Patient has patchy white spots after braces — do you really whiten, or will that just make the spots stand out more?

Tetracycline staining darker than your darkest shade tab — is bleaching even worth attempting, or is it veneers by default?

A single dark, root-filled central incisor — can you fix it without picking up a drill at all?

And how do you talk a patient through weeks, shades and cost so they actually consent to the slow, non-invasive route?

This is Part 2 of the trayless whitening series with Dr Wyman Chan — inventor of trayless teeth whitening and the Get2Smile system — and Dr Elvis Law, who now runs around 90% of his whitening trayless. Part 1 covered the science and the everyday protocol; this part applies it to the three cases dentists find hardest, with the costing and consent conversations that make them work.

Protrusive Dental Pearl: Treating Family and Friends

Almost every clinician has a story about a case that went wrong on a family member, a friend, or a loved one. It’s not a random fluke. When we treat someone we love, we put our guard down — we relax the checklist, skip a step, get driven by emotion, and lose our judgement.

So if you must treat family and friends, stay razor-sharp and treat them exactly as you would a stranger. Be extra vigilant, extra hot on your protocols, and take the emotion out of it. If that tooth needs a root canal, it needs a root canal — don’t bend the plan to preserve pulp vitality that was never the right call. The best pearl is not to treat loved ones at all; the real-world one is to not lose your judgement when you do.

What You’ll Take From This Episode

The frosted glass model — a patient-ready way to explain white spots: enamel is clear glass, dentine is a yellow sponge, and acid has turned the glass frosty.
A two-stage white spot protocol — remineralise and condition the gums first, then whiten trayless, and why a dirty tray would have sabotaged the result.
Whitening tetracycline staining — realistic timelines, why darker teeth lift faster, and how to frame it honestly against veneers.
The non-vital tooth without a drill — whiten every tooth to target, then paint the single dark tooth to match, and why leakage (not the bleach) causes rebound.
Costing and consent — charging “almost by time,” staged reviews, and matching invasiveness to the mouth in front of you.

Highlights of This Episode

00:00 Teaser
01:05 Trayless Whitening Part 2: Recap of Part 1
03:55 Protrusive Dental Pearl: Treating Family and Friends
06:55 Whitening White Spot Lesions After Orthodontics
11:55 Whiten First or Restore First? Cavitated Anterior Caries
18:35 The Frosted Glass Analogy: Explaining White Spots to Patients
21:05 A Two-Stage White Spot Protocol: Remineralise, Then Whiten
32:57 Midroll
36:23 Whitening Tetracycline-Stained Teeth
40:03 Costing and Consent: Bleaching vs Veneers
46:23 Whitening a Non-Vital Yellow Central Incisor
47:43 Why Root-Filled Teeth Rebound After Bleaching
53:13 Trayless Single-Tooth Whitening Without a Drill
1:00:43 How to Access Trayless Whitening and Training
1:03:40 Outro

From the Guest

Dr Wyman Chan is the inventor of trayless teeth whitening and the Get2Smile system, with a PhD in the efficacy and safety of teeth whitening and a whitening clinic in London’s West End. Dr Elvis Law trained in safe dental bleaching under Dr Wyman Chan and now runs the majority of his whitening trayless.

Start Offering Trayless Whitening for Your Office

UK Dentists:

In the UK you need the Get2Smile Kit which is 6% formulation applied twice daily for 30 minutes.

Head to directoralcare.com and register for a free professional account. Approval unlocks the full shop, pricing, offers and their upcoming educational courses.

At checkout, use code: DOCSUMMER20

International Dentists wishing to offer Get2Smile, please enquire from Dr Chan's website. The international version uses 10% formulation applied for 15 minutes, twice daily.

???? Want to learn directly from Dr Wyman Chan? Join him for Redefining Early Caries Management and Aesthetic Dentistry in Shanghai, China, on 20–21 October 2026.

Saturday 5th September London, UK CPD EVENT:

????Join Dr Wyman Chan for an exciting event focused on redefining the management of dental plaque-induced oral diseases.

???? Royal Asiatic Society, London NW1 2HD

The session will include a live lecture, clinical demonstration, and the opportunity to take part in practical, hands-on training. Dr Wyman Chan will be joined by Dr Niki Shah and Dr Elvis Law, who will also showcase their clinical cases.

Want more?

If you enjoyed this episode, check out: MAGIC Teeth Whitening with Dr. Wyman Chan – PDP245 — Wyman’s first Protrusive episode, covering whitening myths, sensitivity, and whether in-office lights do anything at all..

Tags

PDPMainEpisodes

Listen, Subscribe, Earn CPD

Listen: Subscribe to the Protrusive Dental Podcast on Spotify, Apple Podcasts, or YouTube.

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 780 Esthetics/Cosmetic Dentistry.

Aim & Learning Outcomes

Aim: To give dental practitioners a practical, non-invasive approach to three difficult whitening presentations — post-orthodontic white spot lesions, tetracycline staining, and a discoloured non-vital tooth — together with the expectation-setting and consent conversations that make treatment succeed.

Learning Outcomes — by the end of this episode, dentists will be able to:

Describe how enamel demineralisation produces white spot lesions and explain, in patient-friendly terms, why a repair-then-whiten sequence addresses both the surface and the underlying tooth colour.
Apply a staged, non-invasive protocol to manage white spot, tetracycline and non-vital discolouration cases, selecting an appropriate route by matching invasiveness to the individual patient.
Articulate realistic expectations on shade, timeline and cost, and use them to obtain informed consent for an extended, reviewable whitening course.

View Details

Patient has patchy white spots after braces — do you really whiten, or will that just make the spots stand out more?

Tetracycline staining darker than your darkest shade tab — is bleaching even worth attempting, or is it veneers by default?

A single dark, root-filled central incisor — can you fix it without picking up a drill at all?

And how do you talk a patient through weeks, shades and cost so they actually consent to the slow, non-invasive route?

https://youtu.be/1PyL-dXRVHoWatch PDP278 on YouTubeProtrusive Dental Pearl: Treating Family and Friends

What You’ll Take From This Episode

The frosted glass model — a patient-ready way to explain white spots: enamel is clear glass, dentine is a yellow sponge, and acid has turned the glass frosty.
A two-stage white spot protocol — remineralise and condition the gums first, then whiten trayless, and why a dirty tray would have sabotaged the result.
Whitening tetracycline staining — realistic timelines, why darker teeth lift faster, and how to frame it honestly against veneers.
The non-vital tooth without a drill — whiten every tooth to target, then paint the single dark tooth to match, and why leakage (not the bleach) causes rebound.
Costing and consent — charging “almost by time,” staged reviews, and matching invasiveness to the mouth in front of you.

Highlights of This Episode

00:00 Teaser
01:05 Trayless Whitening Part 2: Recap of Part 1
03:55 Protrusive Dental Pearl: Treating Family and Friends
06:55 Whitening White Spot Lesions After Orthodontics
11:55 Whiten First or Restore First? Cavitated Anterior Caries
18:35 The Frosted Glass Analogy: Explaining White Spots to Patients
21:05 A Two-Stage White Spot Protocol: Remineralise, Then Whiten
32:57 Midroll
36:23 Whitening Tetracycline-Stained Teeth
40:03 Costing and Consent: Bleaching vs Veneers
46:23 Whitening a Non-Vital Yellow Central Incisor
47:43 Why Root-Filled Teeth Rebound After Bleaching
53:13 Trayless Single-Tooth Whitening Without a Drill
1:00:43 How to Access Trayless Whitening and Training
1:03:40 Outro

From the Guest

Start Offering Trayless Whitening for Your OfficeUK Dentists:

In the UK you need the Get2Smile Kit which is 6% formulation applied twice daily for 30 minutes.

Head to directoralcare.com and register for a free professional account. Approval unlocks the full shop, pricing, offers and their upcoming educational courses.

At checkout, use code: DOCSUMMER20

The Trayless whitening system is called Get2Smile.

International Dentists wishing to offer Get2Smile, please enquire from Dr Chan’s website. The international version uses 10% formulation applied for 15 minutes, twice daily.

???? Want to learn directly from Dr Wyman Chan? Join him for Redefining Early Caries Management and Aesthetic Dentistry in Shanghai, China, on 20–21 October 2026.

Saturday 5th September London, UK CPD EVENT:

????Join Dr Wyman Chan for an exciting event focused on redefining the management of dental plaque-induced oral diseases.

???? Royal Asiatic Society, London NW1 2HDThe session will include a live lecture, clinical demonstration, and the opportunity to take part in practical, hands-on training. Dr Wyman Chan will be joined by Dr Niki Shah and Dr Elvis Law, who will also showcase their clinical cases.

Want more?

Tags

PDPMainEpisodes

Listen, Subscribe, Earn CPD

Listen: Subscribe to the Protrusive Dental Podcast on Spotify, Apple Podcasts, or YouTube.

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 780 Esthetics/Cosmetic Dentistry.

Aim & Learning Outcomes

Learning Outcomes — by the end of this episode, dentists will be able to:

Describe how enamel demineralisation produces white spot lesions and explain, in patient-friendly terms, why a repair-then-whiten sequence addresses both the surface and the underlying tooth colour.
Apply a staged, non-invasive protocol to manage white spot, tetracycline and non-vital discolouration cases, selecting an appropriate route by matching invasiveness to the individual patient.
Articulate realistic expectations on shade, timeline and cost, and use them to obtain informed consent for an extended, reviewable whitening course.

View Details

What if the tray is the reason your whitening results are inconsistent?

Why would a dentist who owns a whitening lab — and holds four patents on making bleaching trays — tell you to skip the tray?

Trayless whitening does not mean strips. It means the patient puts in a retractor and paints the gel directly onto the teeth, twice a day, for half an hour. No impression, no lab bill, no two-week wait, and no soft plastic reservoir quietly absorbing your peroxide.

This is Part 1 of a two-part conversation with Dr Wyman Chanand Dr Elvis Law, recorded live in their central London whitening practice. Wyman has done nothing but whitening since 2002, has a PhD on the efficacy and safety of whitening processes, and — despite owning the lab that makes the trays — now does most of his cases without one. Elvis trained under him and reckons around 90% of his own cases are now trayless.

Part 1 is the mechanism, the protocol and an honest list of who it doesn’t suit. Part 2 takes it into the hard cases.Protrusive Dental Pearl: Let the Patient Pick the ShadeMost of us ask “how white do you want to go?”, get a laugh about Hollywood white or Simon Cowell white, then hold a B1 tab against the canine and call that the destination. Try flipping it.

Under corrected light, record where the patient is now. Then hand over the whole shade guide, arranged by value, and let them choose the tab they want to reach. Photograph both.

This is the VITA Shade guide arranged by value:

B1 → A1 → B2 → D2 → A2 → C1 → C2 → D4 → A3 → D3 → B3 → A3.5 → B4 → C3 → A4 → C4

Two things change. You now know the target precisely instead of inferring it, and you can track progress against a fixed reference. Most patients land on B1 — it’s the last shade before the bleach range, and it reads natural rather than veneered. Some will point at 0M1 and that’s a different conversation, which is exactly the point.

Because whatever they choose dictates how many weeks, how much gel and how many reviews the case needs — and therefore what it should cost. A single flat whitening fee assumes every case takes the same work. They don’t. Someone starting at C4 who wants a bleach shade can get there, but it takes more gel, more time, more reviews and probably a protocol change along the way. Price that honestly.

Only you can decide what the tiers look like in your practice. But it might be worth sitting down as a team of dentists and therapists and asking: how are we delivering whitening? Two tiers? More? Based on what?

What You’ll Take From This Episode

Conscious bleaching — why an awake patient with an open mouth is a completely different chemical situation to a sealed tray worn overnight, and what that does to sensitivity.
The formulation constraint — peroxide needs acid to stay stable on the shelf, which is why pre-mixed products lean acidic and why two-component gels exist at all.
The full trayless protocol — wear schedule, spacing, patient positioning, review intervals and what to troubleshoot first when a case is behind.
Who it doesn’t suit — an honest contraindications list, including the one objection patients raise most often and the answer to it.
Tray hygiene as a clinical instruction — the reason results vary so much between patients using the identical gel.
An A3.5 to B1 case — start to finish in three weeks, with the review points and the maintenance plan.

Highlights of This Episode

00:00 TEASER
01:05 Trayless Teeth Whitening Explained
03:40 Protrusive Dental Pearl: Let Patients Pick Their Whitening Shade
06:05 Meet the Guests: A Career Built on Teeth Whitening
10:27 What Is Trayless Whitening? (It's Not Whitening Strips)
13:44 Why Whitening Trays Waste Your Bleaching Gel
15:37 Are Whitening Strips Acidic? Gel Formulation Explained
19:17 Conscious Bleaching and Whitening Sensitivity
24:43 When NOT to Use Trayless Whitening
29:05 The Trayless Whitening Protocol: 30 Minutes Twice a Day
32:55 Midroll
42:45 How to Clean Whitening Trays Properly
50:02 A3.5 to B1 in Three Weeks: A Case Walkthrough
56:16 Tooth Porosity and the 45-Degree Recline Rule
1:02:09 Whitening Top-Ups and the Five-Year Guarantee
1:06:49 How to Price Teeth Whitening and Let Patients Pick the Shade
1:07:45 OUTRO
1:12:56 What's Coming in Part 2

Start Offering Trayless Whitening for Your Office

UK Dentists:

In the UK you need the Get2Smile Kit which is 6% formulation applied twice daily for 30 minutes.

Head to directoralcare.com and register for a free professional account. Approval unlocks the full shop, pricing, offers and their upcoming educational courses.

At checkout, use code: DOCSUMMER20The Trayless whitening system is called Get2Smile.International Dentists wishing to offer Get2Smile, please enquire from Dr Chan's website. The international version uses 10% formulation applied for 15 minutes, twice daily.

