for patients, for clinicians, for academics, for researchers, all about MIH, and the causes, and how to distinguish, for example, between fluorosis and MIH. So to understand that, so these children is a one in eight of the UK children, let’s say have MIH. So therefore, you can’t, from a mild point of view, the treatment is whitening from the mildest point of view. From the major point of view, it’s restorative. So it’s combination with restorative and anesthetic, but you know, you have to do early intervention, and you can’t do normal seals on the children, you have to do glass ionomer. And treat as soon as that you see this post eruptive break down. Don’t leave it, you know, so we that’s what our conference was on Friday, all about treating these kids with that. And so what happens is that enamel is so weak and poorest that soon after eruption, the teeth become brown because they’re absorbing all the food. And this is when the children are teased at school walking around with brown teeth. So I see this kids. And what we are doing with permission from the mothers is we record the child’s story. And we record the mother’s story. Because sometimes at the end of treatment, the mothers cry and it’s not because of the fees associated with the treatment. It’s because of the impact on the child that what we did is we took them on the journey for wiping and microabrasion and resin infiltration, but we sorted it out so simply. And that’s all it takes for the child to feel good about themselves. And most of the biggest impact is the children in your six when they’re just finishing junior school and going into high school. They’ve had already many years of being bullied and often we treat these kids when so just before the end of junior school, those that last term, we get these seeds sorted so they can go into junior school and say Wow, look at my teeth now and stop the bullying. So when they move into high school, that is not an issue for them.

[Jaz]
What’s the lower limit in terms of age, Linda in terms of, can now we’ve gotten past the fact that okay, even though this silly law says it’s illegal, whoever, we’re, you know, when there is a health issue, and it falls in the category and you can improve a child’s mental health, and you’ve accepted that, what is the the lower age limit for whitening that you would suggest?

[Linda]
About 11 or 12? There’s no. So again, I consulted my mentor Van Haywood, to ask him what is the lower limit, there is actually no lower limit, because it’s perfectly safe. So Jaz, I just want to tell you that the person who’s done the most research on whitening for kids, his name is Kevin Donly and Kevin Donly’s in the US, he’s a pediatric dentist. So in 2019, we brought him over to the UK to present at our conference saving kids teeth. And he presented his evidence and research to show that it’s perfectly safe. So the law, it’s a matter of classification and clarification. It’s not because it’s not safe, because from his research and other research, just because the child has a large pulp doesn’t necessarily mean they’re going to be sensitive. Actually, it’s the other way round, it actually helps to clear out the whitening gel through the pulp. And actually, that’s an advantage. So there’s no question on safety. There’s another researcher whose name is Yiming Li, at the University of Loma Linda. So his life’s work, his last 30 years, they’ve been dedicated and devoted to safety of whitening. And again, all of them categorically have looked at this. It’s not a safety issue. So now we’re going back to it. Okay, what can we do to change the law? You have to go back and we’ve met with, we’ve consulted with many people, and we come back to the same argument about is it safe? But we know the law was only a matter of admin. That they said, Okay, well, let’s just not allow it, there was no reason for it. So when you try, I’ve been lobbying for this for a long time, like 10 years, lobbying the people say, Okay, now we’re not in Europe anymore. So we don’t have to listen to the European legislation. Let’s just make our own rules. Let’s just do this, and what is it going to take to change the rules? And so we’ve been consulting to see and can we do this? And can we do this? And then we have to consult with the chief dental officers of the United Kingdom. Now, as you know, during COVID, they’ve got a lot of other issues. So tooth whitening to them is trivial, because they’re solving other world problems in oral health and oral health inequalities. But to that child is being bullied at school, that is not a trivial situation. So we are consulting with psychologists to be able to look at this to measure the impact of, it’s basically measuring the impact of appearance on a child who’s suffering because they’ve been bullied from their appearance, to be able to present that evidence. We should not even have to present the scientific story that we are, we busy collating for the Royal College now, a whole new document. So just to rewind a little bit, we in Europe, we presented a document to the European Commission of dental CED. And it was really well done with all the evidence in the literature. And they sort of said, Oh, but it’s only 66 pages, not 100. And we’re like, seriously? And so and when we got there, the Belgians are a little bit concerned, they were like, So what’s gonna happen? I said, Don’t worry, nothing’s gonna happen. It’s all gonna be fine. And then the next minute, we were out of Europe, and it was a whole show, but the other European countries are not listening. They don’t follow the whitening that, you know, we are so strict. And so then when we presented our paper on the under 18, when all here are the 10 categories, this is when you can do it, just go ahead and do it and do what’s in the child’s best interest because these child’s are being impacted.

