Those Pesky White Spots: Now You See Them, Now You Don't

You're listening to the Phil Klein Dental Podcast. We've all seen the white spot lesions on our patient's teeth. By any measure, they're not particularly aesthetic, and most patients would love them to disappear. So why is it that for a large majority of patients that are actually visiting their dentist regularly, these lesions persist and essentially detract from their smile? The only logical answer I can come up with is that many dentists are not utilizing something called resin infiltration. It's a simple procedure that is remarkably effective in essentially making white spot lesions disappear. To tell us all about it is our guest Irene Iancu. Irene is a Canadian RRDH. an acronym for Restorative Registered Dental Hygienist. She's a successful entrepreneur with experience in various specialties like pediatrics, orthodontics, and periodontics. She has combined all of these elements in her startup dental practice in Toronto, Tooth Life Studio. Irene is an international speaker, key opinion leader, host of the Tooth or Dare podcast, and creates educational content on all social platforms under the handle at toothlife.irene. Irene, it's a pleasure to have you on the show. Thanks for having me again. How are you? I'm doing very well, and I'm glad you're in the phase of moving to the warmer weather in Canada and getting out of that rough. winter although i do speak to a lot of people that actually like the super cold over there but you just told me offline that you prefer to warm up so yeah um i'm in a bubble though toronto has a little bubble around it we don't it doesn't get as cold here as like coasts right east coast west coast so i'm good we're okay in this little bubble of the city There you go. My wife and I want to, we've been to Montreal, but we want to visit Toronto. I've never been there. So this summer, maybe it's this summer. I say that every summer, but maybe this summer. All right. So we're talking about something called resin infiltration today. And it's certainly an interesting topic and procedure. It's not new. It's been around a long time. I've been in this industry for over three decades. I've heard about resin infiltration for a long time. I don't know how much it's caught on over the years, but I know that. It seems to be picking up some steam right now, especially people like you who reach a lot of people. You're talking about it. You've had success with it. So to begin, before we get too deep into the details, tell us what resin infiltration is. Yeah. I would consider it to be a procedure because there's a couple of different ways you could do it product-wise. But essentially, it's using an unfilled resin to infiltrate white spot lesions. And when we classify white spot lesions, a variety of different ways. We can look at enamel lesions, E1 lesions, D1 lesions, all the way to developmental lesions and fluorosis. So we're able to use an unfilled resin in a variety of different steps. So you start with an isolation, whether... a liquid dam or a rubber dam, which is what I prefer. And then you use a 15% hydrochloric acid, not to be mistaken with our phosphoric etch that we use. And then you use an ethanol solution that dries out the tooth, dries out the tubules, allows you to visualize a white spot lesion. You do that in a couple of different steps. Etching, for example, can take up to three minutes in order for us to reach the base of those white spots. And the infiltrant itself is then used sometimes for up to 20 or 30 minutes to allow the tooth to pull in or suck in that resin. And it can go all the way to like 400 microns. You're thinking of a lesion that's quite deep. So it's a very, like you said, it's not a new procedure, but it is picking up speed because we're trying to be very minimally invasive and buy people time. I guess you think about someone that has generalized fluorosis for many years of their lives. They probably were told that there's nothing that they could do about it. Uh, and then, you know, here comes resin infiltration now in the hands of people like me, a restorative dental hygienist. And I operate under the license of a dentist, um, where the dentist can do bigger procedures, crown preps in another room. And then I'm able to do this kind of life changing dentistry for people in my operatory. So essentially it's, you know, a series of steps that allows you to mimic the color of a white spot lesion to make it resemble the remainder of the tooth. And it does that with a refractory approach. So you've probably talked about, you know, omni -chroma or other mimicking kind of composites. And that's what this does. It takes an unfilled resin liquid and it mimics the color of the remainder of the tooth. So to the naked eye, it becomes virtually invisible. So this is considered a super minimally invasive procedure, right? There's no drilling. There's no manipulation of the actual hard tissue. Other than the etching, there's no mechanical removal of tooth structure, right? Yeah, absolutely. There are ways, you know, depending on the depth of the lesion, the color of the lesion, you know, I've done some courses that people will... want to look into to figure out what are the limitations. But generally speaking, you don't really have to touch or prepare the tooth at all. And just out of curiosity, how did you come across this procedure? Yeah. So I opened my own practice recently. I have a COVID dental baby. And I saw my demographic is very young professionals, young people in their 30s. And I had one patient who came in and she was dating. And she said, I'm really bothered by