???? Want to learn directly from Dr Wyman Chan? Join him for Redefining Early Caries Management and Aesthetic Dentistry in Shanghai, China, on 20–21 October 2026.

Join Dr Wyman Chan for an exciting event focused on redefining the management of dental plaque-induced oral diseases.The session will include a live lecture, clinical demonstration, and the opportunity to take part in practical, hands-on training. Dr Wyman Chan will be joined by Dr Niki Shah and Dr Elvis Law, who will also showcase their clinical cases.

Want more?

Tags

PDPMainEpisodes

Listen, Subscribe, Earn CPD

Listen: Subscribe to the Protrusive Dental Podcast on Spotify, Apple Podcasts, or YouTube.

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C.

AGD Subject Code: 780 Esthetics/Cosmetic Dentis...

View Details

What if the tray is the reason your whitening results are inconsistent?

Why would a dentist who owns a whitening lab — and holds four patents on making bleaching trays — tell you to skip the tray?

This is Part 1 of a two-part conversation with Dr Wyman Chan and Dr Elvis Law, recorded live in their central London whitening practice. Wyman has done nothing but whitening since 2002, has a PhD on the efficacy and safety of whitening processes, and — despite owning the lab that makes the trays — now does most of his cases without one. Elvis trained under him and reckons around 90% of his own cases are now trayless.

Part 1 is the mechanism, the protocol and an honest list of who it doesn’t suit. Part 2 takes it into the hard cases.

https://youtu.be/aAAoUxTIkxoWatch PDP277 on YouTubeProtrusive Dental Pearl: Let the Patient Pick the Shade

Most of us ask “how white do you want to go?”, get a laugh about Hollywood white or Simon Cowell white, then hold a B1 tab against the canine and call that the destination. Try flipping it.

Under corrected light, record where the patient is now. Then hand over the whole shade guide, arranged by value, and let them choose the tab they want to reach. Photograph both.

This is the VITA Shade guide arranged by value:

B1 → A1 → B2 → D2 → A2 → C1 → C2 → D4 → A3 → D3 → B3 → A3.5 → B4 → C3 → A4 → C4

What You’ll Take From This Episode

Conscious bleaching — why an awake patient with an open mouth is a completely different chemical situation to a sealed tray worn overnight, and what that does to sensitivity.
The formulation constraint — peroxide needs acid to stay stable on the shelf, which is why pre-mixed products lean acidic and why two-component gels exist at all.
The full trayless protocol — wear schedule, spacing, patient positioning, review intervals and what to troubleshoot first when a case is behind.
Who it doesn’t suit — an honest contraindications list, including the one objection patients raise most often and the answer to it.
Tray hygiene as a clinical instruction — the reason results vary so much between patients using the identical gel.
An A3.5 to B1 case — start to finish in three weeks, with the review points and the maintenance plan.

Highlights of This Episode

00:00 TEASER
01:05 Trayless Teeth Whitening Explained
03:40 Protrusive Dental Pearl: Let Patients Pick Their Whitening Shade
06:05 Meet the Guests: A Career Built on Teeth Whitening
10:27 What Is Trayless Whitening? (It’s Not Whitening Strips)
13:44 Why Whitening Trays Waste Your Bleaching Gel
15:37 Are Whitening Strips Acidic? Gel Formulation Explained
19:17 Conscious Bleaching and Whitening Sensitivity
24:43 When NOT to Use Trayless Whitening
29:05 The Trayless Whitening Protocol: 30 Minutes Twice a Day
32:55 Midroll
42:45 How to Clean Whitening Trays Properly
50:02 A3.5 to B1 in Three Weeks: A Case Walkthrough
56:16 Tooth Porosity and the 45-Degree Recline Rule
1:02:09 Whitening Top-Ups and the Five-Year Guarantee
1:06:49 How to Price Teeth Whitening and Let Patients Pick the Shade
1:07:45 OUTRO
1:12:56 What’s Coming in Part 2

Start Offering Trayless Whitening for Your OfficeUK Dentists:

In the UK you need the Get2Smile Kit which is 6% formulation applied twice daily for 30 minutes.

Head to directoralcare.com and register for a free professional account. Approval unlocks the full shop, pricing, offers and their upcoming educational courses.

At checkout, use code: DOCSUMMER20

The Trayless whitening system is called Get2Smile.

International Dentists wishing to offer Get2Smile, please enquire from Dr Chan’s website. The international version uses 10% formulation applied for 15 minutes, twice daily.

???? Want to learn directly from Dr Wyman Chan? Join him for Redefining Early Caries Management and Aesthetic Dentistry in Shanghai, China, on 20–21 October 2026.

Saturday 5th September London, UK CPD EVENT:

Join Dr Wyman Chan for an exciting event focused on redefining the management of dental plaque-induced oral diseases.

Want more?

Tags

PDPMainEpisodes

Listen, Subscribe, Earn CPD

Listen: Subscribe to the Protrusive Dental Podcast on Spotify, Apple Podcasts, or YouTube.

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C.

AGD Subject Code: 780 Esthetics/Cosmetic Dentistry.

Aim & Learning Outcomes

Aim: To give dental practitioners a mechanism-led understanding of external tooth whitening delivered without a tray — how gel containment and contact time influence sensitivity and efficiency, how formulation constrains the delivery method, and how to select, sequence and price a whitening case around the patient’s chosen target shade.

Learning Outcomes — by the end of this episode, dentists will be able to:

Describe how containment and contact time influence bleaching sensitivity, gingival irritation and the proportion of active gel that reaches the tooth.
Apply a structured protocol for tray-free external whitening, including wear scheduling, patient positioning, review intervals and technique troubleshooting.
Differentiate between patients suited to tray-based and tray-free delivery, and justify a fee structure derived from the patient’s target shade rather than a flat rate.

View Details

Just qualified — so why does it feel like the learning is only just beginning?

What should you actually focus on in year one: the flawless dentistry on your feed, or something far less glamorous?

How do you tell a patient their nerve might die — without it sounding like YOUR fault?

And when a patient says “just do whatever you think” — what do you say back?

This is the conversation every new dentist needs and every experienced one recognises. Our guest is Dr Emma Hutchison — a former dental nurse who trained at the University of Glasgow, and has been the face of the Protrusive Students series across her studies. We recorded in her final weeks of dental school, right on the threshold of practice, and talked through everything the syllabus skips: the safe-beginner mindset, what to learn (and what to ignore) early on, how to protect your standards under time pressure, which cases to take on, and how to talk to patients about risk, cost and consent so the words actually land. If you’re fresh out, this one hits hard. If you’re an oldie, it’s a trip down memory lane — and a reminder of how far you’ve come.

https://youtu.be/gjJiDVP4w-4

Watch PDP276 on YouTube

Protrusive Dental Pearl: Predict the Complication Before It Happens

A communication pearl for every deep restoration. When a filling sits close to the nerve — a big cavity, a crack — name the likely complication before it happens. Show the patient the images, then tell them what to expect: a twinge to cold or hot that can linger a few days, so keep taking painkillers and keep the area clean. And warn them what a red flag looks like: a severe throbbing ache keeping them up at night, or pain out of the blue without eating or drinking, means the nerve is struggling and they should call you.

Do this and, if the complication ever arrives, you look like the expert who called it — not someone something went wrong for. Skip it and reception fields the panicked calls instead. It reassures the patient, lowers your callback rate, and quietly reduces your risk profile. Obvious, easy to forget, and worth saying out loud every single time.

What You’ll Take From This Episode

The safe-beginner mindset — why qualifying is the driving licence, not the destination, and how the happiest dentists keep getting 1% better.
Just-in-time learning — study for the cases actually in your diary, not the obscure pathology you won’t meet for years.
Get good before you get fast — master the bread and butter, protect a little extra time early, and reflect on every procedure.
Clever hacks vs cutting corners — how to tell the difference, and why every shortcut quietly rewires the habit.
Consent that works — getting patients to own the problem, and giving a clear recommendation instead of a fifteen-item menu.

Highlights of This Episode

00:00 Teaser
01:05 The Things Dental School Doesn’t Prepare You For
03:05 Communication Pearl: Predict the Complication Before It Happens
05:35 Life as a Final-Year Dental Student on Outreach
09:55 Why You’re Only a “Safe Beginner” When You Qualify
13:45 Master Bread-and-Butter Dentistry Before the Fancy Stuff
16:05 Just-in-Time Learning: Study for the Cases in Front of You
18:05 Get Good Before You Get Fast (and Protect Your Time)
19:45 Clever Hacks vs Cutting Corners: Don’t Lose Your Standards
24:14 Midroll
27:46 The Skills to Nail in Your First Year as a Dentist
30:11 Which Cases to Take On — and Learning From Mistakes
35:46 How to Explain Risk and Get Patients to Own the Problem
41:26 When Patients Refuse the Ideal Treatment: Start With Their Goal
44:26 Treatment Planning Without the Overwhelm: Loom & “Guess Who”
47:36 Claim Your CPD & Become the Next Protrusive Student
47:38 Outro

Dr Emma Hutchison came to dentistry the long way round — from a dental nursing background into dental school at the University of Glasgow, with final-year outreach on the Kintyre peninsula in Campbeltown. She has been the face of the Protrusive Students series throughout her studies, and this episode marks her crossing from student to newly qualified dentist. On behalf of the whole Protruserati: we’re proud of you, Emma.

Become the next Protrusive Student: with Emma qualifying, we’re looking for the next keen student who wants part-time work, an income while studying, and to contribute to Protrusive — or a nudge if you know one. DM the team inside the Protrusive Guidance app.

Resources & Mentions From This Episode

Quick & slick rubber dam — the in-app video series on quadrant isolation, for building the rubber dam habit from day one.
21-Day Photography Challenge — the in-app challenge that walks you through capturing every clinical photo, including the dreaded occlusal shots, in your first three weeks.
Loom School — in-app training on async, Loom-video treatment planning (roughly 90 minutes of CPD across around 15 bite-sized lessons).

Access the above masterclasses and more when you subscribe to the Ultimate or Infinity plan.

Want more?

If you enjoyed this episode, check out: Periodontics for Beginners – PS008

PDPMainEpisodes #CareerDevelopment #Communication

Listen, Subscribe, Earn CPD

Listen: Subscribe to the Protrusive Dental Podcast on Spotify, Apple Podcasts, or YouTube.

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and D.

AGD Subject Code: 770 Self-Improvement

Aim & Learning Outcomes

Aim: To give early-career dentists a practical framework for the transition from dental school to independent practice — how to keep developing, how to protect clinical standards under time pressure, and how to communicate risk and treatment options as part of valid consent.

Learning Outcomes — by the end of this episode, dentists will be able to:

Apply a “just-in-time” approach to continuing development, prioritising the competencies relevant to the cases in front of them over isolated advanced techniques.
Differentiate time-saving efficiencies from quality-compromising shortcuts, and describe strategies to maintain clinical standards early in practice.
Apply structured communication techniques to explain procedural risk, establish a patient’s treatment goal, and make a clear, defensible recommendation as part of va...

View Details

Your patient brushes well, avoids sweets — and still keeps getting decay. What if the answer isn’t in their mouth at all?

What if two inexpensive finger-prick tests told you more about a patient’s gum disease and implant prognosis than anything on the radiograph?

And here’s the uncomfortable one: if the science is this clear, is not checking starting to look like a medico-legal risk? Especially for imlpant surgery!

This is a conversation with Dr Tif Qureshi— the dentist who changed how the profession thinks about the lifelong patient, the envelope of function, and Align, Bleach, Bond. He’s gone down a new rabbit hole: metabolic health. In general practice he’s now doing blood tests — HbA1c and vitamin D — and making the case that the mouth isn’t connected to the body, it is the body. This isn’t about becoming a “biological dentist” (as you’ll hear, Tif is refreshingly blunt about the wilder end of that world). It’s about respecting the biology, screening sensibly, and helping patients where we’re genuinely placed to help.

https://youtu.be/mt1MXLFCTp0

Watch PDP275 on YouTube

Protrusive Dental Pearl: Test Yourself First

Before you even think about introducing blood tests for your patients, ask whether you’re checking your own biomarkers at a sensible interval. The deepest way to understand this topic is to learn it on yourself and your family first — run your own HbA1c, vitamin D, iron, and liver and kidney markers, and see what the data tells you.

Start quarterly, like hygienist visits, then stretch to six-monthly or annual once things look good. Getting invested in your own numbers is what makes better food and lifestyle choices actually stick — and it’s the honest starting point for ever offering this to a patient.

What You’ll Take From This Episode

The metabolic lens — why one disordered glucose-and-insulin system sits under so much chronic and dental disease, and why dentistry is well placed to act on it.
Sugar, redefined — why patients who avoid sweets still get decay, and how frequency of starchy carbs drives the problem.
The two biomarkers that matter most — what HbA1c and vitamin D each tell you about caries, perio and healing.
How to run it in practice — finger-prick logistics, what to test, and how to raise it on the medical history form.
The medico-legal case — why documenting these markers can protect you before implant, graft and perio work.

Highlights of This Episode

00:00 Why Dentists Should Care About Blood Tests
06:00 Metabolic Disease: The Root Cause Dentists Miss
13:00 Why Starchy Carbs Cause Decay, Not Just Sugar
15:50 HbA1c and Caries: What the SHIP Study Shows
21:00 Insulin Resistance: The Hidden Driver of Gum Disease
26:00 How to Talk to Patients About Diet Without Scaring Them
31:00 Why Vitamin D Deserves a Place in Dentistry
34:00 Vitamin D, Implant Failure and Perio Risk
37:00 Blood Tests as Medico-Legal Defence
42:00 What Dentists Should Test: HbA1c and Vitamin D
44:00 How In-Practice Blood Testing Actually Works
50:00 The Mouth Is the Body: Screening, Not Diagnosing
51:00 Is This Biological Dentistry? An Honest Answer
57:00 How to Learn Blood Testing for Your Practice

From the Guest

Dr Tif Qureshi qualified from King’s College London in 1992 and is a Past President of the British Academy of Cosmetic Dentistry. He is Founder and Clinical Director of IAS Academy, best known for pioneering Align, Bleach, Bond and Progressive Smile Design, and as a teacher of the Dahl concept. His current focus is metabolic health in general practice.

