Protrusive Dental Podcast

Teaser:
Because I think a lot of dentists are afraid of doing that because they’re afraid of not being able to adequately bleach the cervical area.

So here’s another point. You can’t adequately bleach the cervical area. It’s never going to be the same shade. And that’s a myth- The last two millimeters of the bleaching tray. So that actually tray is not rubbing on the cervical area. And they found it improved sensitivity and made no difference to the whitening effect whatsoever. So you can do that.

Jaz’s Introduction:
Protruserati, this just might be the most actionable and impactful piece of content you’ll ever consume on the topic of teeth whitening sensitivity to really help our patients to whiten better without having the horrible side effect of teeth sensitivity.

I don’t know about you, but for some patients it can be so bad that after about three days they don’t whiten ever again. And you have to have that awkward conversation with the patient. But now, following Dr. Linda Greenwald’s protocols, We can eliminate teeth sensitivity. Like, we could have spoken for like hours and hours and hours.

But what we did bring together in this episode is like the top things. Think of the Pareto Principle. I’m a big fan of the Pareto Principle. This principle suggests that 80 percent of your benefits or your rewards or effect happens from 20 percent of the contributions or inputs. So for example, 80 percent of your sensitivity reduction will happen from the 20 percent of the little tweaks and the changes you make in your whitening protocols. Let’s focus on those 20 percent of the protocols that are going to make an 80 percent reduction in your sensitivity, and for some patients, a 100 percent reduction.

Hello, Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Because there are so many actionable gems and protocols and so much goodness in this episode, we’ve created a famous Protrusive Infographic.

If you’d like to download this infographic, for free, head over to protrusive. app. If you’re already part of our community, you will see this infographic everywhere where we post this episode. But if you haven’t joined yet, what are you waiting for? It is the community of the nicest and geekiest dentists in the world.

So the platform is called Protrusive Guidance, and the easiest way to make a free account is www. protrusive. app. And once you’ve made an account, you can download it on iOS or Android. When you click on this episode, you’ll be able to download the infographic. You can laminate it. You can do what you want, but all the goodness is there because sometimes like me, if you listen to podcasts, when you’re driving to actually action on some things to actually have like an aid memoir, a good revision source, we already have the premium notes, which are also downloadable for paid members, as well as claiming the CE credit or the CPD hours.

Dental Pearl
But as part of the gift from this episode, the pearl for this episode, you can freely download our infographic. Now, I appreciate it may sound a little bit attractive to you now, but wait till you get to the end of this episode. You will definitely want this infographic. So don’t forget, protrusive.app. I’ll see you on Protrusive Guidance. I’m not going to waste a second more. You’re going to absolutely love Linda, as always. Let’s check it out.

Main Episode:
Dr. Linda Greenwall, welcome back again to the Protrusive Dental Podcast. You are such a welcome guest because we’ve done a few episodes about whitening under 18s and icon resin filtration. Everyone loved those and they love it because I love your direct nature in teaching.

I really love direct educators. You tell it how it is. And so I’m especially interested in today’s conversation about sensitivity. But for those few people who, for some silly reason, they have not enjoyed that episode just yet. And they’re, it’s like a gem waiting to be uncovered for them now. Please tell us, because they haven’t heard about you. Tell us about yourself.

[Linda]
So my name is Linda Greenwall. I’m a prosthodontist, specialist in restorative dentistry. This is my year 40 in practice and I’m still inspired. I still love it every day.

[Jaz]
Say that again. How many years in practice?

[Linda]
It is now 40, 40 years.

[Jaz]
4-0?

[Linda]
40, 1984. Schooled up at university in South Africa. 1984, we had a special reunion this year because, I said to my colleagues in my class, hey guys, we really need to commemorate this. And the one guy said to me, Linda, I hated everyone in my class then, I still hate them now. I said, forget about that. We need to commemorate. And we got our professors and they came in.

And the first thing I wanted to say to our professors, I wanted to say thank you and show gratitude because the way they taught us in the eighties was very, very tough. There was no mincing words. And I wanted to say thank you because our training was excellent and it was tough. And we have all learned from that.

So I just wanted to show gratitude because we always, there are always people Jaz, who bring us up with them through mentoring and helping. And even though they may be our biggest critics, we learn from them. So we have to pay gratitude to say, thank you. Each challenge, this is my new thing. Each challenge becomes your opportunity.

Every single challenge and you can go through that. So we say, why do we have these challenges? Let’s call it in dentistry. It’s to reach, to help you reach your growth point to your next level. And that’s why it’s coming. It’s not because you’re a bad dentist or anything else. It’s your challenge to grow. And that’s when you learn that, that takes you to the next level of all that we do. It gives you a bit of wisdom.

[Jaz]
And now of course you do all sorts. You’re in practice, you do so much teaching. I love the webinars that you do. And so, everyone, I encourage to follow Linda on Instagram. All her social channels, they’re very, very active and the Academy and whatnot. So I’m a big fan of yours.

[Linda]
It was 13 years ago that I decided it was time to give back to dentistry. And that’s when I set up the charity. My husband told me I was mad, but I said, I’m doing it anyway. And it’s brought a lot of joy, really. And again, on gratitude, but we currently look after 60, 000 kids globally, and we do 23, 000 children in Luton, helping them with toothbrushing, screening, varnish application, working with refugees, providing free dental care in our practice.

In South Africa, we run 12 soup kitchens daily. We’ve served over half a million meals. since COVID and we have 16 toothbrush mamas who help us and each toothbrush mama helps to look after at least 2, 000 kids a month going to do toothbrushing at schools but also in the communities. So that is kind of how I balance with some of my high end, very, very specific, difficult, anxious, kind of stressed patients with their phones out to check the levels of their bonding at all angles and their selfies, to going into outreach in the less in deprived areas where you can give of yourself and your soul to help others with gratitude. Nobody needs to say thank you to you. You go to give yourself and it puts your whole life into perspective. So it’s a big difference in balancing.