these two white spots, two developmental spots on her upper front teeth. I guess for the Americans, it's eight and nine. For us, it's one, one and two, one. And I did some research. I had seen a previous practice that had done resin infiltration before, had offered it. And as a new practice owner and new restorative hygienist, I wanted to figure out, is there a solution for these patients in order for me not to have to prep and put veneers on? So she was my guinea pig and my first candidate. I wanted to offer something else. And since then, it's really changed my practice. It's changed a lot of the reviews that we have coming in to new patients. I needed more. I need to offer my people what they needed. Yeah. And what I've heard about resident infiltration is that some of the patients that eventually get it were told previously by another dentist, there's really not much we can do. They used other techniques that weren't as successful. So like you mentioned, it is a huge practice builder because it's so non-invasive. for them to get a solution where they can get an aesthetic result, rebuild the enamel to what it was naturally without having to drill. I mean, there's amazing things that are involved here psychologically to the patient that, you know, hey, I love you. You're a great dentist. So what do you say to those dental professionals that contend that resin infiltration is very similar to a flowable composite? You etch, you dry, you flow the material into the lesion. What's your response to that? I mean, there are two different compositions. One's filled versus one's unfilled. So resin infiltration in its truest form is a liquid. The resin itself that comes out is not, you don't have to press. hard on a device to extrude it. And the etching time is significantly increased. And then there's this additional ethanol component. So they're not even close to one another. And I would tell people to be very cautious if there are procedures that people are publicly recommending that involves a filled resin. It's not going to do the same thing. The tooth is not going to be able to suck in the thicker material. So they're very, yeah, they're not nearly the... the same thing at all. So learning curve. Let's talk about that quickly. An office that's never done this before, they see white spots. Sometimes they just surrender to them and say, you know, this is just the aftermath of orthodontic treatment. The white spots will probably recalcify over time. And then they're listening. this podcast and saying, hey, resident infiltration, or they see it on your social media, or they listen to it on your podcast, what's the learning curve? How long does it take for the office to get up to speed to start implementing this right away? Yeah, I'd be surprised how many people send me DMs on Instagram with a photo, one this morning saying, do you think that this would be a good candidate for resident infiltration? So the learning curve is pretty... I wouldn't say that it's steep at all. The steps are written. If you're using the proprietary product that's purchased, you can. see the steps directly on the packaging. I also have my own little workflow that I've figured out over time. Certain things that you might want to consider is for deeper lesions, allow the resin to infiltrate for much longer. There are tons of videos on YouTube and creators like myself. I've done a couple of Instagram lives showing the procedure from beginning to end on smooth surfaces and also interproximal lesions. Those lesions that we were once waiting and watching, now we're actually able to do something with them. So there's lots of availability of resources and people like myself and Jeanette McLean and Carla Cohen, great KOLs that are a finger press away from a DM or a message. And of course, the reps, like any distributor that distributes this product is going to have someone on speed dial to be able to assist, if not come into your op with you. Yeah, and as far as the dentin goes, it doesn't, this infiltrant doesn't go into the dentin. It doesn't penetrate in the dentin, right? Because Icon is... It can. Okay, because I was under the impression because the dentin is organic and hydrophilic and the infiltrant is hydrophobic, that it won't get into the dentin. That's not the case. And that's what the... Ethanol does. So yeah, the longer you etch for, the deeper you're reaching layers of the tooth and of the enamel and of the dentin. So resin infiltration can be used into a D1. lesion so dentinal initial dentinal lesion in some cases even a d2 lesion depending on how deep it is so that's why the prolonged etchant really drying the tooth out the tooth is extremely desiccated the ethanol that is in between the the hydrochloric etch and then the resin infiltration dries up those tubules and it does neutralize this hydrophobic tophilic environment so that's good to know so yeah Talk to us about the interproximal lesion from the standpoint of clinical technique. Can you walk us through, you know, your tooth numbers, as you mentioned, your nomenclature is different than ours. So let's just talk about a lower bite. Let's just talk about molars and premolars. Right, right. Lower bicuspid, the first bicuspid, distal, mesial of the second bicuspid. you've got a lesion on the first bicuspid or even both. There's interproximal decay or both. So walk us through how to make sure we control the etch and make sure that we have good isolation. What are the key things we have to be aware of? And overall, what's the clinical technique here? Yeah, absolutely. So a rubber dam is preferred. I've seen clinicians not use a rubber