???? IAS Academy — Align, Bleach, Bond, the Dahl concept, and blood-testing / metabolic health training

Coming soon: Join Dr. Tif in one-day metabolic health programme. He has spent years connecting the dots between what’s happening in the mouth and what’s happening in the body. The results are undeniable: better outcomes, stronger case acceptance, and a rock-solid medico-legal position.

This one-day course will change the way you practise. For good.????Metabolic Health in Dentistry

References & Further Reading

Studies and sources referenced in this episode:

Song I-S, et al. Severe Periodontitis Is Associated with Insulin Resistance in Non-abdominal Obese Adults. J Clin Endocrinol Metab, 2016;101(11):4251–4259. Insulin resistance as an independent risk factor for severe perio in normal-weight adults.
Botelho J, et al. Vitamin D Deficiency and Oral Health: A Comprehensive Review. Nutrients, 2020;12(5):1471. Vitamin D across caries, periodontitis, orthodontic and surgical outcomes.
Schmolinsky J, Kocher T, Rathmann W, Völzke H, Pink C, Holtfreter B. Diabetes status affects long-term changes in coronal caries – The SHIP Study. Sci Rep. 2019 Oct 30;9(1):15685. doi: 10.1038/s41598-019-51086-z. PMID: 31666549; PMCID: PMC6821733.

Want more?

If you enjoyed this episode, check out: Why do some Dentists find Dahl Distasteful? – PDP016.

PDPMainEpisodes #BeyondDentistry #Communication

Listen, Subscribe, Earn CPD

Listen: Subscribe to the Protrusive Dental Podcast on Spotify, Apple Podcasts, or YouTube.

This episode is eligible for 1.0 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C and A.

AGD Subject Code: 730 Oral Medicine, Oral Diagnosis, Oral Pathology

Aim & Learning Outcomes

Aim: To help dental practitioners understand the link between metabolic health and oral disease, and to evaluate whether simple in-practice biomarker screening has a place in their care of patients.

Learning Outcomes — by the end of this episode, dentists will be able to:

Describe how disordered glucose and insulin metabolism relates to caries, periodontal disease and healing outcomes, and explain what HbA1c and vitamin D each indicate.
Apply a structured, non-alarmist approach to discussing diet and biomarker screening with patients, within the professional boundary of screening rather than diagnosing or prescribing.
Evaluate the clinical and medico-legal case for documenting relevant biomarkers before periodontal and surgical treatment, and identify when to refer to a medical colleague.

View Details

Your patient brushes well, avoids sweets — and still keeps getting decay. What if the answer isn’t in their mouth at all?

What if two inexpensive finger-prick tests told you more about a patient’s gum disease and implant prognosis than anything on the radiograph?

And here’s the uncomfortable one: if the science is this clear, is not checking starting to look like a medico-legal risk? Especially for imlpant surgery!

This is a conversation with Dr Tif Qureshi — the dentist who changed how the profession thinks about the lifelong patient, the envelope of function, and Align, Bleach, Bond. He’s gone down a new rabbit hole: metabolic health. In general practice he’s now doing blood tests — HbA1c and vitamin D — and making the case that the mouth isn’t connected to the body, it is the body. This isn’t about becoming a “biological dentist” (as you’ll hear, Tif is refreshingly blunt about the wilder end of that world). It’s about respecting the biology, screening sensibly, and helping patients where we’re genuinely placed to help.

https://youtu.be/mt1MXLFCTp0Watch PDP275 on YouTubeProtrusive Dental Pearl: Test Yourself First

What You’ll Take From This Episode

The metabolic lens — why one disordered glucose-and-insulin system sits under so much chronic and dental disease, and why dentistry is well placed to act on it.
Sugar, redefined — why patients who avoid sweets still get decay, and how frequency of starchy carbs drives the problem.
The two biomarkers that matter most — what HbA1c and vitamin D each tell you about caries, perio and healing.
How to run it in practice — finger-prick logistics, what to test, and how to raise it on the medical history form.
The medico-legal case — why documenting these markers can protect you before implant, graft and perio work.

Highlights of This Episode

00:00 Why Dentists Should Care About Blood Tests
06:00 Metabolic Disease: The Root Cause Dentists Miss
13:00 Why Starchy Carbs Cause Decay, Not Just Sugar
15:50 HbA1c and Caries: What the SHIP Study Shows
21:00 Insulin Resistance: The Hidden Driver of Gum Disease
26:00 How to Talk to Patients About Diet Without Scaring Them
31:00 Why Vitamin D Deserves a Place in Dentistry
34:00 Vitamin D, Implant Failure and Perio Risk
37:00 Blood Tests as Medico-Legal Defence
42:00 What Dentists Should Test: HbA1c and Vitamin D
44:00 How In-Practice Blood Testing Actually Works
50:00 The Mouth Is the Body: Screening, Not Diagnosing
51:00 Is This Biological Dentistry? An Honest Answer
57:00 How to Learn Blood Testing for Your Practice

From the Guest

???? IAS Academy — Align, Bleach, Bond, the Dahl concept, and blood-testing / metabolic health training

This one-day course will change the way you practise. For good.????Metabolic Health in Dentistry

References & Further Reading

Studies and sources referenced in this episode:

Song I-S, et al. Severe Periodontitis Is Associated with Insulin Resistance in Non-abdominal Obese Adults. J Clin Endocrinol Metab, 2016;101(11):4251–4259. Insulin resistance as an independent risk factor for severe perio in normal-weight adults.
Botelho J, et al. Vitamin D Deficiency and Oral Health: A Comprehensive Review. Nutrients, 2020;12(5):1471. Vitamin D across caries, periodontitis, orthodontic and surgical outcomes.
Schmolinsky J, Kocher T, Rathmann W, Völzke H, Pink C, Holtfreter B. Diabetes status affects long-term changes in coronal caries – The SHIP Study. Sci Rep. 2019 Oct 30;9(1):15685. doi: 10.1038/s41598-019-51086-z. PMID: 31666549; PMCID: PMC6821733.

Want more?

If you enjoyed this episode, check out: Why do some Dentists find Dahl Distasteful? – PDP016.

PDPMainEpisodes #BeyondDentistry #Communication

Listen, Subscribe, Earn CPD

Listen: Subscribe to the Protrusive Dental Podcast on Spotify, Apple Podcasts, or YouTube.

This episode is eligible for 1.0 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C and A.

AGD Subject Code: 730 Oral Medicine, Oral Diagnosis, Oral Pathology

Aim & Learning Outcomes

Aim: To help dental practitioners understand the link between metabolic health and oral disease, and to evaluate whether simple in-practice biomarker screening has a place in their care of patients.

Learning Outcomes — by the end of this episode, dentists will be able to:

Describe how disordered glucose and insulin metabolism relates to caries, periodontal disease and healing outcomes, and explain what HbA1c and vitamin D each indicate.
Apply a structured, non-alarmist approach to discussing diet and biomarker screening with patients, within the professional boundary of screening rather than diagnosing or prescribing.
Evaluate the clinical and medico-legal case for documenting relevant biomarkers before periodontal and surgical treatment, and identify when to refer to a medical colleague.

View Details

Filling, stainless steel crown, pulpotomy or extraction — how do you actually decide on a deciduous tooth?

Why is the lower first primary molar the one that always seems to flare up?

When should you reach for silver diamine fluoride instead of the drill — and when is a child’s cooperation telling you to change the plan entirely?

And how do you actually do a pulpotomy, step by step, without it blowing up under the crown?

This is a paediatric dentistry masterclass with Dr Nidhi Kotak — “The Baby Tooth Dentist,”. It’s built for the general dentist who treats children and wants clearer rules: when to fill versus crown, how to read the radiograph, silver diamine fluoride, local anaesthetic and behaviour guidance, isolation, and a full pulpotomy and stainless steel crown technique. The through-line is simple — in children you decide fast, protect the airway, and treat for predictability rather than heroics.

https://youtu.be/3OscfwF7SIQWatch PDP274 on YouTubeProtrusive Dental Pearl: Strategic Flexibility

You cannot be rigid when treating children. The mindset shift is to stop asking “what should be done for this child?” and start asking “what can be done for this child?” With children you have to be fast and efficient, and curveballs are constant — sometimes the parent is harder to manage than the child. So the plan has to bend.

The worked example: you planned a conventional prepped stainless steel crown, but cooperation drops mid-appointment. Rather than abandon the visit, switch to a no-prep whole-crown approach and protect the tooth anyway. It stays in the child’s best interest — and it’s far kinder to your own mental health. It’s a mindset worth carrying into all of dentistry, not just children’s.

What You’ll Take From This Episode

When to fill vs crown — the surface rule for baby molars, why crowns are so predictable in children, and where composites still work.
The “D” devil tooth — why the lower first primary molar flares up, and why mesial caries on a D is an automatic crown.
Pulpotomy indications — the signs that say vital pulpotomy, the ones that say extraction, and why a pulp exposure in a primary tooth is an automatic pulpotomy.
SDF, sedation and isolation — arresting decay without drilling, matching sedation to the child, and protecting the airway.
The pulpotomy technique — a full step-by-step from caries removal to cementing the stainless steel crown, including the modern medicament choice.

Highlights of This Episode

00:00 TEASER
00:59 Pediatric Dentistry for GDPs: The Strategic Flexibility Mindset
07:24 Why GDPs Struggle Treating Children
08:19 When to Fill vs When to Crown a Baby Tooth
12:18 Class II vs Stainless Steel Crown: The Surface Rule
13:41 Reading Pediatric Radiographs & When to Take Bitewings
19:15 SDF vs Fluoride Varnish: When to Use Each
22:37 Resin Infiltration (Icon) for Children’s Teeth
25:15 Pulpotomy in Primary Teeth: When It’s Indicated
26:19 The “D” Devil Tooth: Why Mesial Caries Means a Crown
27:31 Hall Crowns and the Modified Whole Crown Technique
27:48 Midroll
38:39 Local Anaesthetic & Behaviour Guidance in Children
40:38 Sedation Options: Oral, Nitrous & Intranasal
46:22 Rubber Dam vs Isolite: Isolation for Kids
48:59 How to Do a Pulpotomy: Step-by-Step Technique
58:03 OUTRO

Dr Nidhi Kotak is a dual US and Canadian board-certified paediatric dentist — a Diplomate of the American Board of Pediatric Dentistry and a Fellow of the Royal College of Dentists of Canada.

Follow Dr. Nidhi for more paediatric dentistry tips ???? @babytoothdentist on Instagram

Want more?

If you enjoyed this episode, check out: Zirconia vs Metal Hall Crowns vs Conventional with Dr Tim Keys – PDP227

PDPMainEpisodes #EndoRestorative

Listen, Subscribe, Earn CPD

Listen: Subscribe to the Protrusive Dental Podcast on Spotify, Apple Podcasts, or YouTube.

This episode is eligible for 1.0 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 430 Pediatric Dentistry.

Aim & Learning Outcomes

Aim: To give dental practitioners a clear, decision-led approach to restorative paediatric dentistry — how to choose between filling, crowning, pulpotomy and extraction, how to manage caries conservatively, and how to carry out a pulpotomy and stainless steel crown safely.

Learning Outcomes — by the end of this episode, dentists will be able to:

Differentiate the presentations that indicate a direct restoration, a stainless steel crown, a vital pulpotomy, or an extraction in the primary dentition, using clinical and radiographic findings.
Describe minimally invasive and behaviour-management options in children — silver diamine fluoride, fluoride varnish, resin infiltration, local anaesthesia, sedation and isolation — and select them appropriately for the individual child.
Apply a step-by-step technique for a vital pulpotomy and stainless steel crown in a primary molar, including the current choice of medicament and cementation.

View Details

Filling, stainless steel crown, pulpotomy or extraction — how do you actually decide on a deciduous tooth?

Why is the lower first primary molar the one that always seems to flare up?

When should you reach for silver diamine fluoride instead of the drill — and when is a child’s cooperation telling you to change the plan entirely?

And how do you actually do a pulpotomy, step by step, without it blowing up under the crown?

https://youtu.be/3OscfwF7SIQWatch PDP274 on YouTubeProtrusive Dental Pearl: Strategic Flexibility

What You’ll Take From This Episode

When to fill vs crown — the surface rule for baby molars, why crowns are so predictable in children, and where composites still work.
The “D” devil tooth — why the lower first primary molar flares up, and why mesial caries on a D is an automatic crown.
Pulpotomy indications — the signs that say vital pulpotomy, the ones that say extraction, and why a pulp exposure in a primary tooth is an automatic pulpotomy.
SDF, sedation and isolation — arresting decay without drilling, matching sedation to the child, and protecting the airway.
The pulpotomy technique — a full step-by-step from caries removal to cementing the stainless steel crown, including the modern medicament choice.

Highlights of This Episode

00:00 TEASER
00:59 Pediatric Dentistry for GDPs: The Strategic Flexibility Mindset
07:24 Why GDPs Struggle Treating Children
08:19 When to Fill vs When to Crown a Baby Tooth
12:18 Class II vs Stainless Steel Crown: The Surface Rule
13:41 Reading Pediatric Radiographs & When to Take Bitewings
19:15 SDF vs Fluoride Varnish: When to Use Each
22:37 Resin Infiltration (Icon) for Children’s Teeth
25:15 Pulpotomy in Primary Teeth: When It’s Indicated
26:19 The “D” Devil Tooth: Why Mesial Caries Means a Crown
27:31 Hall Crowns and the Modified Whole Crown Technique
27:48 Midroll
38:39 Local Anaesthetic & Behaviour Guidance in Children
40:38 Sedation Options: Oral, Nitrous & Intranasal
46:22 Rubber Dam vs Isolite: Isolation for Kids
48:59 How to Do a Pulpotomy: Step-by-Step Technique
58:03 OUTRO

Dr Nidhi Kotak is a dual US and Canadian board-certified paediatric dentist — a Diplomate of the American Board of Pediatric Dentistry and a Fellow of the Royal College of Dentists of Canada.