[Jaz]
I love that. And you’re quite right to mention the contrast. In my faith in Sikhism, there’s something called Sevā. We call that selfless service. And what you described there was exactly that. So hats off to you. And I’d love to support more of what you do. So put any links that are relevant so we can continue to help you support. And so we’ll definitely put that on.

Today’s topic is a very pertinent one, very global one. No matter where you are in the world, you’re likely utilizing, hopefully, teeth whitening as one of the most brilliant, minimally invasive ways to help someone smile. We accept that. That is the most minimally invasive way that can have a huge difference to someone’s smile and confidence.

In particular, we talk about young people with all sorts of enamel mottling and brown spots. And we also did an episode on icons. So well-versed with the benefits. But one of the drawbacks of the benefits when the side effects is teeth sensitivity, but we all warn our patients about sensitivity. I’ve got so many questions of so many things I want to draw out for you from protocols to different things to try to avoid and case selection. But can we just start off with the very basics? Why does teeth sensitivity exist as a result of using peroxide gel?

[Linda]
Actually, before we even start that question, Jaz, I’m just going to go back a few steps.

[Jaz]
Please.

[Linda]
Because the first thing is that 70 percent of patients walk around with sensitive teeth and we as dentists don’t have any protocols to assist those patients who live with their sensitivity. And so before we even start on whitening, we give everybody listening today a things to do list. So while you’re listening to the podcast take a sheet of paper on one side we’re going to talk clinically and the other side we’re going to talk what to do now and what are your next moves. So that you can make this a habit.

So your first thing is to set up a patient desensitizing a protocol for sensitivity in your practice. And you ask every single patient, if you say to them, do you have any sensitivity? They go, no. Then you say, but do you have, you ask the four questions. You know about the four questions?

[Jaz]
No, please tell me.

[Linda]
The four questions, really, really important. The first thing is, number one, do you have sensitivity to cold? Because that means they have gingival recession and all kinds of other things. So that’s the first question. Second question is, do you have sensitivity to heat? As you know, the heat question is about pulpitis because there’s a big difference between pulpitis and sensitivity. The patient may not know that.

The third question is, do you have sensitivity to sweet? Because that means there’s caries somewhere and we need to look at that. And the fourth question is, do you have sensitivity to cold and pain on biting? Because the pain on biting means that there’s a fracture somewhere.

And then you may say to me, well, is that important relating to whitening? And absolutely. First of all, if you’ve diagnosed that they have a cracked tooth, you need to treat the crack, let’s call it a crack tooth syndrome. You need to treat the crack tooth syndrome, whatever you’re going to do, whether it’s replacing the old restoration with a composite, putting on a provisional crown, but you need to manage that immediately.

So that is protocol number one. Protocol number two, does it matter about heat sensitivity? Absolutely. Because that a pulpitis left untreated when you will whiten the tooth will lead to needing a root canal, which needed a root canal anyway, but you’ve got an unhappy bunny as a patient because you as the dentist didn’t diagnose and explain to the patient that they need to have a root canal first.

First, so the rule coming backwards is that any discolored tooth needs a periapical radiograph. Really, really important, because you are looking for undiagnosed periapical lesions. And most dentists don’t know, if there is an undiagnosed periapical lesion and you put whitening gel into, so you take oxygen and you shove it into an anaerobic area, you are going to have max of sensitivity anyway, requiring a root canal, which it already needed a root canal. But when you do the RCT on that tooth, it’s going to be difficult to control.

[Jaz]
And the patient’s perception is that, oh, there was a whitening that caused it, or it was an underlying issue all along. You taught me this as I was a third or fourth year student. You were lecturing the BDA. And so this was like 13, 14 years ago. I remember learning that from you on stage. So I always associate with this you, and when I’m thinking about teeth whitening, always look at any discolored teeth, any teeth that have got large composites worth doing a sensibility test before we prescribe the whitening, because hey, this could be, may not be symptomatic, but it could be necrotic. And this could be a flare up.

[Linda]
Absolutely. And then to try and do a root canal on that, you can’t do it in one visit, you might be able to do it in two and you often need to do in three, which is unusual, but it doesn’t settle down. And so the next thing to also look at while we’re talking about radiographs relating to whitening is post ortho.

So as you know, it’s very trendy now, everyone having then aligning and whitening, or first before you even do that, aligning or ortho, and then they want to go into whitening. That’s another topic we can discuss our whole thing on that. But you need to know what’s the nerve status of this. What’s the nerve status of the tooth?

Because if they’re post ortho, they’re going to have flattened roots with a little bit of resorption. And again, the whitening is not going to make it worse, but you need to know what are you dealing with now. Where are we with the, what is looking at, at the nerve? So coming back to the sensitivity question, we’ve spoken about sensitivity to heat needing a root canal.

We spoke about sensitivity to sweet. Was that sensitivity anyway? It’s all lumped together. And the sensitivity to sweet is normally interproximal decay. . So does that matter? And the answer is not really, because you’re gonna whiten first and then you’re gonna go back and change your restorations with the blended shade of the new composite.

[Jaz]
Has that changed at all, Linda? Because I’ve seen on social media groups where dentists are, and some dentists have this very strong opinion that, so for example, this is what some dentists do, and I disagree with it because I think you’re double treating. But essentially they all say stabilize the caries first, then do the whitening, then go back.

Insult the pulp again and do the restorations again. And that’s why I always follow, especially with anterior work, you bleach, even though you’ve got caries. Okay. And then you treat it with composite. And a few times I felt as though I was being a bit naughty doing this. And I was thinking, Hmm, is this kosher? Is this halal? Is this allowed? Basically, what do you think?

[Linda]
So you just said Linda Says. Linda says, do the bleaching first, because the research has shown that it shrinks the decay. That’s the whole purpose, because it’s chemically cleansing the decay. Unless we’re talking about a massive lesion, a mega open hole. Of course, you’re going to put a glass on a mirror. You’re not going to leave an open cavity, a huge open cavity. I’m talking about small, little-

[Jaz]
Small class threes, class twos, that kind of stuff.