[Jaz]
Linda, can I can I share that paper with the Protruserati? Can I put that in the show notes? Yeah, thanks so much. Brilliant.

[Linda]
Yeah, it’s on my website for download. But absolutely, I’ll give you that paper. But actually, it’s really important that everybody knows that they can go ahead and do this whitening without being worried. In my textbook, which was published by second edition 2017. It took me another 17 years because I had another baby started a practice and started a charity, you know, all that stuff. And so I wrote an impact report an index of treatment need for whitening, you know how we have an index of treatment need for orthodontics. I’d wrote an impact index of treatment need for bleaching into five categories, which is that you know, which is the most severe if, for example, if the child is impacted, you know, and they’re suffering then absolutely, that’s the right all different categories are you know, How much stain? What’s the situation? Is their sensitivity etc. If the mother is impacted, but not the child, it doesn’t really need to be done because the child isn’t, you know, so these are a whole lot of scenarios, but I wrote that up because I had to give it clear thought as to when is the best time for undertaking the treatment for the children. So that is, in my opinion, but age 15, you know, your teenage years are really stressful, I feel sorry for these kids. So there’s 11, 12, 13, then 15, they become even more body conscious, at 15. And then they, and then again, they wanted and at 17 is just before the end of high school. At all ages, is when it’s appropriate if their child is being impacted. And if all you need to do is change those brown marks to white or to, you know, to sort this out through whitening microabrasion and whitening microabrasion, resin infiltration and bonding, minimally invasive, that is the best option for patients. So then we took this evidence to the medical defense union and spoke to them and said, Okay, here’s the story. You know, we need to change, you know, in terms of how you’re going to cover for indemnity, how are you going to cover the dentist in the UK? Here’s the information, here’s the stuff. And they go, I can’t see a reason why you can do whitening, there can be no legal reason for doing whitening. And we said absolutely not. That’s really, that’s not the case. So we are still in debate. And I’ve disgusted with other medical defense organizations to explain this is in the child’s best interest. This needs to be done. You can’t leave the child for six years. Now. I’ll just take it personally, my child was born with a hemangioma, my fourth child was born with a hemangioma on his face. And it grew and grew to the size of a little cherry tomato. And I was sitting in a lecture at the ADA conference when the child was 2, listening to the impact of these children’s suffering from they used to call them FLKs, they’re not allowed to call them FLK, that called funny looking kid. You’re not allowed to say that anymore. But they were suffering from the appearance. And I thought wait a minute, my own child is sitting with a strawberry, cherry, a hemangioma on his face and look when I’m doing to him. And somebody stopped me in the street and said, you know, you can get treatment for this. So again, I went to the UK dentists, UK surgeons and nobody would operate and we had to fly to Germany. And the child could have this hemangioma removed. In age 2, his whole personality changed, because that hemangioma was removed from his face. And to this day, he weren’t eat strawberries or cherries, because of this experience. He’s now going to be 19 next week. But when it came to his teeth, he had trauma to his teeth. We you know, I repaired them. I whiten them, you know, it’s a very important, their appearance. And, you know, we’ve done whitening for him, of course we have to you know, to help him. But so it’s a personal story as well. When I realized from these children, they’re not impacted. It’s the right thing to do. And we need to act in the child’s best interest. When it comes to a complaint, it’s not only the clinical dentistry, its notes, its communication. There’s all other aspects which all medical defense organizations, protection societies, that’s what they cover. It’s not only the clinical dentistry, because that’s a tiny part of it. So I think we blowing it out of proportion. And everybody gets very, what’s the word? They all got these opinions, but they’re not listening to the science and the research and the evidence.

[Jaz]
Dentists are very afraid, Linda, because they’re worried about backlash. They’re worried about going against what the authority is telling us, they’re worried about will if something happens if the proverbial hits the fan, will my defense society back me up? What I really want to know is do you think a dentist could get in trouble with the law by carrying out whitening in under 18s?

[Linda]
No.

[Jaz]
Good. That’s exactly what I was hoping.