Follow Dr. Nidhi for more paediatric dentistry tips ???? @babytoothdentist on Instagram

Want more?

If you enjoyed this episode, check out: Zirconia vs Metal Hall Crowns vs Conventional with Dr Tim Keys – PDP227

PDPMainEpisodes #EndoRestorative

Listen, Subscribe, Earn CPD

Listen: Subscribe to the Protrusive Dental Podcast on Spotify, Apple Podcasts, or YouTube.

This episode is eligible for 1.0 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 430 Pediatric Dentistry.

Aim & Learning Outcomes

Learning Outcomes — by the end of this episode, dentists will be able to:

Differentiate the presentations that indicate a direct restoration, a stainless steel crown, a vital pulpotomy, or an extraction in the primary dentition, using clinical and radiographic findings.
Describe minimally invasive and behaviour-management options in children — silver diamine fluoride, fluoride varnish, resin infiltration, local anaesthesia, sedation and isolation — and select them appropriately for the individual child.
Apply a step-by-step technique for a vital pulpotomy and stainless steel crown in a primary molar, including the current choice of medicament and cementation.

View Details

How good is your consent for orthodontics — really?

More adults are having ortho, and more GDPs are providing it. So which risks should you be discussing with every single patient — and which ones depend on the person in the chair?

When a case is heading for a big overjet or a tricky rotation, is that a conversation you have at the start, or one you scramble to explain halfway through?

And what actually makes a consent form legally valid — the signature, or everything around it?

This episode brings together two perspectives you don’t often hear in the same room. Dr Zaid Esmail is a specialist orthodontist and founder of the Online Orthodontic Academy, who mentors GDPs through fixed and aligner cases. Dr Neel Jaiswal returns for the dento-legal view — he’s a dentist and the founder of Professional Dental Indemnity (PDI). Together with Jaz, they get very specific about what individualised consent looks like in practice, and how to build a process your patients remember and a court respects.

https://youtu.be/YvsiIiX1Q1wWatch PDP273 on YouTubeProtrusive Dental Pearl: Make Your Patient Feel Unique

It might be your 100th, 500th or 1,000th case — but for the patient in the chair, this is a significant event. Never forget that. A routine extraction is routine for you; for them it’s a big deal, and remembering that makes you a better communicator.

To make a specific risk stick, make the patient feel unique. Point to their OPG: “Your sinus here is actually really interesting,” or “Did you know your roots are unusually long?” Patients remember a risk framed as if they’re a special case far better than a generic warning. Make it personal, and the consent becomes memorable.

What You’ll Take From This Episode

The whole episode turns on one idea: generic, templated consent is no longer defensible — the skill is individualising the form to the patient in front of you. Premium members get the full breakdown; here’s the shape:

The layers of valid consent — consent is like an onion; a signed form and a documented conversation each cover a gap the other leaves open.
Individualising risk from the records — how the OPG and photos turn a generic warning (resorption, devitalisation, recession, relapse) into a patient-specific one.
The two-appointment consent flow — records, individualised risks, thinking time, and why you sign or initial every line.
The Class II Div 2 overjet trap — the case that looks like simple crowding and ends in a big overjet, and how to consent for it before you start.
When to treat, add an option, or refer — the GDC line on offering all options, and building alternatives into the form.

Highlights of This Episode:

00:00 Teaser
01:01 Consent in Orthodontics: Why It Has to Be Individualised
02:59 Protrusive Dental Pearl: Make Your Patient Feel Unique
07:58 What Makes Orthodontic Consent Different
10:08 How Much Ortho Litigation Comes From Consent?
11:53 What Makes Consent Valid and Patient-Specific
12:26 Individualising Ortho Risk from the OPG
13:11 Using the ClinCheck as a Consent Tool
14:40 How to Structure the Consent Appointment
15:30 Root Resorption, Devitalisation, Recession and Relapse
19:37 Should You Initial Every Line of a Consent Form?
21:50 Midroll
27:11 Building a Multi-Layered Consent Process
29:31 Consenting for Fees, Relapse and Retainers
34:41 The Class II Div 2 Overjet Trap
37:51 When Should a GDP Refer an Ortho Case?
40:31 How to Learn Orthodontics with Mentorship
47:01 Outro

Dr Zaid Esmail is a specialist orthodontist. He founded the Online Orthodontic Academy to teach GDPs orthodontics — assessment, diagnosis and treatment planning across fixed appliances and aligners — with one-to-one case mentorship. He’s extended a 10% discount to the community with the code PROTRUSIVE.

???? Online Orthodontic Academy — online ortho mentorship, fixed & aligners, Level 7 Diploma

Dr Neel Jaiswal returned for the dento-legal perspective. He’s a dentist and the founder of Professional Dental Indemnity (PDI), which introduces dentists to insurance-based indemnity cover.

Request a Quote for Insurance and Get £100 off

???? Professional Dental Indemnity (PDI) — insurance-based dental indemnity

Want more?

If you enjoyed this episode, check out: Consent Is Like An Onion – Are You Consenting Your Patients Correctly? – PDP113

Tags

PDPMainEpisodes #OrthoRestorative #Communication

Listen, Subscribe, Earn CPD

Listen: Subscribe to the Protrusive Dental Podcast on Spotify, Apple Podcasts, or YouTube.

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A

AGD Subject Code: 565 Documentation & Risk Management

Aim & Learning Outcomes

Aim: To help dental practitioners obtain valid, individualised consent for orthodontic treatment — identifying the risks that apply to every patient, tailoring them to the individual, and structuring a consent process that is both comprehensible to the patient and defensible in law.

Learning Outcomes — by the end of this episode, dentists will be able to:

Describe the elements that make orthodontic consent valid and patient-specific, including the material-risk standard and the role of reasonable alternative treatments.
Apply a structured, multi-layered consent process — individualising risk from the clinical records and documenting the discussion — to an individual orthodontic patient.
Identify the case types and clinical situations that warrant additional consent, an alternative option, or onward referral to a specialist.

View Details

How good is your consent for orthodontics — really?

More adults are having ortho, and more GDPs are providing it. So which risks should you be discussing with every single patient — and which ones depend on the person in the chair?

When a case is heading for a big overjet or a tricky rotation, is that a conversation you have at the start, or one you scramble to explain halfway through?

And what actually makes a consent form legally valid — the signature, or everything around it?

https://youtu.be/YvsiIiX1Q1wWatch PDP273 on YouTubeProtrusive Dental Pearl: Make Your Patient Feel Unique

What You’ll Take From This Episode

The layers of valid consent — consent is like an onion; a signed form and a documented conversation each cover a gap the other leaves open.
Individualising risk from the records — how the OPG and photos turn a generic warning (resorption, devitalisation, recession, relapse) into a patient-specific one.
The two-appointment consent flow — records, individualised risks, thinking time, and why you sign or initial every line.
The Class II Div 2 overjet trap — the case that looks like simple crowding and ends in a big overjet, and how to consent for it before you start.
When to treat, add an option, or refer — the GDC line on offering all options, and building alternatives into the form.

Highlights of This Episode:

00:00 Teaser
01:01 Consent in Orthodontics: Why It Has to Be Individualised
02:59 Protrusive Dental Pearl: Make Your Patient Feel Unique
07:58 What Makes Orthodontic Consent Different
10:08 How Much Ortho Litigation Comes From Consent?
11:53 What Makes Consent Valid and Patient-Specific
12:26 Individualising Ortho Risk from the OPG
13:11 Using the ClinCheck as a Consent Tool
14:40 How to Structure the Consent Appointment
15:30 Root Resorption, Devitalisation, Recession and Relapse
19:37 Should You Initial Every Line of a Consent Form?
21:50 Midroll
27:11 Building a Multi-Layered Consent Process
29:31 Consenting for Fees, Relapse and Retainers
34:41 The Class II Div 2 Overjet Trap
37:51 When Should a GDP Refer an Ortho Case?
40:31 How to Learn Orthodontics with Mentorship
47:01 Outro

???? Online Orthodontic Academy — online ortho mentorship, fixed & aligners, Level 7 Diploma

Dr Neel Jaiswal returned for the dento-legal perspective. He’s a dentist and the founder of Professional Dental Indemnity (PDI), which introduces dentists to insurance-based indemnity cover.

Request a Quote for Insurance and Get £100 off

???? Professional Dental Indemnity (PDI) — insurance-based dental indemnity

Want more?

If you enjoyed this episode, check out: Consent Is Like An Onion – Are You Consenting Your Patients Correctly? – PDP113

Tags

PDPMainEpisodes #OrthoRestorative #Communication

Listen, Subscribe, Earn CPD

Listen: Subscribe to the Protrusive Dental Podcast on Spotify, Apple Podcasts, or YouTube.

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A

AGD Subject Code: 565 Documentation & Risk Management

Aim & Learning Outcomes

Learning Outcomes — by the end of this episode, dentists will be able to:

Describe the elements that make orthodontic consent valid and patient-specific, including the material-risk standard and the role of reasonable alternative treatments.
Apply a structured, multi-layered consent process — individualising risk from the clinical records and documenting the discussion — to an individual orthodontic patient.
Identify the case types and clinical situations that warrant additional consent, an alternative option, or onward referral to a specialist.

View Details

Ever fancied teaching dental students part time… but no real idea how you’d actually get in?

Are you the kind of person teaching would energise — or quietly drain?

Is a PGCert in dental education actually worth it, or just wishy-washy theory?

And the honest question nobody asks out loud: does it pay anything?

This is an Interference Cast — the non-clinical arm of the podcast — with Dr Rima Hussain, a general dentist who teaches restorative dentistry to undergraduates at King’s a couple of days a week. It’s a candid look at what a career in dental education actually involves: how to get in, who thrives and who burns out, what the work is really like, and the honest truth about the pay and the rewards. The bigger theme: dentistry is a career you can mould in endless directions — and for the right person, teaching is one of the most energising of them.

https://youtu.be/DzmcM-SbD68Watch IC076 on YouTubeWhat You’ll Take From This Episode

The full self-assessment and the step-by-step route into a teaching role are in the Premium Notes. Here’s the shape of what we cover:

Are you built for the classroom? — the two-camp self-check (energised vs drained) that predicts whether teaching will recharge you or wear you down.
How to actually land a role — the ‘BDJ Jobs’ plus pick-up-the-phone route, and why “who you know” so often cuts through the application process.
Relatability as a strength — why being closer to a student’s level can beat decades of experience for an absolute beginner.
Back to basics — the “monkey see, monkey do” risk from YouTube and AI, and what the tutor’s real job becomes.
The honest pay-and-balance picture — why you don’t do it for the money, what you do get, and how teaching and practice keep each other fresh.

Highlights of This Episode

00:00 Teaser
01:08 Should You Teach Dentistry? How to Know If It’s for You
04:39 How a General Dentist Gets Into Dental Education
06:15 Signs You’re Suited to Teaching Dentistry
08:52 Is a PGCert in Dental Education Worth It?
12:07 How to Land a Clinical Teaching Post at a Dental School
14:38 Why a Relatable Tutor Beats Decades of Experience
16:52 How Dental Students Have Changed Since COVID
19:20 Is Social Media and AI Helping or Hurting Dental Students?
21:55 Midroll
26:43 Why “Back to Basics” Beats Chasing Advanced Techniques
29:20 How to Get a Teaching (or Associate) Job: Pick Up the Phone
31:50 Why Dental Tutors Quit After Six Months
36:29 The Most Rewarding Part of Teaching Dentistry
38:46 Teaching, Practice and Pay: How to Avoid Burnout
44:39 Outro

From the Guest

Dr Rima Hussain is a general dentist who also teaches restorative (conservative) dentistry to undergraduates at King’s College London — a route she fell into via tutoring as a teenager and has been in since 2019. Her advice for anyone curious: you’re probably already teaching in some form, so try it; the worst case is you find it isn’t for you.

???? Reach Rima on Instagram

References & Further Reading

Mentioned in this episode:

Rath T. StrengthsFinder 2.0. Gallup Press, 2007. The strengths-assessment book referenced for the “Learner” theme and the idea of building your career around your natural strengths. “Learner” is one of its 34 themes; the assessment is now delivered as CliftonStrengths.
BDJ Jobs. The British Dental Journal jobs board where clinical tutor and academic posts are advertised, usually with short application windows.

Want more?

If you enjoyed this episode, check out: 2 Years Out of Dental School – Insights for New Grads – IC066

InterferenceCast #CareerDevelopment #BeyondDentistry

Listen, Subscribe, Earn CPD

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B

AGD Subject Code: 770 Self-Improvement

Aim & Learning Outcomes

Aim: To help dentists evaluate a part-time career in dental education — what the role involves, how to obtain one, and how to sustain it alongside clinical practice.

Learning Outcomes — by the end of this episode, dentists will be able to:

Identify the personal attributes and expectations that distinguish dentists who thrive in clinical teaching from those who do not.
Describe the practical routes into a dental-school teaching post, including where posts are advertised and how a direct, proactive approach can work.
Recognise the workload, financial and work-life-balance realities of part-time teaching, and strategies to avoid burnout while balancing teaching and practice.

View Details

Ever fancied teaching dental students part time… but no real idea how you’d actually get in?

Are you the kind of person teaching would energise — or quietly drain?

Is a PGCert in dental education actually worth it, or just wishy-washy theory?