[Linda]
That’s what I’m talking about. When they have sensitivity, the patient may say when I floss, it’s a bit sensitive. So that is a plan. It’s your strategy plan, right? And then coming back to the cold sensitivity, you’re managing the gingiva. So coming back to patients in general, because so many patients experience sensitivity and we just ignore it or maybe give them a soothing toothpaste. So what we would do on all new patients and all patients, discussing, ask the question, do you have any sensitivity?

Don’t leave it as no, I don’t. You then put an optogate in and you take the three in one and you spray air onto every single cervical area all the way around the mouth. And you note where they sensitive on the cervicals. Okay. Then you’re going to note, where they have NCCLs.

[Jaz]
Yep. Non-carious for the students. Yeah, please explain more about what they are for any students listening.

[Linda]
Okay, so an NCCLs, very big buzzword, which just rolls of your tongue. NCCL, non-carious cervical lesions. We think that we see much more of it these days than ever before because of patient’s diets and the Diet Coke and this busy water and the everything else and their lifestyle of what they drink.

Everything that they drink. So we see a lot of it. Now, most dentists, I don’t know why, and we can discuss the why, but I don’t know why they leave it. So you’ve got like a deep class five lesion and you spray air and they’re jumping out the root out the chair. And it’s such a simple restoration to do.

But I want to talk about how we would do that. So once we’ve noted where the sensitivity is, and we’ve noted it down, becomes part of our charting. And before we even take a scan these days, or or we take an impression for bleaching trays, we get those restored. We restore them. My restoration of choice is a resin modified glass ionomer.

And the reason for that is several reasons. Number one, it retains beautifully. Number two, the resin modified, the GRC loves the dentine. Number three, you don’t get the, you know, you see the, not, of course, not your composites. But when you see somebody else’s beautiful class five composites, number one, they never match.

And they’ve got a black line. They’re always leaking at the join. So the GRCs don’t leak. You don’t get a black line around the join. You get beautiful shades because of the new color or coloring. And we would choose a couple of shades larger. So if the patient has, they generally, A3. 5 teeth, I would choose an A2 shade to work onto all those class 5 lesions. And I want you to go through the technique if it’s okay with you of how I’m doing that.

[Jaz]
Please, I’m sure everyone’s loving this so far in terms of, because these are daily problems that we see in like 70, 90 percent of our patients.

[Linda]
And so when you ask me, what procedure do you do? Do you do crowns, bridges, onlays, zirconia, etc? I sit and I do my GICs a lot. So let’s just go through the protocol. So number one, we use a micro brush. Which is a tiny, not of a prophy brush. It’s a prophy brush with about a millimeter of bristles. Not the whole cup. And we put in pumice with heavy scrub. We make our own, but you can get consepsis. So you put the pumice and hibiscrub and you clean into that class 5 lesion.

So we were just had a hands on course at the practice on Friday and one of the dentist delegates very kindly allowed us to examine her mouth. And actually we showed the protocol because it’s so simple and straightforward and the color looks good. But let’s go back.

[Jaz]
So hibiscrub is like a proprietary branded product, right? It’s got is chlorhexidine containing that one or?

[Linda]
Hibiscrub. It’s chlorhexidine.

[Jaz]
Yes.

[Linda]
So you take pumice with chlorhexidine, we mix it up ourselves, but the actual product is called consepsis. And then you would polish, clean, polish, there’s so much plaque, you see the toothbrush lines in the class 5 lesion, the vertical, the horizontal lines, pumice and Hibiscrub.

Then you clean it, wash it off and take your probe and you check again and you’ll see there’s still, even though you’ve cleaned it, there’s still plaque in the rivers of the toothbrush marks. So, we go back again, but before we even do that, have a look at what the gingiva was doing around the class 5 lesion.

Because often, the gingiva was growing back into the lesion. So you need to then retract. We would cut a retraction cord, six millimeters in length and sometimes we double retract. So we use like a thicker one the brown one first then the black one and we tuck it back so that we just bring it back underneath. So we can actually see the full extent of the lesion on the class 5 lesion. So pumice and hibiscrub maybe twice, then we go to the aqua care.

[Jaz]
I was just going to mention air abrasion and you, yeah, just like that, you got in there.

[Linda]
Yeah, so you can use air abrasion, you can use your bicarb, you can use your aluminum oxide, any 30 or 50, it doesn’t make a difference. But I put in sylc. S Y L C is got, it’s Novamin. We’re the same as Sensodyne. So the Novamin, we jet wash it inside the tooth. And again, we use it for all restorative. We jet wash, cleanse it. So now the pumice and hibiscrub is soothing and blocking the tubules. The Aqua Seal is blocking the tubules. We then-

[Jaz]
The Aquaseal is the-

[Linda]
Aqua Care.

[Jaz]
Aqua Care, yeah.

[Linda]
Yeah. We then would etch the tooth. And because you’re dealing with sclerotic dentine, sometimes you need a double etch. Again, there’s so much plaque stuck inside, even though we’ve done all these cleansing procedures.

[Jaz]
Is this standard 37 percent phosphoric acid etch, or is it the conditioner that often comes with your glass enema?

[Linda]
No, I personally go to the etch.

[Jaz]
Okay.

[Linda]
And then I use HurriSeal. And the HurriSeal is a hema product, which is for soothing, or you could actually use Gluma. And I drip that on into the teeth, drip, drip, drip. So all the time I’ve been treating and soothing all the time. Then I go with my GRC and the GRC I jet into the tooth, there’s many different brands.

I like one of the brands called Riva from SDI and it’s quite liquid. So I squirt it in. I take a probe and just retract around there and then I sculpt it with a normal brush dipped in bond and we sculpt up, vertically up and contour around the tooth and then the final bit is the probe, light cure it.

And with any excess you remove with a flame and then you do the whole quadrant. Don’t leave any of them out. Because what’s going to happen if you leave it? It’s just going to get worse It’s just going to be more brushing. So I actively believe being proactive and just sort that because that blocks the sensitivity. So that’s why that’s the first stage we do a lot of proactive before we start.