dam and you have a really hard time controlling moisture. And of course, that etch tastes horrible. So does the resin and so does ethanol in its purest form. So a rubber dam is really important. There are two different types of kits that you can use if you're buying the Icon kit from DMG. If you're doing an interproximal lesion, I wouldn't recommend using a DIY technique because it's so difficult to isolate where your resin goes and also where you're etching. So for a new clinician trying interproximal lesions, you will want to kind of etch and infiltrate one surface at a time and then do the other surface. For someone like me where I've done quite a few of these, I use two handles interproximal at the same time. all at the same time so follow the instructions on the box if it's the first time if not then you can be a little bit more creative and do do two lesions at the same time but essentially you're doing the same as a smooth surface you're using your 15 hydrochloric etch for anywhere between two to three minutes agitating the etch into the lesion the device that allows you to go interproximal has a little wedge to it so it'll help separate the teeth and you want to be agitating it and then you know good rinse water air try ethanol, observe the lesion. You may do that etching procedure two or three times, depending on the depth, and then allowing your resin to infiltrate for anywhere between five to even 10 minutes, depending on the depth of it. The longer you infiltrate for, the better. I see people often rushing or not allowing the resin enough time and contact, and then you end up not infiltrating to the depth of the lesion. So what about shrinkage and voids? There's no voids because it's a pure liquid. So you only have voids in your composite resins because either you're packing or you're lifting your tip when you're doing your box or your CAVO surface. But in this case, it's not a compactable material. The tooth is sucking in this liquid resin all on its own without your assistance. So there won't be any voids because it's a completely viscous material. I've yet to have a void on a smooth surface and I can see it with... eyes. So I wouldn't worry about that at all. There's a second part to your question. Shrinkage, marginal shrinkage or polymerization shrinkage. The longer you infiltrate for, the less option there is for shrinkage. And there's no physical prep margin. So there is no cavitation. That's the beauty of these lesions is that they're cavitation free. So you shouldn't have any shrinkage at all. And what about excess material that would cause the contact? configuration to change. Yeah. If you're using the device that's provided correctly, then you shouldn't have excess flash. The only time I see excess flash is if I've infiltrated for a long period of time, which I prefer. And then the tooth just has no more space to suck in any of that resin. In that case, I'll use a blade, just a regular 12 blade or 15 blade, whatever you have handy. And there is a polishing technique specifically on smooth surfaces. You'll want to polish. with your discs. And sometimes I'll use a little white stone. On an interproximal surface, I might take a disc, a soft flex disc, the like orange or yellow, and just gently polish around the surface. But most of the time I can get it off with a scaler or with a little blade. And very few instances do I cement the two teeth together. Blossing is important too. Yeah. If you're doing one tooth at a time, you're pretty safe. Overall chair time, and I also want to ask you about delegating this to an EFTA, or do they still call them EFTAs? Is that an old term? We don't have EFTAs here. So dental assistants in the province of Ontario are not able to do this procedure. Only a restorative dental hygienist is able to use this procedure on white spot lesion management for anterior teeth. So if it's an aesthetic thing, you have to be a restorative hygienist. If you're using it for remineralization of... active carious lesions so for example let's say you your only alternative would be to do silver diamine fluoride then a regular registered dental hygienist in this province can do it but not for aesthetic purposes so the scope of practice is kind of interesting i can't speak to the united states because i know every state has a different designation so um your your sales reps would know or your your state board or whatever your regulating body is should be able to tell you. Yeah, that's exactly correct. I was going to say it's a state by state thing. It's up to the state board. Same like here, province by province. So I can only really speak to what I know in my province. Yeah, that's why they call our country a republic. A republic means state run, but we're not going to get into politics here, Irene. What we also want to ask you while we have you. What's the total chair time, do you think, for typical, let's say, class two? And how do you bill for this? Like, what's the compensation typically in Canada? I know Canada is different than the U.S., but what should a U.S. dentist expect to get as compensation based on a code? Well, there is a code for resin infiltration, both on the Canadian side and on the American side. So you've got your code, we've got ours, which is a 1-3 code for us. I don't know about the American code. What I can say is in the province of Ontario, the fee guide that we have says that this should cost $73. Now, that is preposterous. So what we do is we price it. at the same price as what that restoration would cost. So let's say I'm doing an anterior tooth, and that anterior tooth technically has white spot lesions on