And the honest question nobody asks out loud: does it pay anything?

https://youtu.be/DzmcM-SbD68Watch IC076 on YouTubeWhat You’ll Take From This Episode

The full self-assessment and the step-by-step route into a teaching role are in the Premium Notes. Here’s the shape of what we cover:

Are you built for the classroom? — the two-camp self-check (energised vs drained) that predicts whether teaching will recharge you or wear you down.
How to actually land a role — the ‘BDJ Jobs’ plus pick-up-the-phone route, and why “who you know” so often cuts through the application process.
Relatability as a strength — why being closer to a student’s level can beat decades of experience for an absolute beginner.
Back to basics — the “monkey see, monkey do” risk from YouTube and AI, and what the tutor’s real job becomes.
The honest pay-and-balance picture — why you don’t do it for the money, what you do get, and how teaching and practice keep each other fresh.

Highlights of This Episode

00:00 Teaser
01:08 Should You Teach Dentistry? How to Know If It’s for You
04:39 How a General Dentist Gets Into Dental Education
06:15 Signs You’re Suited to Teaching Dentistry
08:52 Is a PGCert in Dental Education Worth It?
12:07 How to Land a Clinical Teaching Post at a Dental School
14:38 Why a Relatable Tutor Beats Decades of Experience
16:52 How Dental Students Have Changed Since COVID
19:20 Is Social Media and AI Helping or Hurting Dental Students?
21:55 Midroll
26:43 Why “Back to Basics” Beats Chasing Advanced Techniques
29:20 How to Get a Teaching (or Associate) Job: Pick Up the Phone
31:50 Why Dental Tutors Quit After Six Months
36:29 The Most Rewarding Part of Teaching Dentistry
38:46 Teaching, Practice and Pay: How to Avoid Burnout
44:39 Outro

From the Guest

???? Reach Rima on Instagram

References & Further Reading

Mentioned in this episode:

Rath T. StrengthsFinder 2.0. Gallup Press, 2007. The strengths-assessment book referenced for the “Learner” theme and the idea of building your career around your natural strengths. “Learner” is one of its 34 themes; the assessment is now delivered as CliftonStrengths.
BDJ Jobs. The British Dental Journal jobs board where clinical tutor and academic posts are advertised, usually with short application windows.

Want more?

If you enjoyed this episode, check out: 2 Years Out of Dental School – Insights for New Grads – IC066

InterferenceCast #CareerDevelopment #BeyondDentistry

Listen, Subscribe, Earn CPD

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B

AGD Subject Code: 770 Self-Improvement

Aim & Learning Outcomes

Aim: To help dentists evaluate a part-time career in dental education — what the role involves, how to obtain one, and how to sustain it alongside clinical practice.

Learning Outcomes — by the end of this episode, dentists will be able to:

Identify the personal attributes and expectations that distinguish dentists who thrive in clinical teaching from those who do not.
Describe the practical routes into a dental-school teaching post, including where posts are advertised and how a direct, proactive approach can work.
Recognise the workload, financial and work-life-balance realities of part-time teaching, and strategies to avoid burnout while balancing teaching and practice.

View Details

Sleep, Airway and Mouth Breathing: An ENT’s Guide for Dentists

Could a “normal” sleep study still be missing your patient’s airway problem?

Why do women and children with real symptoms keep scoring “mild”?

Should a mouth-breathing child see a myofunctional therapist — or an ENT first?

And which four questions screen a child for sleep problems in under a minute?

The roof of the mouth is the floor of the nose — so ENT and dentistry should be in constant dialogue. In practice, they rarely are. In this one, Dr David McIntosh — an Australian ear, nose and throat surgeon with a deep niche in sleep-disordered breathing — makes the case for why that has to change, and gives dentists practical ways to screen and refer. He is direct, analogy-rich and doesn’t mince words; expect a few positions that cut against the grain of how sleep apnoea is usually handled.

https://youtu.be/QVEc0ocxTCcWatch PDP272 on YouTubeProtrusive Dental Pearl: When the Numbers Mislead

Dentists love data — the AHI, the cut-offs (over 5 is mild, over 30 is severe). But take those numbers with a pinch of salt: the thresholds are arbitrary, and a single score tells you nothing about why a patient has the problem.

They don’t account for individual variability — especially in women and children, where a mild score can sit right alongside significant symptoms. Read the number with the anatomy and the phenotype — the clinical signs and the airway assessment — never instead of them.

What You’ll Take From This Episode

This conversation reframes sleep-disordered breathing from a number on a report into something you can localise and refer.

A sleep study tells you IF, not WHY — sleep-disordered breathing is the whole spectrum; a normal study doesn’t mean normal breathing.
Phenotyping the airway — map the individual anatomical causes instead of trusting a single score.
Why women get missed — the gender bias built into standard adult screening tools, and what to ask instead.
The four-question filter for children — snore, mouth breathe, stop breathing, wake up tired: any ‘yes’ means refer.
Treat the cause before the function — why myofunctional therapy comes after the obstruction is cleared, not before, and how expansion and surgery are matched to the anatomy.

Highlights of This Episode

00:00 Teaser
01:00 Why ENT and Dentistry Should Be Talking
02:51 Protrusive Dental Pearl: When Sleep Data Misleads You
03:46 Meet the ENT Who Works With Dentists
06:00 Sleep Physician, ENT or Dentist: Who Should Lead?
07:26 Why Children and Adults Are Completely Different
08:58 Sleep-Disordered Breathing Is Not the Same as Sleep Apnoea
09:39 Why a Normal Sleep Study Doesn’t Mean Normal Breathing
10:01 Same AHI, Different Cause: A Tale of Two Patients
12:54 Why One Night’s Sleep Study Isn’t Enough
13:44 Where the AHI Cut-Off Numbers Really Came From
15:27 CPAP Explained: A Bridge, Not a Cure
18:27 When Snoring Hides Something Serious
19:10 What Phenotyping the Airway Actually Means
20:27 Splint, CPAP, or Both?
21:33 Why a CBCT Can Miss a Deviated Septum
25:32 Is STOP-Bang Enough to Screen for Sleep Apnoea?
26:06 Why the Epworth Sleepiness Scale Is a Blunt Tool
26:50 Why STOP-Bang Is Biased Against Women
31:17 Sleep Apnoea in Women: Mild on Paper, Severe in Life
32:05 Midroll
36:56 The Triad: Airway, TMD and Orthodontics
37:12 The Three Most Common Causes of Night-Time Grinding
39:41 The Four Questions That Screen a Child for Sleep Problems
41:03 Tired vs Not Tired: The Sign That Changes Everything
43:36 Should You Refer to Myofunctional Therapy Before an ENT?
45:58 The Hidden Dangers of Forcing Nasal Breathing
52:28 Maxillary Expansion vs Surgery: Which One Fixes It?
54:51 How Dentists Can Assess Adenoids
56:25 Save the Child First: The Drowning Analogy
57:56 Where Dentistry and ENT Go From Here
1:00:05 Outro – New-Look Premium Notes & CPD Outro

From the Guest

Dr David McIntosh is an ear, nose and throat surgeon (MBBS, FRACS, PhD) with a special interest in sleep-disordered breathing and airway obstruction. A self-described compulsive educator, he is the author of several books on Amazon— including dENTal health, on the connection between ENT and dental disease, and Snored to Death, on the lesser-recognised causes of obstructive sleep apnoea in adults.

References & Further Reading

Sources discussed in this episode:

Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Medicine, 2000;1(1):21–32. The 22-item PSQ; a score above 0.33 suggests sleep-disordered breathing.

Loved This Episode? Try Next

Airway Dentistry with Jeff Rouse – PDP229

Listen, Subscribe, Earn CPD

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 730 – Oral Medicine, Oral Diagnosis, Oral Pathology (Sleep medicine)

PDPMainEpisodes #OralSurgeryandOralMedicine

Aim & Learning Outcomes

Aim: To help dental practitioners recognise sleep-disordered breathing across the whole airway, screen adults and children appropriately, and refer at the right time and to the right clinician.

Learning Outcomes — by the end of this episode, dentists will be able to:

Differentiate sleep-disordered breathing from obstructive sleep apnoea, and explain why a normal sleep study does not exclude clinically significant breathing problems.
Apply a structured screening approach for adults and children, including recognising why standard adult tools under-detect sleep-disordered breathing in women and children.
Evaluate when to refer for specialist airway assessment, and articulate why addressing anatomical obstruction should precede functional (myofunctional) therapy.

View Details

Sleep, Airway and Mouth Breathing: An ENT’s Guide for Dentists

Could a “normal” sleep study still be missing your patient’s airway problem?

Why do women and children with real symptoms keep scoring “mild”?

Should a mouth-breathing child see a myofunctional therapist — or an ENT first?

And which four questions screen a child for sleep problems in under a minute?

https://youtu.be/QVEc0ocxTCcWatch PDP272 on YouTubeProtrusive Dental Pearl: When the Numbers Mislead

What You’ll Take From This Episode

This conversation reframes sleep-disordered breathing from a number on a report into something you can localise and refer.

A sleep study tells you IF, not WHY — sleep-disordered breathing is the whole spectrum; a normal study doesn’t mean normal breathing.
Phenotyping the airway — map the individual anatomical causes instead of trusting a single score.
Why women get missed — the gender bias built into standard adult screening tools, and what to ask instead.
The four-question filter for children — snore, mouth breathe, stop breathing, wake up tired: any ‘yes’ means refer.
Treat the cause before the function — why myofunctional therapy comes after the obstruction is cleared, not before, and how expansion and surgery are matched to the anatomy.

Highlights of This Episode

00:00 Teaser
01:00 Why ENT and Dentistry Should Be Talking
02:51 Protrusive Dental Pearl: When Sleep Data Misleads You
03:46 Meet the ENT Who Works With Dentists
06:00 Sleep Physician, ENT or Dentist: Who Should Lead?
07:26 Why Children and Adults Are Completely Different
08:58 Sleep-Disordered Breathing Is Not the Same as Sleep Apnoea
09:39 Why a Normal Sleep Study Doesn’t Mean Normal Breathing
10:01 Same AHI, Different Cause: A Tale of Two Patients
12:54 Why One Night’s Sleep Study Isn’t Enough
13:44 Where the AHI Cut-Off Numbers Really Came From
15:27 CPAP Explained: A Bridge, Not a Cure
18:27 When Snoring Hides Something Serious
19:10 What Phenotyping the Airway Actually Means
20:27 Splint, CPAP, or Both?
21:33 Why a CBCT Can Miss a Deviated Septum
25:32 Is STOP-Bang Enough to Screen for Sleep Apnoea?
26:06 Why the Epworth Sleepiness Scale Is a Blunt Tool
26:50 Why STOP-Bang Is Biased Against Women
31:17 Sleep Apnoea in Women: Mild on Paper, Severe in Life
32:05 Midroll
36:56 The Triad: Airway, TMD and Orthodontics
37:12 The Three Most Common Causes of Night-Time Grinding
39:41 The Four Questions That Screen a Child for Sleep Problems
41:03 Tired vs Not Tired: The Sign That Changes Everything
43:36 Should You Refer to Myofunctional Therapy Before an ENT?
45:58 The Hidden Dangers of Forcing Nasal Breathing
52:28 Maxillary Expansion vs Surgery: Which One Fixes It?
54:51 How Dentists Can Assess Adenoids
56:25 Save the Child First: The Drowning Analogy
57:56 Where Dentistry and ENT Go From Here
1:00:05 Outro – New-Look Premium Notes & CPD Outro

From the Guest

References & Further Reading

Sources discussed in this episode:

Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Medicine, 2000;1(1):21–32. The 22-item PSQ; a score above 0.33 suggests sleep-disordered breathing.

Loved This Episode? Try Next

Airway Dentistry with Jeff Rouse – PDP229

Listen, Subscribe, Earn CPD

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 730 – Oral Medicine, Oral Diagnosis, Oral Pathology (Sleep medicine)

PDPMainEpisodes #OralSurgeryandOralMedicine

Aim & Learning Outcomes

Aim: To help dental practitioners recognise sleep-disordered breathing across the whole airway, screen adults and children appropriately, and refer at the right time and to the right clinician.

Learning Outcomes — by the end of this episode, dentists will be able to:

Differentiate sleep-disordered breathing from obstructive sleep apnoea, and explain why a normal sleep study does not exclude clinically significant breathing problems.
Apply a structured screening approach for adults and children, including recognising why standard adult tools under-detect sleep-disordered breathing in women and children.
Evaluate when to refer for specialist airway assessment, and articulate why addressing anatomical obstruction should precede functional (myofunctional) therapy.

View Details

The most important part of your surgery isn’t plugged in, mounted, or calibrated. It’s the person standing beside you.

Have you ever dreaded walking into a beautiful practice with lovely patients — purely because of who you share the surgery with?

What do you actually do, in the moment, when your assistant rolls their eyes at a request for rubber dam?

And should you be friends with your assistant at all — or does that cross a line you’ll regret?

This is an Interference Cast — a non-clinical but deeply practical episode — with Dr. Sarah Braun, a dentist in Australia and a fellow Protrusive Guidance member who DM’d to suggest this very topic. No course, no book, nothing to sell: just two clinicians comparing notes (and the odd scar) on the one relationship that quietly shapes your whole working life. It sits inside this month’s theme of the relationships that support your career.

https://youtu.be/OyztRyPpcHMWatch IC075 on YouTubeWhat You’ll Take From This Episode

The full breakdown is in the Premium Notes; here’s the shape of the thinking that runs through the episode:

Engagement is the whole game — the assistant relationship sets the mood of the room, the patient’s experience, and whether good people stay.
Speak their language — appreciation only lands if it’s delivered in the form that particular person actually values.
Appreciation is a verb — specific, named praise lands far harder than a vague “good job.”
Let them, let me — you don’t control how someone reacts in the moment; you only control your response to it.
Lead the room — dentistry is a performance, and the room takes its emotional cue from whoever is leading it.