[Jaz]
So the questions I have now is around about these NCCLs, right. The way I’m managing at the moment is, is differently for if I’m doing whitening or not, because I’ve listened to you for, I’ve done your webinars for, before starting teeth whitening, I follow that.

Now the protocol is little micro steps. I love it. I’m going to implement some of those because I think they make so much sense to me. And so for those patients about to start whitening NCCLs to be restored just makes sense to me. In those patients who we’re not talking about, we’re not having that whitening conversation.

They have NCCLs, but they are completely asymptomatic. The kind of conversation I have, the kind of assessment I have in my brain is, there are three reasons you may wish to restore an NCCL. A, if it’s sensitive, then it needs doing in my opinion. If it’s so big and it’s the first time you see the patient and they’re so big, then you think, okay, there’s a massive crater here.

This needs some sort of protection or if it’s an aesthetic issue. So I guess what I’m trying to ask is, aside from those, these scenarios, is it acceptable to just monitor because it’s not symptomatic, it’s not in the aesthetic zone and it’s small.

[Linda]
So that is one approach. And again, you put it to the patient. It’s up to the patient with consent, but I just normally just fill them in. I guess you can monitor them, but we start to see inside the ones that are untreated the root decay. There’s a lot of areas. Yes, they’re resorbing and yes they can place topical toothpaste or mousses, et cetera, but nothing really changes in them. So I rather, my tendency is just to restore them.

[Jaz]
I think you’re right in the sense that when we see these patients year by year by year, and then eventually you find, see patients in their seventies and eighties, and I find that what used to be a very cleansable area of NCCL is now just plaque-laden and there’s gingival inflammation. And so to promote better cleansability, it totally makes sense. And it’s something that’s not very invasive. It is proactive. And I like the idea of it.

[Linda]
So that’s the option number one. Before, so you’ve seen that we’re still talking about diagnosing the sensitivity because we have to go right back to basics. We’ve spoken about the assessing where the sensitivity is, what is it, what start, what type of sensitivity is, but then if, let’s call it, the gums are a little bit receded, you can’t put a GRC there, and you’re modifying the tooth brushing technique, the research shows that brushing with Sensodyne for two weeks before you start whitening makes a massive difference.

So you can put the patient on to a Sensodyne protocol or any soothing toothpaste protocol brushing. Just that, this was early research from Professor Van Haywood, will stop the sensitivity. So there you have the next way.

[Jaz]
And this is just, so two questions back and back, this is just tooth brushing, not necessarily the protocol where you rub it on your finger and you leave it in those areas. This is just regular tooth brushing.

[Linda]
Yeah.

[Jaz]
And is it a specific type of Sensodyne? Like, for example, I think previously you’ve talked about repair and protect. I don’t know if they still have that terminology anymore. Is there one that works better than the others prior to whitening?

[Linda]
I think all of them are absolutely fine. Absolutely fine. And there’s newer versions of whatever works for the patient. What I do check though is on all toothpastes and soothing toothpastes and in general the current toothpastes that are being used many patients suffer from sloughing of the cheeks of the new codes. I don’t know if you see this.

[Jaz]
Yes, yes.

[Linda]
So you need to, I always ask the patient when I’m doing a general exam, what toothpaste they are using because some cause more sloughing of the cheeks. And so we say, change your brand. So when it’s talking about a sensitive desensitizing toothpaste, use it for two weeks, then go on to the next brand and then just change it a little bit.

[Jaz]
So we want A, the sensitivity sorted and be no sloughing. Sloughing is, do we believe that’s the SLS component?

[Linda]
Yeah, we think it’s the SLS. Some of them have Covarine blue dye in to make the teeth look whiter, but it may be too strong or, so you need to just check and monitor with the patients.

[Jaz]
Okay, so you’ve done your diagnosis, you’ve noted the NCCLs, for those that are amenable to treatment, and which most are based on this conversation, let’s use that, you’re going to use a Riva, like you said, you’re going to follow that fantastic protocol, which we’re going to get the video for, and a little checklist, and our team, a lot of people are driving or on a train, they haven’t got access or making a license or download and then also link everything to your website as well, which would be great.

[Linda]
And we’ve got a new WhatsApp group on bleaching just by the way.

[Jaz]
Oh, wonderful. I love that. Fantastic.

[Linda]
It’s really amazing people put their cases on.

[Jaz]
Brilliant. Now you’ve also talked about using Sensodyne for two weeks prior to teeth whitening and then just brushing. And if they’re having the sloughing or that brand is not working for them, then maybe change a brand. Would you agree with that? Because I found patients where they tried something already using a Sensodyne toothpaste and just by suggesting a change in the chemical formulation, a different brand, then they suddenly come back and their sensitivity is significantly improved. Is that something that you’ve observed as well?

[Linda]
Yeah. So when it comes to the different Sensodyne brands, there’s a lot of different ones. So you can, again, you can swap between the brands because they’ve got different functions like that. So that’s one option. Then, the next thing is to understand why patients get sensitive during whitening. And we would then-

[Jaz]
Can I just, before you talk about it, because this is such a big part, but it’s one thing, I just want to cross off before we move to the actual mechanics of teeth sensitivity during bleaching, is with your protocol, which sounds wonderful, are we expecting that patients can hopefully say that, you know what, I can have my ice cream again?

Because sometimes they say, like, my centrals are super sensitive, but when you look, you don’t really see much recession, you don’t really see any NCCLs, they just have, generally, they’ve always had, oh, since I’ve been 12, I’ve always had sensitive teeth. Are we going to help that patient as well?

[Linda]
It helps that patient as well. Just recently, I saw a patient who we did this treatment exactly what I’m talking about, and she had massive erosion on her teeth as well on the occlusal surfaces. So we did a three step technique, written up a lot by Dr. Francesca Vailati. So we did the NCCLs on the outside, we built her up on the occlusal composites, we opened her up to a vertical dimension, I hadn’t seen her for a year, and she said to me, now, finally, I can eat so many different things. I can eat everything now, whereas before, I was so restricted on what I could eat because of the tooth sensitivity, because of the erosion.