[Linda]
No. But as a dentist, I’ve had to do a lot of medical legal write ups for you know, as an expert witness, but when we learn about what can go wrong, you need to practice good dentistry, it comes back to the basics of professionalism at all times. It’s always about professionalism, about doing the right thing of making contemporaneous notes and asking the patient what’s you know, what would be your hopes and aspirations? I asked the child what would you like to happen? What would be your hopes and ask the mother and then we, I do ask a child, Are you being teased at school? Are you being bullied? Is anyone saying nasty comments about your teeth? I’m not a psychologist, so we can’t go into the psychology but I do ask them directly to get the impact, Is this impacting you? And based on all that, will absolutely do the treatment and as the treatment progresses, after we whiten you know when we break down the whitening, the protocol is that whiten for the upper first, but as long as you take the patient through the journey, and you see how their self esteem is building up, because those yellow marks are now removed after two weeks, how they life has changed. I mean, we don’t say anything, but you see it in themselves, the kid feels better about themselves, they got more confidence. Some of them wear the white t shirt, because it’s white teeth and the white t shirt. And you know, they’re starting to feel better about themselves and all, you know, the child needs right to dignity and respect. And that’s all it takes then absolutely.

[Jaz]
Are there any changes or modifications to your protocols that we into for teeth whitening in general, that because of the age, so let’s say you’ve got a 14, 15 year old, they have a brown appearance of the teeth, because maybe potentially MIH, and we’re starting some teeth whitening, because we don’t want to let them suffer mentally. And we don’t want to hack these teeth down or add any compensate and it’s the right thing to do. So that’s exactly what we do the basis of what we’ve discussed so far. But in terms of your protocol, is there any unique considerations for this age group, that might change your usual protocol?

[Linda]
I think that one mistake that most dentists make internationally, is they use too high of concentration of bleach. In the US and Canada, they go straight for the highest strength. And the rule is that the higher the concentration of gel, the more the sensitivity, okay? And so and then the more the child if it’s too sensitive, then there’s likely to stop treatment or terminate treatment. So we go, as we’ve always done low and slow, low concentration, whitening over a period of time. And most dentists and I talked to many dentists about whitening all the time, they go for the highest strength first to go, Oh, let’s be quick. And if it’s too quick, then you get regression of the shade. So by building it up low and slow, appetit first for two weeks, then you review, look at the canines see what shade they are. Then you go into the lower, the lower is longer, the lower’s more sensitive, and so the app is quicker and no sensitivity or less sensitivity. You take them on this journey of confidence building, value building and trust in the dentist as the patient is going. Wow. And you get the improved appearance in the oral health. Let’s come back. I just wanted to tell you one, a couple more things. [Jaz] Yes, please. [Linda] Carbamide peroxide is used in neonates, in eyedrops and ear drops. In 1968, the orthodontist whose name is Bill Classmen, in North Carolina, did a report of him using this technique in the children’s retainers for 40 years and reported that, you know nobody, there was no breakdown, there was no need for you know, no one needed a root canal, broke a tooth, you know, as a result of this technique. So it’s been around a long time. So when you turn it all around, and it’s not about aesthetics, it’s about health, Hydrogen Peroxide heals the gingiva. It heals, it stops the swelling, and stops the retention of plaque, it heals root decay, heals tooth decay. The carbamide peroxide elevates the pH, and elevates because it contains urea. So all this is about health. So when you start with before anything else, as dentists, we are oral health healers, and we always wanting our patients to have oral health sustainability, improving, their oral health is improving, and it’s about oral health, and hydrogen peroxide is about oral health. So, you use these products, so often on patients we use whitening for the purpose of healing the mouth. So, we use the whitening gel, so we make a bleaching tray. Then instead of giving the, instead of giving 10% Carbamide peroxide, we used 5% Carbamide peroxide. 5% Carbamide peroxide is known as NOVON® mild. NOVON® mild is from Optident, that’s lower strength for healing the gingiva. Elderly patient as well poor oral hygiene, arthritis, they can’t brush, they can’t hold the toothbrush, root decay, you clean up the mouth by using carbamide peroxide in a bleaching tray. So when it comes back to it, these children have been, the treatment has been done on children for healing the gingiva post ortho. So it comes back to health again, it’s always about health for these kids. And just by the way, for those kids during ortho. Do you know you see your kids if their kids come back off to ortho and their teeth are a little bit more yellow or orange or brown? Post ortho? There’s a reason for it. The reason is that as you having the braces put on this microbleeds that occur in the bone from on the ligament, there’s micro bleeding and that bleeding causes the discoloration post ortho that you see,