Highlights of this episode:

00:00 TEASER01:13 Why This One Relationship Can Make or Break You03:49 A Non-Clinical Interference Cast: What to Expect04:47 Meet the Guest: Nine Years In, City to Country07:01 A Week in Private Practice09:15 How Much Does the Dentist–Assistant Relationship Matter?11:01 Engagement at Work: The Gallup Lens12:30 People Remember How You Made Them Feel14:21 When the Relationship Turns Toxic15:23 The Power Imbalance You Might Not See18:11 The First-Day Conversation20:52 Keeping Your Assistant Engaged22:23 Specific Praise Beats a Vague “Good Job”23:55 Midroll27:37 You Can Only Control Yourself29:34 The Eye-Roll Moment: Let Them, Let Me31:23 Off Days vs Patterns32:12 Appreciation, Gifting & Speaking Their Language35:32 Run the Relationship Like It Matters36:48 Friends With Your Assistant, or Keep Your Distance?39:08 A Best Friend at Work: The Engagement Link41:15 Advice for New Grads: Start With Time Management44:26 Teaching as a Tool: Show Your Working Out48:05 Wrap-Up & a Healthy Debate48:37 CPD Outro & the Protrusive Vault

References & Further Reading:

Sources and further reading from this episode:

Chapman G. The Five Love Languages. Northfield Publishing, 1992. The five ways people give and receive appreciation — words of affirmation, quality time, acts of service, receiving gifts, and physical touch — applied here to the dentist–assistant relationship.
Robbins M, Robbins S. The Let Them Theory. Hay House, 2024. The “let them / let me” reframe for releasing what you can’t control and owning your own response.
Rath T. StrengthsFinder 2.0. Gallup Press, 2007. The CliftonStrengths assessment; “Learner” is one of its talent themes, referenced in the discussion of teaching as a way to engage your assistant.
Gallup employee-engagement research. The Gallup Q12 engagement survey (including the validated “I have a best friend at work” item) and Gallup’s State of the Global Workplace reports. Source of the workforce-engagement framing in this episode. Exact figures vary by year — see Reviewer Note.

Want more?

If you enjoyed this episode, check out: How to Find a Mentor in 5 Seconds Flat! – IC058.

InterferenceCast #CareerDevelopment #Communication #BeyondDentistry

Listen, Subscribe, Earn CPD:

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and B

AGD Subject Code: 550 Practice Management and Human Relations

Aim & Learning Outcomes:

Aim: To help dental practitioners understand and strengthen the working relationship between dentist and dental assistant — recognising its impact on team engagement, patient experience and personal job satisfaction, and building practical habits to improve it.

Learning Outcomes — by the end of this episode, dentists will be able to:

Explain how the working relationship between a dentist and a dental assistant affects team engagement, the patient experience, and clinician wellbeing.
Identify practical strategies for communicating appreciation and recognition in ways suited to the individual, and for involving an assistant according to their preferences.
Apply self-management and emotional-regulation approaches to leading the surgery and responding constructively to interpersonal friction.

View Details

The most important part of your surgery isn’t plugged in, mounted, or calibrated. It’s the person standing beside you.

Have you ever dreaded walking into a beautiful practice with lovely patients — purely because of who you share the surgery with?

What do you actually do, in the moment, when your assistant rolls their eyes at a request for rubber dam?

And should you be friends with your assistant at all — or does that cross a line you’ll regret?

https://youtu.be/OyztRyPpcHMWatch IC075 on YouTubeWhat You’ll Take From This Episode

The full breakdown is in the Premium Notes; here’s the shape of the thinking that runs through the episode:

Engagement is the whole game — the assistant relationship sets the mood of the room, the patient’s experience, and whether good people stay.
Speak their language — appreciation only lands if it’s delivered in the form that particular person actually values.
Appreciation is a verb — specific, named praise lands far harder than a vague “good job.”
Let them, let me — you don’t control how someone reacts in the moment; you only control your response to it.
Lead the room — dentistry is a performance, and the room takes its emotional cue from whoever is leading it.

Highlights of this episode:

References & Further Reading:

Sources and further reading from this episode:

Chapman G. The Five Love Languages. Northfield Publishing, 1992. The five ways people give and receive appreciation — words of affirmation, quality time, acts of service, receiving gifts, and physical touch — applied here to the dentist–assistant relationship.
Robbins M, Robbins S. The Let Them Theory. Hay House, 2024. The “let them / let me” reframe for releasing what you can’t control and owning your own response.
Rath T. StrengthsFinder 2.0. Gallup Press, 2007. The CliftonStrengths assessment; “Learner” is one of its talent themes, referenced in the discussion of teaching as a way to engage your assistant.
Gallup employee-engagement research. The Gallup Q12 engagement survey (including the validated “I have a best friend at work” item) and Gallup’s State of the Global Workplace reports. Source of the workforce-engagement framing in this episode. Exact figures vary by year — see Reviewer Note.

Want more?

If you enjoyed this episode, check out: How to Find a Mentor in 5 Seconds Flat! – IC058.

InterferenceCast #CareerDevelopment #Communication #BeyondDentistry

Listen, Subscribe, Earn CPD:

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and B

AGD Subject Code: 550 Practice Management and Human Relations

Aim & Learning Outcomes:

Learning Outcomes — by the end of this episode, dentists will be able to:

Explain how the working relationship between a dentist and a dental assistant affects team engagement, the patient experience, and clinician wellbeing.
Identify practical strategies for communicating appreciation and recognition in ways suited to the individual, and for involving an assistant according to their preferences.
Apply self-management and emotional-regulation approaches to leading the surgery and responding constructively to interpersonal friction.

View Details

Is rotary really better than reciprocating?

Can you safely skip the glide path with modern reciprocating systems?

What is the best file system for a GDP who wants predictable endodontic results?

And perhaps the biggest question of all: does the file system matter as much as we think it does?

In Part 2 of the Endo Showdown, Dr Samuel Johnson returns to tackle some of the most common questions dentists have about file systems, glide path preparation, retreatment, and endodontic workflow. From practical negotiation tips to choosing a system that works in your hands, this episode focuses on the decisions that can make endodontics simpler, safer, and more predictable.

https://www.youtube.com/watch?v=onZMR-872HQWatch PDP271 on YouTubeProtrusive Dental Pearl

Cut your gutta-percha at the level of the canal orifice and thoroughly clean the pulp chamber before placing the coronal restoration.

⚠️ Leaving gutta-percha and sealer coronally can compromise the coronal seal and promote leakage.

✅ Use isopropyl alcohol to clean resin-based sealer residue before bonding. Water is effective for cleaning bioceramic sealers.

Key Takeaways

Establish a glide path before shaping whenever possible.
D-Finders can negotiate difficult canals more predictably than traditional K-files.
Intermediate files such as size 12 or 12.5 can help bridge the jump from size 10 to size 15.
Straight-line access reduces file binding and improves shaping efficiency.
Avoid forcing glide path files to working length.
Gates Glidden drills may be unnecessarily aggressive for routine coronal flaring.
Consistency with one file system is often more important than chasing the latest product.
WaveOne Gold remains a simple and user-friendly option for many GDPs.
Rotary and reciprocating systems can both achieve successful outcomes when used appropriately.
A good glide path is often more important than the type of motion being used.
Hand files and Hedström files remain valuable during retreatment.
Mechanical GP removal near the apex increases the risk of extrusion.
Solvents are best reserved for residual gutta-percha rather than used at the start of retreatment.
Understanding motor settings, torque, and RPM improves file safety and efficiency.
Knowing when to refer is a sign of clinical maturity, not weakness.
Clear consent and expectation management reduce stress for both clinician and patient.

Highlights of this episode:

00:00 Teaser
01:09 Introduction
02:15 Protrusive Dental Pearl: Coronal GP Removal & Pulp Chamber Clean-Up
03:59 Glide Path File Protocol & Canal Negotiation
06:24 Access Cavity Design & Coronal Flaring in RCT
08:38 File Taper & Canal Preparation Philosophy
09:54 Managing Difficult Canals in Endodontic Treatment
11:48 When to Introduce the Glide Path File
13:24 Using Intermediate File Sizes
15:39 Useful Negotiation & Shaping Tips
17:19 Choosing a File System
20:19 Rotary vs Reciprocating in Clinical Practice
21:29 Motor Settings & File Control
21:40 XP-Endo & Specialised File Designs
22:05 Endo Motor Ads
24:44 XP-Endo & Specialised File Designs
25:16 Retreatment Files & GP Removal
26:08 Preferred Gutta-Percha Removal
31:21 Recommended System for Simplicity
32: 44 Building Skills Faster in Endodontics
36:13 Consent & Managing Expectations
41:51 Reciproc vs WaveOne Gold
42:22 Preferred Retreatment Protocol
43:33 Using Rotary Files in Reciprocation
45:12 Curved Canals & Shaping Efficiency
46:32 Can Reciproc Blue Bypass the Glide Path?
49:29 Outro

Want more?

Check out the previous episode with Dr. Samuel Johnson: Working Lengths and Troubleshooting Apex Locators – PDP216

???? Looking for an endomotor?

Upgrade your endodontic workflow with the Woodpecker Endo Radar Pro. Head to protrusive.co.uk/endomotor and use coupon code PROTRUSIVE at checkout to claim an exclusive discount and your choice of complimentary file system.

???? Subscribe to Dr. Samuel Johnson’s amazing YouTube Channel: I Love The Pulp for more helpful endodontics tips and tricks.

PDPMainEpisodes #EndoRestorative

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 070 – Endodontics

Aim: To enhance clinicians’ understanding of glide path preparation, rotary and reciprocating instrumentation, canal negotiation, retreatment strategies, and risk management in contemporary endodontic practice.

Dentists will be able to –

Dentists will be able to evaluate the role of glide path preparation in improving shaping efficiency and reducing procedural errors.
Dentists will be able to compare practical considerations when using rotary and reciprocating file systems.
Dentists will be able to apply safe and predictable approaches to canal negotiation, retreatment, and clinical decision-making.

View Details

Is rotary really better than reciprocating?

Can you safely skip the glide path with modern reciprocating systems?

What is the best file system for a GDP who wants predictable endodontic results?

And perhaps the biggest question of all: does the file system matter as much as we think it does?

https://www.youtube.com/watch?v=onZMR-872HQWatch PDP271 on YouTubeProtrusive Dental Pearl

Cut your gutta-percha at the level of the canal orifice and thoroughly clean the pulp chamber before placing the coronal restoration.

⚠️ Leaving gutta-percha and sealer coronally can compromise the coronal seal and promote leakage.

✅ Use isopropyl alcohol to clean resin-based sealer residue before bonding. Water is effective for cleaning bioceramic sealers.

Key Takeaways

Establish a glide path before shaping whenever possible.
D-Finders can negotiate difficult canals more predictably than traditional K-files.
Intermediate files such as size 12 or 12.5 can help bridge the jump from size 10 to size 15.
Straight-line access reduces file binding and improves shaping efficiency.
Avoid forcing glide path files to working length.
Gates Glidden drills may be unnecessarily aggressive for routine coronal flaring.
Consistency with one file system is often more important than chasing the latest product.
WaveOne Gold remains a simple and user-friendly option for many GDPs.
Rotary and reciprocating systems can both achieve successful outcomes when used appropriately.
A good glide path is often more important than the type of motion being used.
Hand files and Hedström files remain valuable during retreatment.
Mechanical GP removal near the apex increases the risk of extrusion.
Solvents are best reserved for residual gutta-percha rather than used at the start of retreatment.
Understanding motor settings, torque, and RPM improves file safety and efficiency.
Knowing when to refer is a sign of clinical maturity, not weakness.
Clear consent and expectation management reduce stress for both clinician and patient.

Highlights of this episode:

00:00 Teaser
01:09 Introduction
02:15 Protrusive Dental Pearl: Coronal GP Removal & Pulp Chamber Clean-Up
03:59 Glide Path File Protocol & Canal Negotiation
06:24 Access Cavity Design & Coronal Flaring in RCT
08:38 File Taper & Canal Preparation Philosophy
09:54 Managing Difficult Canals in Endodontic Treatment
11:48 When to Introduce the Glide Path File
13:24 Using Intermediate File Sizes
15:39 Useful Negotiation & Shaping Tips
17:19 Choosing a File System
20:19 Rotary vs Reciprocating in Clinical Practice
21:29 Motor Settings & File Control
21:40 XP-Endo & Specialised File Designs
22:05 Endo Motor Ads
24:44 XP-Endo & Specialised File Designs
25:16 Retreatment Files & GP Removal
26:08 Preferred Gutta-Percha Removal
31:21 Recommended System for Simplicity
32: 44 Building Skills Faster in Endodontics
36:13 Consent & Managing Expectations
41:51 Reciproc vs WaveOne Gold
42:22 Preferred Retreatment Protocol
43:33 Using Rotary Files in Reciprocation
45:12 Curved Canals & Shaping Efficiency
46:32 Can Reciproc Blue Bypass the Glide Path?
49:29 Outro

Want more?

Check out the previous episode with Dr. Samuel Johnson: Working Lengths and Troubleshooting Apex Locators – PDP216

???? Looking for an endomotor?

???? Subscribe to Dr. Samuel Johnson’s amazing YouTube Channel: I Love The Pulp for more helpful endodontics tips and tricks.

PDPMainEpisodes #EndoRestorative

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 070 – Endodontics

Dentists will be able to –

Dentists will be able to evaluate the role of glide path preparation in improving shaping efficiency and reducing procedural errors.
Dentists will be able to compare practical considerations when using rotary and reciprocating file systems.
Dentists will be able to apply safe and predictable approaches to canal negotiation, retreatment, and clinical decision-making.

View Details

Rotary or reciprocating files — which should you actually be using?

Is one safer than the other? Does reciprocation really reduce file separation? Are you choosing your system because it suits the canal anatomy, or because it is simply the one you were taught?

Endodontic file systems can feel like a maze of brands, tapers, alloys, motions and marketing claims. But beneath all that noise, the real question is much more practical: what is your file doing inside the canal, and what compromise are you accepting?