[Jaz]
So that’s controversial question. Does Linda say that bruxism and occlusal forces may be a contributor to sensitivity?

[Linda]
Yep, because of the micro cracks within the tooth. So when we’re talking about sensitivity to patients, the first thing we need to understand that within five to ten minutes of placing whitening gel we are in the nerve of the tooth. And so, because some dentists think, well, they make up whitening as they go along because they’ve never really learned it and they just think it’s very, very cosmetic.

But actually, understand that it goes into the nerve of every tooth. That’s why we need to, that’s why I’m saying take a radiograph. We need to know, what are we dealing with here? Because the way bleaching works and the way sensitivity works, it’s all related to the actual anatomy of that particular tooth.

So if, and the way that the whitening works, it goes into the weakest part of the tooth first. So it will go into those micro cracks on those bruxes. It will grow into the crack where the patient has a crack tooth syndrome. It will go into a porous tooth and it will go into the non vital tooth.

It will find the weakest link to travel, which is why we need to know, that’s how exactly that’s how it works. And that’s why some patients, I know we spoke about white spots, but some patients, we’ve never had white spots. Suddenly when they were doing whitening, they come become very alarmed that suddenly there is white patchy areas on the tooth that were never there, according to them.

[Jaz]
This freaks them out, this absolutely freaks them out. And then what the patient does, they stop whitening. Whereas I’m hoping you’re going to say that actually they should be encouraged to continue, reassure them. And then we’ll get a good result. And obviously what you’ve taught me before, and I’m always echoing anything teeth whitening related, I’ve always learned from you, which is that is a sign of enamel damage. What’s that’s highlighting is damaged enamel.

[Linda]
So what is actually highlighting is there’s porous parts within the tooth and the whitening has, taken up too quickly. So that particular part of the tooth is actually the enamel anatomy is porous. So you particularly find this with the higher strength whitening gels, which is why we like you to go low strength. So suddenly they’re on 16% everything is suddenly all mottled when they never had mottled teeth. We’ve seen a lot of patients referred from other dentists because of this problem. And as you say, it’s reassurance that they need to continue whitening. They also shouldn’t do stop, start whitening where they’ll do two days and they’d stop for a week and then, because you want to have slow and low. Still, Jaz, that particular part of the protocol is still the same slow and low concentration as you go along.

[Jaz]
Excellent. So we now know the mechanisms. We know that the peroxide is reaching the nerve within 10, 15 minutes and always go the path of least resistance. In terms of predicting who is acceptable.

Obviously, now that we know this background information about, okay, the four questions that we’re going to be employing using restorative materials like Riva Light Cure, for example, to restore those NCCLs using desensitizing toothpaste. beforehand and finding the right formulation before you even start whitening.

So already we’re on to a winner, but I found it a surprise that some patients, I warn everyone on sensitivity and some people come back with significant sensitivity that they just can’t do it. My wife being included, like she, within like two days, she can’t do it anymore. I get a bit, but not too much.

Whereas some patients, there’s a particular patient I saw a few weeks ago, And bless her, she’s so sensitive to everything. Every time I’ve done a restoration, super sensitive, the bite needs time to settle, go very slow with her, easy with her, warner of everything. And I double, triple warned her before we started teeth whining that, okay, I think your teeth will be very, very sensitive.

I just have a hunch. She came back and she said, nothing, zero. Okay. And so, and her teeth looks fine. There’s no NCCLs and there’s no difference to some other patients. Are there any individual characteristic traits that people’s baseline level sensitivity is more than the others?

[Linda]
I think it also depends on tolerance. And I also think it depends on hydration. Hydration is a new area they’d be looking at. Because a lot of patients who have like a high lip line like me, the lower third of the tooth is darker. And the hydration, it’s to do with, if they’re not hydrated, the tooth, it’s dehydrated. And the whitening dehydrates as well, and so I think that contributes to the sensitivity.

So now, we also, with our patients, and especially with the little kids with the white spots, we’re looking at their hydration levels, and we’re looking at their dietary levels. Because the patients have high lip lines, class 2, sticking out teeth, they’re dehydrated, they’re not drinking enough water. And the teeth are porous and so they’re accumulating more stain.

But we go back to, first of all, water for all patients, because none of us actually drink enough water. So we look at the hydration and looking at why they’re sensitive. But most of the time, you can’t predict. So the research shows up to 80 percent of patients are going to be sensitive during whitening.

And this is particularly with higher strength. We try and predict and we look at what would cause them to be more sensitive. So some of the protocols would use the whitening gel 15 minutes in the morning, 15 minutes in the evening, and they discovered those protocols were more sensitive.

[Jaz]
Oh, wow.

[Linda]
And so, there are a lot of protocols like that, oh, you just do 15 minutes of double whitening a day, makes it more sensitive. Then it comes back to the tray, the tray design, and they think that a rigid tray makes it more sensitive. They did a study, and they just put bleaching trays in, and they discovered with no gel that 30 percent of people were sensitive just with a tray sitting around it.

[Jaz]
Wow.

[Linda]
So then the next study they did was they cut off the last two millimeters of the bleaching tray. So that actually tray is not rubbing on the cervical area and they found it improved sensitivity and made no difference to the whitening effect whatsoever. So you can do that. So if they’re so sensitive, like you were talking about your wife, cut back two millimeters off the bleaching tray on the cervical area. So it’s not rubbing.

[Jaz]
So you’re shying away from the gingiva. You’re like supragingival two millimeters.

[Linda]
You’re supragingival two millimeters above or even a millimeter above. And you may find that will improve it.

[Jaz]
That’s fascinating because I think a lot of dentists are afraid of doing that because they’re afraid of not being able to adequately bleach the cervical area.

[Linda]
So here’s another point. You can’t adequately bleach the cervical area. It’s never gonna be the same shade and that’s a myth. It’s never going to end. When patients come to see and they go, look, look, look, this is not right. And then we go, well, then just don’t bring, don’t bring your teeth down. Nobody’s going to see that.