[Jaz]
I did not know that. There we are. I’m sure a lot of listeners learn something then notes so much on this episode. We’ve got a couple minutes left and I want to ask you this final question for I just open the mic to you to you know, your passionate plea is in so infectious, or we definitely need to do something to reset everything actually make everything right. But the question I had was communication one, when you have a child who is potentially being bullied, and you’re considering teeth whitening, is there anything you say to the mother and the child to say that Actually, here’s what I’m suggesting. Technically, if you Google it, it might say it’s illegal. But I think I’m passionate about this because x, y, and z, or do you think we don’t need to go in that direction? I personally do say, technically, it’s illegal, but I’d rather do that, then cut your teeth down, or add composite or this, and I have that spiel, what do you do? And what do you recommend?

[Linda]
After I’ve understood again, this is Stephen Covey, it always says, first seek to understand. So after we understand from the child, what it is that’s worrying them about it? So I mean, we’ve treated children who need major ortho and the teeth are all sticking out like that. But actually, it’s the color that’s really impacting them. So I asked them what it is that you would like? And then we discuss and I say to the mother, that it’s their child human rights, it’s their right have the right to health. I don’t, do you realize I could be locked up in jail for doing this? Because it’s what is in the patient’s best interest? And, you know, it’s all about the patient with proper notes, with proper photos, with explaining that the law says in the UK that there’s no whitening for under 18 inless it’s a disease. So that’s how I tell it. I said, we can do this. If there’s a disease process under 18, we can do that, your child has MIH, amelogenesis imperfecta, stain from the medication, white spots, brown spots, trauma, then this is the right thing to do. Often, I mean, if it Yeah, so that’s how we handle that. The mother, I’ve explained to the mother why we’re doing it, I’ve given the diagnosis, I’ve given the options for treatment, do nothing, observe, monitor, composite bonding, whitening, ICON microabrasion, I’ve given the whole range. And then again, if it’s an MHI patient, treating restoratively first, take them out of pain, and then take them on the journey.

[Jaz]
Amazing. That covers it really well. So that’s one of the other things that people are asking on our Protrusive Dental Community Facebook group. Okay, how do you even communicate this once we actually go over the fact that a lot of dentists are passionate that we shouldn’t be doing this in under 18s and these are the Dentists that I respect and I love so I’m so glad to share the opinion and advice of someone who I respect so much in their arms a teeth whitening. Linda, you’ve absolutely given so much value in this episode, I want everyone to check out your website, please tell us your website again, any courses that you put on because I think everyone who hasn’t done a whitening course and is not getting great results and you need to follow some of your techniques and pearls. I would love for them to join you on that. So if you just please tell us about that.

[Linda]
Thank you very much. We do a lot of online hands on treatment by the way that I’m training because of COVID. So you can do it wherever you are, and do the hands on with ICON and resin infiltration, etc. The websites, also my Facebook please look at Greenwall Dental, Greenwall Dental Education, Dental Wellness Trust for my charity, and lindagreenwall.com. Go to resources, all my publications are there, the list of courses and events and look at our study groups, and all that it’s all online, all the information.

[Jaz]
I’m going to link that all in the show notes. So do click on and check Linda’s work out, please support what she does, because she is you know, doing so much by profession in terms of making teeth whitening, where it should be. And I applaud you and I encourage you, Linda, keep fighting the good fight. We need people like you to do that. And thank you so much for making time to come on the Protrusive Dental Podcast. I’ve really enjoyed it.

[Linda]
Thanks so much. Thank you.

Jaz’ Outro: Well, there we have it. Hope you enjoyed that episode with Linda, I told you it was something special. And I hope you like how we covered this very controversial subject. You know, I’m no stranger to controversy. You kind of have to have thick skin and be able to deal with controversy if you’re putting yourself out there like I do with the podcast. I’m totally cool with that. But it’s all about sharing different views. And I’m definitely on Linda’s side here. Like if I have a young patient who’s getting bullied for their health, it’d be a wrong thing to deny their human right of it. So teeth whitening may be part of that. So I’m all for it. I hope you are now as well. And if you’re not that’s totally cool. You do what feels right to you. Now if you’d like Linda do check out her website. All the information you need is on the show notes on the Protrusive website, including the wonderful charity work that she does, please do show her your full support. So I’ll catch you in the next episode guys. Thank you