In this episode, Dr Samuel Johnson returns to unpack the Endo Showdown: rotary versus reciprocating files. We cover file motion, glide paths, shaping philosophy, NiTi metallurgy, cyclic fatigue, torsional fatigue, and why no system is perfect.

https://youtu.be/HfWDBbNgjsAWatch PDP270 on YouTubeProtrusive Dental Pearl

A palliative root canal can be useful for an unrestorable tooth if disinfecting the canal allows infection to heal and natural bone to recover before extraction and future implant planning.

⚠️ Do not dismiss root canal treatment purely because the tooth is not a long-term functional restoration.

✅ Where appropriate, consider whether endodontic disinfection could improve the future implant site by allowing natural bone healing.

Key Takeaways

The purpose of shaping is not simply to scrape canal walls; it is to create space for irrigant flow.
Irrigation is the most important part of root canal disinfection.
Rotary files move in a continuous 360-degree rotation.
Reciprocating files cut in one direction and reverse before excessive stress builds up.
Modern reciprocation is designed to cut, release and gradually progress apically.
File choice is not just about motion; metallurgy, taper, design and operator experience all matter.
NiTi hand files with strong shape memory may be problematic in curved canals because they want to straighten.
Martensitic heat-treated files are more flexible and can better follow canal curvature.
Unwinding flutes are a warning sign that a file may be close to separation.
Inspect files regularly during treatment, especially in curved, calcified or difficult canals.
A glide path is essential before introducing larger rotary or reciprocating files.
Without a glide path, a shaping file may create its own path, risking ledging, transportation or perforation.
“Grabby” files pull themselves into the canal; this can be useful in experienced hands but risky if forced.
Reciprocating systems can feel simpler and safer, but they are not foolproof.
Cyclic fatigue happens when a file repeatedly bends around a curve until microcracks form.
Torsional fatigue happens when part of the file binds while the motor continues to turn.

Highlights of the episode:

00:00 Teaser
00:47 Introduction
02:13 Protrusive Dental Pearl: Palliative Root Canal Treatment
05:30 Main Question: Rotary vs Reciprocating Files
06:31 Hybrid File Motions
08:19 File Choice Is More Than Motion
10:26 Purpose of Shaping in Endodontics
11:10 Chemo-Mechanical Preparation
11:34 Rotary Motion in Root Canal Treatment
11:45 Origins of Reciprocation
12:21 Balanced Force Technique
18:00 NiTi K-Files vs Stainless Steel K-Files
22:37 Practical Advice: Inspect the File
23:40 Rotary Can Also Be a One File System
24:24 Reciprocation and Sense of Safety
24:47 “Grabby” Files
24:53 Midroll
33:54 Choosing Between Rotary and Reciprocating
35:20 Cyclic Fatigue
37:41 Endo Radar Pro Ads
40:20 Torque and RPM in Endodontics
41:41 Why Reciprocation Advances
42:56 Debris Extrusion in RCT
43:34 Benefits of Rotary Systems
44:13 Tactile Feedback in Root Canal Treatment
45:21 Outro

Want more?

Check out previous episode with Dr. Samuel Johnson: Working Lengths and Troubleshooting Apex Locators – PDP216

???? Looking for an endomotor?

PDPMainEpisodes #EndoRestorative

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes CAGD Subject Code: 070 Endodontics

Aim: To improve dentists’ understanding of rotary and reciprocating endodontic file systems, including file motion, glide path creation, file metallurgy, fatigue mechanisms, irrigation principles, and practical steps to reduce procedural risks.

Dentists will be able to –

Understand the clinical differences between rotary and reciprocating file motions and how these may influence endodontic workflow
Recognise key risk factors for file separation, including cyclic fatigue, torsional fatigue, file distortion and inappropriate file use
Apply practical principles around glide path creation, irrigation, file inspection and system selection in endodontic treatment

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Should we still be drilling early caries lesions?

Where do peptides, resin infiltration, fluoride varnish and SDF actually fit in modern practice?

Is hydroxyapatite toothpaste a genuine alternative to fluoride, or just another dental trend?

And when you see that suspicious grey occlusal shadow, do you seal it, explore it, or actively surveil it?

In part two of this modern caries management episode, Jaz continues the conversation with Prof. Avijit Banerjee on minimal intervention dentistry. This episode moves beyond diagnosis and communication into the practical management of early and progressing caries lesions, including peptides, SDF, hydroxyapatite toothpaste, fissure sealing, xerostomia, root caries and selective caries removal.

https://youtu.be/dGt7FW7C4N0Watch PDP269 on YouTubeProtrusive Dental Pearl

Use the Contemporary Caries Management Implementation Pack as a chairside aid to turn the episode into daily clinical action.

⚠️ Learning the evidence is not enough if it never makes it into your patient conversations, risk assessment or treatment planning.

✅ Print it, laminate it, and use it to support communication, diagnosis, active surveillance and minimally invasive decision-making.

Disclaimer: This is an educational resource produced by Team Protrusive, derived from the two-part Protrusive Dental Podcast episode featuring Prof. Avijit Banerjee. Its contents were not written, reviewed, or endorsed by Prof. Banerjee; they represent Team Protrusive’s own interpretation of the material discussed. It is intended as a practical summary and is not a substitute for primary sources. We strongly encourage all clinicians to consult the latest Clinical Practice Guidelines before making treatment decisions.

Key Takeaways:

Peptides are designed to infiltrate early enamel lesions and create a scaffold for mineral deposition.
Peptide technologies still need minerals from saliva, toothpaste, mouthwash or other sources to work.
Fluoride supports remineralisation; it acts more like the “mortar” than the “bricks”.
Early E1 lesions are usually managed with prevention, fluoride, oral hygiene, diet control and biofilm control.
Deeper enamel lesions, such as progressing E1 or E2 lesions, may be suitable for resin infiltration or peptide infiltration.
SDF is better suited to cavitated lesions where arrest and stabilisation are needed.
In the UK, SDF is licensed for dentine sensitivity, so caries arrest is an off-label use.
SDF can be very useful for children, older adults, medically compromised patients and care-home patients.
The main downside of conventional SDF is black staining, especially on anterior teeth.
Hydroxyapatite toothpaste has more science behind it than charcoal-style fad toothpastes.
Fluoride toothpaste remains the preferred baseline recommendation when patients are happy to use fluoride.
A suspicious grey occlusal lesion should be assessed in the context of the patient’s overall caries risk.
In selected cases, a tiny exploratory opening can act like a diagnostic biopsy.
Sealing fissures on the same tooth being restored can be sensible when the fissure pattern is deep.
For severe xerostomia and root caries risk, consider high-fluoride regimes, close recalls, trays or dentures as carriers for remineralising agents.

YouTube Highlights:

00:00 Teaser
01:17 Introduction
02:17 Pearl: Caries Management Implementation Pack
05:54 What are Peptides?
14:42 SDF: Silver Diamine Fluoride
14:55 Early Enamel Lesion Pathway
15:11 When to Consider Resin or Peptide Infiltration
15:51 Best Use Case for SDF
20:14 Hydroxyapatite Toothpaste
21:18 Fluoride Safety and Evidence
27:00 Midroll
40:53 Preventive vs Therapeutic Sealants
42:09 Severe Xerostomia and Root Caries
44:40 Using Trays or Dentures as Carriers
45:48 Tooth Mousse and CPP-ACP
47:11 Artificial Saliva
47:46 Why the Patient Has Dry Mouth Matters
49:35 Current Position on Stepwise Excavation
50:09 Selective Caries Removal
51:15 Deep Caries Guidelines
53:01 Materials Are Not Everything in Caries Management
55:59 Further Learning Resource
56:44 Outro

Want more?

Check out part one of this modern caries management series for communication, diagnostics, triangulating data and deciding which caries detection tools are actually worth using.

???? Download the Contemporary Caries Management Implementation PackHead to protrusive.co.uk/MID to access the free implementation pack, including key communication points, diagnosis guidance, management flowcharts and evidence links.

Professor Avijit Banerjee’s recommended reading and ongoing work:

New textbook: A Clinical Guide to Advanced Minimum Intervention Restorative Dentistry (Banerjee A., Elsevier, 2024) — the most comprehensive single reference for modern MIOC and MID.

???? uk.elsevierhealth.com (ISBN 978-0-443-10971-3)

Resources mentioned in this episode:

S3 Guidelines: https://pmc.ncbi.nlm.nih.gov/articles/PMC13099699/

???? Interested in Proximal Resin Infiltration?

Explore The Iconic Method with Cat Edney: a free 1-hour webinar on 24 June 2026, followed by a hands-on 1-day Birmingham course on 4 July 2026 covering Icon resin infiltration, tooth whitening and NIRI-guided enamel management, with verifiable CPD available.
Don’t miss out!DMG Icon Proximal discount for dental professionals at protrusive.co.uk/dmg

PDPMainEpisodes #BreadandButterDentistry

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 250 Operative (Restorative) Dentistry

Aim: To improve dentists’ confidence in modern minimal intervention caries management by applying risk-based decision-making, active surveillance, appropriate use of remineralising and arresting therapies, and evidence-informed restorative strategies.

Dentists will be able to –

Assess early and progressing caries lesions using patient risk, clinical signs, symptoms and radiographic findings.
Select appropriate non-operative, microinvasive and stabilisation strategies, including fluoride, peptides, resin infiltration, sealants and SDF.
Manage high-risk patients, including those with xerostomia or root caries risk, using prevention, recall planning and patient-specific delivery methods.

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If you showed the same bitewing to 10 dentists, would they all agree on whether to pick up the drill?

Why does the word monitoring mean nothing to a patient — and how does swapping it for active surveillance change everything from your notes to your indemnity to your government policy meetings?

Is it overtreatment to act on an E2 lesion — or is “watch and wait” actually the lazy answer dressed up as minimally invasive?

And what should you actually do with AI caries detection that flags shadows your eye doesn’t see?

In this episode, Professor Avijit Banerjee — Professor of Cariology & Operative Dentistry at King’s College London, Honorary Consultant at Guy’s & St Thomas’, and First Dean of the Faculty of Dentistry at the College of General Dentistry — sits down with Jaz for what is genuinely one of the most important caries conversations on the podcast. Part one of two.

Avijit doesn’t do soft answers. The drill-fill-bill model is broken. “Monitoring” needs to go. “Treatment planning” is antiquated terminology medics dropped twenty-five years ago. And AI in caries diagnosis? Useful — but the moment it gets things wrong, you are the one with indemnity, not the software.

What you walk away with is a framework (MIOC), a decision filter (three factors that decide whether to pick up a bur), and a vocabulary shift you can implement tomorrow. Part two covers peptides, SDF, hydroxyapatite, stepwise excavation, and managing caries in xerostomia.

https://youtu.be/YriLo8_hXNwWatch PDP268 on YouTubeProtrusive Dental Pearl: Delete the Word “Monitor” from Your Vocabulary

Stop saying monitor. Start saying active surveillance.

⚠️ Active surveillance must not mean passive delay — document your reasoning, risk assessment, and what would trigger intervention.

✅ Explain it to patients as structured, proactive care: clinical checks, radiographs, risk review, behaviour support, and timely action if things change.

Key Takeaways

Minimum intervention oral care is bigger than minimally invasive dentistry.
MIOC is prevention-based, person-focused, susceptibility-related, and delivered by the whole oral healthcare team.
MID is only one part of MIOC: operative dentistry when a tooth actually needs intervention.
The four MIOC domains are: identify the problem, prevent lesions and control disease, provide minimally invasive operative care, then reassess.
A care plan is more useful than a treatment plan because it includes justification, prevention, behaviour change, and review.
Ask patients what matters to you, not just what’s the matter with you.
Cavitation, cleansability, and lesion activity should guide whether to intervene operatively.
A cavitated lesion that cannot be cleaned is much more likely to remain active.
Smooth surface lesions may sometimes be made cleansable without conventional drilling.
Restorations are not just about filling holes; they help recreate a cleansable tooth surface.
There is no single perfect caries detection technology — clinical examination and good radiographs remain fundamental.
If using NIRI, fluorescence, scanners, or AI, understand how the technology works and where it fails.
AI should support diagnosis, not replace clinical judgement.
For uncertain early lesions, triangulate: clinical findings, radiographs, risk, technology, and patient factors.
Proximal resin infiltration has a role in the right patient and situation, especially as part of a wider prevention-led strategy.

Highlights of This Episode

00:00 Teaser
02:17 Protrusive Dental Pearl: Active Surveillance, Not Monitoring
09:14 Minimum Intervention Oral Care vs Minimally Invasive Dentistry
11:28 Core Principles of MIOC
11:48 Domain 1: Identify the Problem
12:46 Domain 2: Prevention of Lesions and Control of Disease
13:18 Microinvasive Care Options
14:41 Domain 3: Minimally Invasive Operative Dentistry
16:38 Why “Active Surveillance” Matters
18:24 MIOC as a Practical Framework
19:43 Applying MIOC in Patient Communication
22:38 Sustainability & Salutogenesis
29:05 When to Pick Up a Drill
30:23 Biofilm as the Engine of Caries
31:33 Purpose of a Restoration in Caries Management
36:13 Caries Detection Technologies
42:44 Watch and Wait vs Detect and Manage
01:02:52 Outro

Professor Avijit Banerjee’s recommended reading and ongoing work:

New textbook: A Clinical Guide to Advanced Minimum Intervention Restorative Dentistry (Banerjee A., Elsevier, 2024) — the most comprehensive single reference for modern MIOC and MID.

???? uk.elsevierhealth.com (ISBN 978-0-443-10971-3)

???? Interested in Proximal Resin Infiltration?

Don’t miss out! DMG Icon Proximal discount for dental professionals at protrusive.co.uk/dmg
Explore The Iconic Method with Cat Edney: a free 1-hour webinar on 24 June 2026, followed by a hands-on 1-day Birmingham course on 4 July 2026 covering Icon resin infiltration, tooth whitening and NIRI-guided enamel management, with verifiable CPD available.