You have to be realistic of what whitening will do and what it’s not going to do. On the root area, it’s not going to be B1++. Ever. With whatever whitening gel you’re going to use. So that’s an important factor. Again, it’s to do with the root anatomy and all that stuff.

[Jaz]
The thin enamel in that region, enamel being so important in the good whitening effect.

[Linda]
It’s not going to be the same. So that’s really, really important. The other factor is medication that patients take. When you were saying you need to look at medication, we also talking about roaccutane at the moment because roaccutane, I don’t know if you know this, but roaccutane, because we’ve got the ortho kids who whitening in the retainers.

And Roaccutane, again, it dries out the teeth, it dries out the skin, but some patients have dry mouths. And those little kids, often after Ortho and Roaccutane, because Roaccutane is a long period of time, the teeth are grey green. I was just looking it up last night again. And they think it’s due to the dehydration, because the Roaccutane dries out the mouth and the saliva as well. And you get the-

[Jaz]
I’ve never heard of this Roaccutane. Can you tell me what it is? I’ve never heard of it.

[Linda]
It’s called isotretinoin and it’s a medication like a vitamin A. It’s called isotretinoin and there’s different versions. The U. S. is Accutane. We call it Roaccutane, but it’s kind of standard protocol for the dermatologist to put the kids onto Roaccutane.

There’s a lot of write ups. I’ll send you some of the press releases about it, but let’s call it the Daily Mail, often those kind of papers will cover stories about Roaccutane because what it does, it causes depression in kids and suicidal thoughts. So this is quite an important thing. So coming back to always checking medical history on all our patients.

And if the kid is on Roaccutane, you need to tell them, well, you need to discuss with the parents and you need to discuss with the dermatologists. The other new drug, and they give it together or they swap them, is Lymecycline. You’ve heard of that one?

[Jaz]
Yes, heard of that one. That’s for, is that for acne?

[Linda]
Yes, but it’s the same. So either they’re on LYME, Lyme cycline, because we used to do minocycline, tetracycline, and doxycycline. But either on that, or they’re on roaccutane. And the roaccutane doses, the way it goes, it goes 20 milligrams, 40 milligrams, 60 milligrams, and it goes on for two years. So then you have to balance the acne versus the discoloration on the teeth.

And again, discussing with parents, of course, we’re not going to say with the child, but out the children’s welfare is really important. So we are understanding that on the racket and how long they’ve been on it. And not every child gets great teeth when they’re on reaction. And then again, you come back to talking about hydration levels.

So my next new business marketing idea is to actually print water bottles with our practice name on to give to the kids. And to give to the adults about drinking water, just drinking more water because of hydration effects, discoloration effects, and healing the mouth with water. I will write a paper on this, there just hasn’t been enough time.

[Jaz]
I love it because it’s putting the mouth back in the body, it’s reminding us that, we are, the theme of the AES, which I like to go to in Chicago, for 2026 is the oral physician and about the putting us back in the body, putting the mouth back in the body, which is so important.

So it’s a nice holistic approach and step back approach on this theme of hydration and dehydration. I’ve seen before exactly that kind of patient described, which had like a two tone appearance of their teeth. And they’re very, very grey. And I have found that on one instance a few years ago, this patient just did not respond as well to whitening as I wanted.

And it makes sense that, okay, it’s because of the fact that they have this profile whereby the lower incisal third or half is too dehydrated, I imagine, but it’s got this grayish appearance. Is there any hope for this patient with teeth whitening? Or are they looking at veneers?

[Linda]
There is hope and everybody responds, so everybody’s difference in their response and sometimes on those patients, because it’s dehydrated enamel, so think of it thinner, desiccated, more dentine laid down, so you get that two tone effect.

You need to go for the six to eight week protocol, whitening with low strength, coming back to the five percents. 5% carbamide peroxide, low and slow, but it can change and it can make a big difference on those patients.

[Jaz]
Can you name a brand of 5% carbamide peroxide?

[Linda]
Yeah, we’ll talk about that, but the last patient yesterday, short lip, the two thirds is dehydrated. Obviously, I spotted it straight away, but we were just having a general discussion about that, about her teeth in general and sensitivity in general. And that is a factor that is a factor and an interesting thing is that her boyfriend said you need to fix your teeth. First fix your teeth, darling and so we come back to understanding diet sheets coming back to those old fashioned diet sheets we was taught.

Get the patient to fill out diet sheets. Either a weekend day two normal days and have a look email it to them and email it back. And just have a look at what they’re actually drinking. You’ll find it’s not enough and that comes back to the discoloration.

So when you say the whitening is difficult, check on the, the whitening gel being water and it still can dehydrate the enamel during the whitening process. And for those patients who already dehydrated the results may take longer. So you keep going you keep going and going and they will get there, but it’s slower.

[Jaz]
With the dehydration often when we’re doing like rubber dam on with dehydration, we see the teeth get whiter, but I think in this instance, it’s like a chronic dehydration, which has the grayish effect. Have I got that right?

[Linda]
Yes, a chronic dehydration and it’s grayish because it’s the enamel is so dehydrated. It’s picked up some internal stain within the food, et cetera, that they’re eating. So yes, so then I want to talk about putting on a rubber dam and the rate of dehydration on a patient. You know when you’re about to start composite bonding. The first thing you have to do even almost before the rubber dam is on is choose your composite shade because so quickly the teeth dehydrate and you’re choosing lighter and lighter composites, which don’t blend.

So coming back to that the same rate that a tooth dehydrates is the rate that a tooth whitens. Now when you put on your rubber dam, just watch the tooth as it’s dehydrating because it doesn’t always dehydrate evenly. It will be a little bit patchy in places as it’s losing water losing water losing water. That’s the same pattern as how the tooth whitening would appear. It’s again associated to the path of least resistance.

[Jaz]
And this is again where we have to reassure a patient after they’ve got up and they remove the rubber dam why they got those patches in the same way with the whitening. You’ve repeatedly said about using a low insert protocol which makes a lot of sense.