all five surfaces, then I would bill it as a five surface restoration under the same code as resin infiltration, which means that it's probably going to be an out-of-pocket for the patient. Most of the time, insurance will cover a small percentage of it if they've got 80%, 70%, and then that co-pay is up to them. So if you were to consider what a five surface filling would cost, timing wise is probably going to be around the same, if not a little bit more. For me to do an upper arch, a complete upper arch, all smooth surfaces, I book about two and a half hours of chair time. I only do one arch at a time. If I'm doing a single site intraproximal, where there's like the quote unquote class two on one side and class two on the other, I'm going to book about an hour and 10 minutes. And that might be the same as what you're doing for two teeth with two surfaces and restoration. So some procedures that we do in the operatory, as we know, can be practice builders. They'll bring in a lot of new patients through word of mouth. It's something that patients just go, wow, that's possible to do here. Because you can imagine a young teenager who just had ortho and there's... of white spots and fluorosis is not an attractive thing to have on a smile. And with social media, they're all aware of the way they look and that's fine. So this could be a real boon for the practice to be able to offer the service. Tell us about your experience with this procedure. And I know you love Icon from DMG. And, you know, it's something that I think dentists should know about, that this is a practice builder. Yeah. So there's two ways that this has helped build my practice. Number one is through ortho. So I reached out to my local orthodontist And I introduced myself, one of whom I refer to. And I said, hey, I don't know if all of the offices that send patients to you do this procedure. Here are some of my before and after cases of white spot lesion management. And I'm not saying that these patients need to come to me and live in my practice forever. But I'm saying that this is a solution that I can provide and I'm down the street. And I'm happy to send them back to their general dentist. So I get a lot of referrals from orthodontists in the neighborhood that say, hey, I've got this person. Here are the photos. can i send them to you before they before they go back to their their practice so that's number one number two Parents, parents with little teeny tiny humans. This is a procedure that's often performed in pediatric offices because it's safe to use as early as their first tooth. So if I've got like six and seven year olds that have just their two front teeth and developmental white spots, it's safe to use on them right away. So I, I get a lot of kids, the mom Facebook groups in our neighborhood are booming. Whenever we do something great with a kid, we end up seeing phone calls from, from other patients. And then that demographic that you mentioned. Earlier, the one that I mentioned, the 20s to 30s that have lived with white spots their whole lives, perhaps from previous orthodontics that wasn't treated with white spot lesion management at the end. Those people are now coming back and they've got money and they've got insurance and they've got jobs. You know, they're the millennials. So these are the three demographics that have really exploded in our office. No, I think this has been really a great conversation. I think it's something that... probably underutilized to some extent. Yeah. Non-invasive, which is so important. You don't remove any tooth structure here. You're rebuilding tooth structure. The last question I had for you is, how often do you need to change this out? Like, what do you see two or three years down the road after you put this unfilled? Because the unfilled resin has no real super strength, right? Because it's not filled. Right. It doesn't have any resistance strength, so to speak. Right. But it also has nowhere to go. So it's infiltrated into the tooth. It's not, you know, a composite veneer that we're putting on the front of the tooth and just fingers crossed hoping that it sticks. So I haven't seen any changes to my patients. I had one actually yesterday who I did. a single tooth, a white spot lesion on her. And we took a post-op photo and it's been two and a half years and it looks the same as it did on the first day. I think post-op instructions are really important. I get patients to avoid anything that's dark, sticking to a white diet for 48 hours when those dental tubules are going to be open. So I want to minimize the opportunity for any internal or intrinsic staining to happen. They can whiten their teeth with, you know, they're in office or. at-home trays that doesn't change the composition of the tooth at all. So I haven't noticed anything at all, really. Yeah, great discussion, Irene. Obviously, you were very prepared to talk on this. You talk as if you're a total expert on it. I know you have many other topics in dentistry that you talk about. And what's the best place for our audience to find you? I know you have many, many followers. But for those of you who don't know Irene, she has a... full gamut of videos and she's very popular on the web. Where can they reach you? Instagram is my preferred platform, Tooth Life Irene. I also have a website. If they go to Instagram or Facebook and type in Tooth Life Irene, they'll find me. Very good. Irene, thank you so much for joining us. And I hope you have a great summer in Toronto and hopefully we'll have you back on the show again. Thank you so much. Appreciate it. Thank you so much. Have a great day, everyone.