In other countries, they’re using ridiculous percentages, 25, 30% sometimes, in Singapore I remember using such percentages actually. And it’s good in a way that we use low percentages here. 5% for carbamide peroxide. Any proprietary brand that you recommend?

[Linda]
There’s not many on the UK market. Basically, it is, the main one is Novon Mild from OptiDent, Henry Schein. And it’s got a special soother inside, which is a toothpaste, glycosine phosphate is the soother inside. So when we’re talking about concentration, we’re talking about, we can also talk about it doesn’t mean carbamide and hydrogen.

Carbamide has 16%, 10% and 5%. You should always have 5% available for a certain category of patients. Number one, those who’ve always like you, like you’re talking about your wife. He’s been so sensitive to whitening, they need to go on the 5%. Then, patients with Medically compromised history, health history, who have got complex medical issues for them.

Then those patients who’ve tried whitening before, and also you can see, we spoke about bruxers. If you ask a dentist, if they’ve done whitening, and then they had sensitivity, they’ll all tell you that they have on the lower incisors, they’re sensitive because we all bruxing, we all stress bunnies, and so we get sensitivity just on those lines, lower incisors, little micro cracks.

So on all those patients, and patients who’ve never been able to manage whitening before, It’s all with a 5% carbamide peroxide. There is another brand called Cavex, it’s from Amsterdam, 5% carbamide peroxide. But we would use that for those patients that are super sensitive. 5% carbamide peroxide is also used for therapeutic aesthetics. I don’t know if you’ve heard of this term.

[Jaz]
No.

[Linda]
Okay, I’ll send you my publications on this. So we use the bleaching tray as a therapeutic tray, which comes back.

[Jaz]
Oh, I see what you mean. Okay. Yes, carry on.

[Linda]
It comes back to all aspects of a patient’s oral health. So the bleaching tray becomes this therapeutic tray and we deliver different chemicals. So tooth mousse, MI Paste particularly, is really good for soothing and desensitizing. So on top of our normal protocol, which we’ve gone through before on home whitening, and that they just do the upper and then they do the lower. And just by the way, the reason for that protocol is because the upper teeth are not as sensitive.

So we always go to the positive upper whitening first. But because of that, we would always give our patients a brand of proprietary soother. There’s quite a few different ones, but I’ll just tell you, tell them to you. The main one is, it’s either tooth mousse or MI paste because it’s got ACP inside. And ACP is a tubular blocker, and it also works on the enamel to smooth the enamel and the defects in the enamel. So, that is great.

[Jaz]
And also good for ortho demineralization, early white spots. It can be quite curative without teeth whitening, right?

[Linda]
Yeah. Decal’s really, really good for that. Yes, you can use the DuraPhat toothpaste as well, but to put in the bleaching tray, we can use Tooth Mousse, MI Paste, and there’s a new one, which is MI Paste Plus.

[Jaz]
That’s the one with fluoride?

[Linda]
Yeah, the tooth mousse doesn’t have fluoride, but the MI paste does have fluoride, different concentrations. Then the proprietary one, there’s one from called Relief Gel, and that’s from Philips, night white, Relief Gel, and Philips brand has got ACP, potassium nitrate, and fluoride inside. And you put that, you run a line into your bleaching tray, and the patient would wear that an hour a day. An hour before lightning. An hour instead of whitening or an hour after whitening, and that should solve your issues with sensitivity.

[Jaz]
And that’s a top tip right there, I think. I mean, did you use it, which I do, and I was going to ask you about that in terms of what you recommend to put inside it. How about those high, in the past what I’ve done, not related to teeth whitening actually, but high caries risk patients, patients where root caries prone patients, patients who’ve had, let’s say radiotherapy, and their saliva is going to be low and poor quality.

I often give them like a very passively fitting Essex retainer. And then I encourage them to use certain agents like Toothmousse. I go and I show them on Amazon, which one to get. Do we have sufficient evidence base for that? Or is that something that you’re a fan of?

[Linda]
Oh, yes, we do have evidence. It’s not just a random thing. There is a lot of evidence on that. And Professor Van Haywood has published a lot on this. Then, the other study that was done by a guy called Lazarchik, 2010, was for special needs patients. So but you use also for those special needs patients, the carbamide peroxide in the low concentration.

So those patients who are high caries rate patients, they did a study and the guy’s name is Yao, 2013, where they looked at the difference between chlorhexidine, and chlorhexidine and carbamide peroxide, and they found that carbamide peroxide was more bactericidal to help the gingiva than actually Chlorhex.

So on another WhatsApp group that I’m on, a digital group, they were showing a case where the patient, they did new crowns, the gums were all swollen afterwards, they redid the crowns, the gums were still, upper 3 to 3, gums were still swollen. So I said to them, put in a bleaching tray with carbamide peroxide 5% inside, and just heal the gingiva.

Then go back to taking all those crowns, putting provisionals, keep with the carbamide peroxide to get everything balanced. Make sure you don’t invade the biological work before you go to be able to do that. But this is quite a top tip in terms of that. Your elderly patients who have poor oral hygiene, the five, on the label, this is a little controversy because on the label it says, only for tooth whitening purposes.

5% or all of them say for tooth whitening purposes, but we use it for healing because it’s been used for healing for 70 years. This was the whole discussion. That’s how the whitening was invented because the orthodontist nurtures the gingiva with swell. So that was, why we would do that, but 5% in the tray, 5 percent upper, 5 percent lower, 1.2 percent. So the other soothes, which we didn’t mention this Pola soothe, Pola soothe is from SDI and that contains potassium nitrate and fluoride. And then you also have Opalescence. It’s called Ultra Ez. It’s from Utah products. Again, it’s another Henry Schein Octanet product.

That one is just a syringe of potassium nitrate. So the way that potassium nitrate works for sensitivity is it stops the polarisation of the nerve. So stops the nerve continuing to fire, it cuts it with the potassium nitrate and just kind of temporarily paralyze if it stops it. So the nerve is not firing.

So that’s why we use fluoride for blocking the tubules. We use potassium nitrate to stopping the repolarization of the nerve. We use ACP for blocking the tubules. And another product which you use, which we mentioned when we’re doing the NCCLs is the HurriSeal or the Gluma. So the Gluma is just a liquid, or the HUrriSeal is a liquid, and again you’re blocking the tubules.

You can use it as an intermediate dentine seal as well. If you’re finding that a lot of your composites don’t work, I’m not you personally, you really know what I mean, but once composites, you do your normal protocol and patient has post operative sensitivity, which we all hate, but sometimes we need to re remove the composite because it’s pulling in, all those stories.

Actually, we do it, you do your etching, you put the HurriSeal in and that stops it. That was a colleague of mine, Dr. Mervyn Druian told me about that. So the HurriSeal is very useful for all those sensitive patients, for all those ones, and again for restorative care/post-operative care

[Jaz]
I think you’ve taught me as well, because I believe your son’s doing wonderful work with AI, actually, and notes and stuff, and I’ve been in this space as well, and often, I don’t know if you’ve actually counted how many words are spoken, in a one hour consultation, it’s like 10, 000 plus, it’s actually crazy, and I feel with the pace that me and you both speak at, we’ve probably hit 20, 000, and I know that dentists have got incredible value from you.

One personal takeaway now, I mean, all the protocols said brilliant. Some things are great revision for me. But what a wonderful reminder you gave us, right? That the cervical region just won’t ever whiten as well as the others. And I think we forget that. And when we, when we talk to patients and we take that photo with the shade tab, we say, it’s going to go this way.

Just pause and say that, oh, but not this part. It’s like, imagine you’re in Lion King. Okay. You can go there, but you can’t go there. Like, just think of Lion King next time you’re whitening your patience. And I think it’s a great reminder and I look forward to adding more resources from you in the show notes.

I know you’re involved with so much. You’ve got some amazing events coming up. I’d love for people to come and learn more from you. Cause every time I speak with you, I learn so much. Every time people meet you, your energy is brilliant. How can we get more of this energy? Where are you next speaking at?

[Linda]
So our next gig is an important conference. It’s called Future Dentistry. It’s on the 1st of November at the BDA. And we would like more dentists to attend. We have an amazing lineup. First of all, talking about dental AI and how we can implement it into our practice from all different aspects. We talk about the future of contemporary restorative zirconia crowns in there’s an onlays, there’s an zirconia veneers.

We talk about early intervention orthodontics because there’s this whole thing everybody waits to the right time but Professor Peter Mossi will be talking about how you really properly early intervene and what you need to do. We’re talking about the latest techniques in implants.

What is new? What’s the future? How are we going to go with this digital dentistry? How we integrate it? the different scanners and all the different techniques. The dental technicians will be talking from their angle. We also have to have a medical legal update, a safeguarding update. So you are fully up to the-

[Jaz]
Core CPD is ticked off as well then.

[Linda]
All your CPD or your core subjects is all ticked off. But the benefit of this is that by attending the conference, you actually are contributing to the charity, to the work of the charity to help more patients attain dental wellness, which is really important.

[Jaz]
Well, I’m definitely gonna put the link but you know for those who are maybe driving around click check the show notes but do you know, is it the BDA website? Is that what they book?

[Linda]
They book through event brite and i’ll send you the link. It’s first of November, BDA.

[Jaz]
Perfect. And those topics that you covered are very sought after topics that Protruserati ask about, especially the inceptive orthontics. AI is such a big thing. I’m a big fan of it. And I encourage everyone to explore these avenues.

I think people are sometimes shy or they’re like, I’ve been doing it for 10 years, I don’t have a problem. When they learn to embrace AI, they suddenly gain four or five hours a week that they never knew they had, they could possibly to have, and it reduces your stress, improves your quality of your notes.

So it’s amazing you’re talking about that. And also yes, zirconia, partial coverage restoration. Something I’ve talked about, not talked about, but such I asked about on the podcast. It’d be interesting to hear an update on that. So I’ll definitely put the link in the show notes and fantastic topics.

Linda, I’ll put all your show notes, all the sort of follow links and all your wonderful things that you do. Thank you so much from the Protrusive community for all you do, the charity work, the education. I can’t believe you’ve been in this game for 40 years plus. That’s amazing. Please can we have another 40 years because we don’t retire anytime soon.

[Linda]
So nice to talk to you. It’s lovely to talk to industry with you. You’re very inspiring. You do amazing work and thank you for all you do on your education and all you do to inspire so many leaders. Your impact is huge all over the place. Whenever I go to dental meeting there, I heard you from the Jaz podcast. It’s all up to you, Jaz, and all the Protrusive things and all the wonderful things you do. Thank you so much.

Jaz’s Outro:
Thank you. Thank you so much. There we have it, guys. Thank you so much for listening all the way to the end. Don’t you just love Linda’s direct nature? She is brilliant. Please go and support her, learn from her and her colleagues on the 1st of November.

And if you want any of the resources, some of them will be available on YouTube or wherever you’re watching this. And the rest are on the Protrusive Guidance. Don’t forget to get that infographic only on Protrusive Guidance. I want to thank my team as always. Erika, Mari, Gian, Krissel, Julia, Nav, Emma.

Our team has been growing throughout the years, as have you guys. The subscriptions on YouTube and everything, they mean a lot. But if you really want to support Protrusive and get the most out of it, we’d love to see you on the app. I’ll also put any papers, any links that Linda suggested, including the Eventbrite link for her event on the 1st of November.

And if you found this episode useful, please share it with a colleague. This is how the podcast grows. This is how we’re able to attract wonderful guests like Linda to help make dentistry tangible, which is the ultimate mission of this podcast. For those on a paid plan and Protrusive Guidance, scroll down, answer questions in the quiz.

Mari, our CPD queen, will email you a certificate. And yes, we are PACE approved. So if you’re in the US, you’re going to love it too. Thank you so much again for listening to the end. I’ll catch you same time, same place next week. Bye for now.