Loved This Episode? Try this next:

Is Caries Detector Dye BS? – PDP138

PDPMainEpisodes #BreadandButterDentistry

Listen & Earn CPD

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and C

AGD Subject Code: 250 Operative Dentistry (Caries Detection and Prevention)

Aim & Learning Outcomes

Aim: To equip dental practitioners with a contemporary, evidence-informed framework for the diagnosis and non-operative or minimally invasive management of dental caries — with a particular focus on the decision-making that determines whether operative intervention is justified.

Learning Outcomes — by the end of this episode, dentists will be able to:

Describe the four underpinning principles and four clinical domains of Minimum Intervention Oral Care (MIOC), and articulate the difference between MIOC and minimally invasive dentistry.
Apply a structured decision filter — incorporating cavitation, cleansability, and lesion activity — to determine whether a carious lesion requires operative intervention or microinvasive/non-operative management.
Differentiate between passive monitoring and active surveillance, and use appropriate language in clinical communication, care planning, and contemporaneous notes

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Why does dentistry on social media look so perfect?

Are those flawless before-and-after cases the reality of everyday practice—or just the highlight reel?

And why aren’t we talking more openly about the failures, frustrations, and imperfect outcomes that every dentist experiences?

In this episode, Dr Artem Mkrtichyan joins Jaz for a refreshingly honest conversation about the realities of modern dentistry. Known for his candid and relatable social media posts, Dr. Artem has built a following by sharing what many dentists think—but rarely say out loud: dentistry is hard, results aren’t always perfect, and social media often paints an unrealistic picture of the profession.

https://youtu.be/uTKaeewgrgEWatch IC074 on YouTubeKey Takeaways

Social media has become a powerful tool for dentists to connect and share experiences.
Mistakes in clinical practice are common and should be openly discussed.
Rural practice may not always lead to higher income as expected.
Success in dentistry is subjective and varies for each individual.
Continuous learning and skill development are crucial for career growth.
Financial freedom in dentistry is not guaranteed and varies widely.
Networking and mentorship can significantly impact career progression.
Social media can be leveraged to attract patients and build a personal brand.

Highlights of this episode:

00:00 Teaser
00:18 Introduction
02:24 Meet Dr Artem Mkrtichyan
05:27 Rejections And Resilience
09:03 Why Honesty Wins
10:58 Rural Dentistry Reality
14:58 Handling Online Criticism
16:01 Associate Vs Owner Myth
18:05 Midroll: Protrusive App
22:48 Dentistry Money Reality
26:57 Design Your Career Path
28:00 Standing Out In Saturated Markets
29:27 Content Marketing Strategy
31:46 Veneer Minimum Ethics
33:48 Final Advice And Community

If this episode resonated with you, don’t miss “I Committed Fraud – Learn from My Mistakes” – PDP248

InterferenceCast #BeyondDentistry

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Ultimate Education Plan.

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Why does occlusion feel so confusing at dental school?

What if the problem is not that occlusion is too complex, but that it was taught in the wrong order?

How do you make sense of worn teeth, bite scans, shimstock, leaf gauges, provisionals and T-Scan without getting overwhelmed?

And which small ideas can genuinely change the way you diagnose, plan and restore?

In this episode, Jaz is joined by Dr. Mahmoud Ibrahim for a brilliant occlusion-focused conversation. They each bring five clinical “pearls” that helped occlusion finally click for them — from facially generated treatment planning to checking the contralateral side, muscle palpation, provisionals and digital occlusal data.

https://youtu.be/REQ_L5NNEF4Watch PDP267 on YouTubeProtrusive Dental Pearl

Create a PowerPoint or Keynote library of your clinical photos so you can quickly show patients relevant examples during consultations.

⚠️ Avoid hunting through random folders chairside — it feels clunky and breaks the flow of the conversation.

✅ Build a scrollable visual library of cracks, before-and-afters, complications, direct restorations, overlays, crowns and consent examples to support clearer patient communication.

Key Takeaways

Occlusion becomes easier when it is placed inside the treatment planning sequence, not treated as a separate subject.
Facially generated treatment planning starts with where the upper teeth need to be for aesthetics.
Once the central incisors are planned, the rest of the occlusion becomes easier to organise.
Worn teeth that are still in occlusion are often in the wrong position.
Anterior wear may be caused by tooth position, contact time, contact force, or a combination of all three.
Gingival levels can reveal whether worn lower incisors have over-erupted.
Digital bite scans are useful, but they are not always a perfect representation of the patient’s bite.
Shimstock remains one of the most valuable and inexpensive tools for checking true occlusal contacts.
After fitting a restoration, checking the contralateral side first can reveal whether the new restoration is high.
Anterior guidance should be steep enough to separate the back teeth, but shallow enough to allow the lower incisors room to move.
Muscle palpation should assess the quality and symmetry of contraction, not just whether the muscles exist.
Always assess the opposing tooth before placing composite, ceramic or an indirect restoration.
A leaf gauge can help create a more repeatable jaw position when planning more complex occlusal cases.
Provisionals are essential for testing aesthetics, function, vertical dimension and occlusion before committing to final restorations.

Highlights of the Episode:

00:00 Teaser
00:56 Introduction
03:36 Pearl: Build a Clinical Photo PowerPoint
12:48 Pearl 1: Facially Generated Treatment Planning
15:56 Pearl 2: Worn Teeth in Occlusion Are in the Wrong Position
18:05 Why Tooth Position Matters
18:22 Three Causes of Wear to Consider
19:34 Pearl 3: Digital Bite Scans Are Not Always Accurate
20:24 Why Shimstock Still Matters in Digital Dentistry
24:18 Pearl 4: Check the Contralateral Side After a Restoration
26:27 Pearl 5: The First Movement of Opening Is Not Pure Rotation
28:27 Midroll
33:10 Pearl 6: Healthy Occlusion Should Have Coordinated Muscle Contraction
35:22 Why Muscle Palpation Is a Useful Data Point
38:18 Practical Muscle Assessment Tip
38:58 Pearl 7: Always Look at the Opposing Tooth
39:33 What to Check Before an Indirect Restoration
39:44 Why the Opposing Tooth Matters
41:13 Pearl 8: Leaf Gauge for Finding a Repeatable Jaw Position
42:43 What a Leaf Gauge Is
44:33 Pearl 9: Provisionals Reduce the Fear of Complex Cases
47:49 Pearl 10: T-Scan Adds Objective Occlusal Data
53:16 Course Options and Learning Pathway
55:59 Outro

✨Connect with Dr. Mahmoud on Instagram

???? Want to make occlusion more practical?

Bulletproof is designed to take occlusion from abstract theory to real-world clinical application — covering posterior crowns, quadrant dentistry, PROPER conformative dentistry, occlusal risk assessment, shimstock, leaf gauges and daily protocols you can use straight away.
The next Bulletproof course takes place on 26th–27th June at London Heathrow (Radisson Blu Hotel)
Don’t miss it — find out more at bulletproofdentistry.com

➡️Check out more episodes on occlusion: Indirect Restorations For Guiding Teeth – PDP196

PDPMainEpisodes #OcclusionTMDandSplints

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 180 Occlusion

Aim: To help dentists improve their understanding and clinical application of occlusion by recognising key diagnostic signs, using practical occlusal assessment tools, and applying occlusal principles to restorative treatment planning.

Dentists will be able to –

Apply facially generated treatment planning principles when assessing occlusal and restorative cases.
Identify how tooth position, contact time and contact force contribute to tooth wear and restoration risk.
Use practical occlusal assessment methods such as shimstock, contralateral checking, muscle palpation, leaf gauges, provisionals and T-Scan data.

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Are we overcomplicating posterior composites?

Are those beautiful fissures and stains actually helping the patient… or just us?

Why does that “perfect” restoration suddenly need 20 minutes of occlusal adjustment after rubber dam removal?

And how can we make functional, predictable composites without burning time or stress?

In this episode, Dr. Vishaal Shah shares a refreshingly practical approach to posterior composites. From understanding the basics, to simplifying anatomy and improving efficiency, this is a grounded, clinically focused conversation on how to deliver restorations that actually serve the patient.

https://youtu.be/tdkTxzcloN0Watch PDP266 on YouTubeProtrusive Dental PearlMatch your composite anatomy to the patient’s dental age and opposing dentition before you start building.

⚠️ Overbuilding cusps in a worn dentition will create occlusal interferences and wasted adjustment time✅ Assess space, wear, and occlusion first—then design the restoration accordingly

Key Takeaways

Function, efficiency, and occlusal compatibility should guide every restoration
Dental age (wear) is more important than chronological age when planning anatomy
Always assess the opposing tooth before designing cusps and fissures
Use the whole arch—not just the contralateral tooth—as your anatomical guide
Follow the central fissure line across the quadrant to orient your restoration
Avoid textbook anatomy in worn dentitions—adapt to what’s present
Large MOD composites often act as interim restorations before crowns
Build proximal walls first to establish contact and control final contour
Use composite slump (with a microbrush) to naturally form proximal curvature
Base layer height should match the deepest fissure level of adjacent teeth
Map out fissures and cusps before building to improve accuracy and speed
Start with the most difficult cusp first to reduce fatigue-related errors
Proper planning before drilling reduces occlusal errors and remakes

Highlights of the Episode:

00:00 Teaser
01:08 Introduction
01:50 Pearl: Matching Anatomy to Dental Age
05:32 Posterior Composite: Start with Basics, Not Complexity
10:42 Efficient Approach to Large Restorations
14:22 Efficiency vs Ideal Posterior Restorations
19:25 Building Proximal Walls First
20:55 Using Putty Stents for Missing Cusps
23:54 Midroll
27:15 Using Putty Stents for Missing Cusps
27:25 Matrix System Selection
28:06 No Pre-Wedging Philosophy
29:06 Managing Composite Overhangs
30:46 Matrix Ring Differences
32:45 Interjection
37:03 Matrix Ring Differences
37:43 Proximal Wall Technique for Posterior Composite
41:03 Base Layer Strategy in Posterior Restorations
42:23 Mapping Anatomy Before Composite Build-Up
43:13 Cusp Build-Up Approach
45:03 Minimal Adjustment Philosophy
46:43 Final Philosophy: Keep It Simple
48:00 Learning Opportunities
49:54 Outro

???? Want to level up your posterior composites?Dr. Vishaal Shah runs hands-on courses focused on simplifying and mastering everyday restorations.???? Visit www.levelupdentistry.com to explore courses and upcoming training opportunities.

More about posterior restorations:Check out more episodes on occlusion and restorative dentistry: How to Place Posterior Composites without Destroying Your Anatomy – PDP200

PDPMainEpisodes #BreadandButterDentistry

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 250 Operative Dentistry

Aim: To enhance clinicians’ understanding of efficient, functional posterior composite techniques with a focus on anatomy, occlusion, and practical workflow.

Dentists will be able to –

Assess dental age and occlusal compatibility when planning posterior composites
Apply simplified, efficient techniques to build functional posterior restorations
Select appropriate materials and matrix systems to optimise contact, contour, and outcomes

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When is it appropriate to consider an MRI for your TMD patient?

What’s actually involved in MRI of the TMJ?

Can you use any MRI machine, or is the choice of imaging center crucial?

And who should be reporting on these scans — does it really matter? (Hint: yes, it does!)

Dr. Kevin Lotzof, a straight-talking radiologist, joins Jaz for a controversial deep dive into the role of MRI in Temporomandibular Disorders. While many experts downplay its importance, Kevin argues that TMJs are under-imaged and under-diagnosed — and that we may be missing critical pathology.

They explore the practicalities of imaging, how to set expectations with your patients, and why strong but differing views in TMD care can ultimately help you refine your own clinical approach.

https://youtu.be/-yo_Qx4Zg5QWatch PDP265 on YouTube Protrusive Dental Pearl: Adopt the mindset of “Find the cancer today.”When carrying out examinations—whether soft tissue or extraoral—approach it with the intention of detecting oral or skin cancers early. This mindset helps clinicians look beyond just teeth, catch unusual or suspicious lesions, and potentially save lives.

Key Takeaways

TMJ is often overlooked but is crucial for overall health.
MRI is essential for accurate TMJ diagnosis.
Cone beam CT cannot replace MRI for TMD assessment.
Patients with headaches may have undiagnosed TMD.
Education on TMJ imaging is lacking among dental professionals.
Asymptomatic patients should still be scanned for TMJ issues.
The quality of imaging directly impacts diagnosis accuracy.
Patients often feel anxious about MRI procedures.
Understanding patient perspectives can improve care.
There is a need for better collaboration between dentists and radiologists.

Highlight of the episode:

00:00 Teaser
00:55 Intro
05:20 Protrusive dental pearl
06:36 Interview with Dr. Kevin Lotzof
09:38 Under-Imaging and Differing Perspectives
13:27 Access and MRI Centers in the UK
17:51 TMJ MRI: Patient Expectations
22:17 Midroll
25:53 Open MRI Machines
27:26 Ideal Candidates for MRI Imaging
29:55 Cone Beam CT vs. MRI
31:53 Screening and Asymptomatic Patients
38:43 Centers with Reliable TMJ Imaging
41:27 Encouragement for General Dentists
46:33 Outro

Where to Get Reliable TMJ Imaging

⭐ Top Pick:

Orion, Wimpole Street, London(Full contact details available via the Protrusive Guidance App)

????️ Other London Options:

Spire Bushey, Circle Hendon, Cavell, Kings Oak, Circle Healthcare Center

Learn more about TMJ radiographic imaging in PDP223: Understanding TMD Radiographic Imaging – Pano vs CBCT vs MRI

PDPMainEpisodes #OcclusionTMDandSplints #CareerDevelopment

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and C.

AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Imaging techniques)

Aim: To highlight the importance of MRI in the diagnosis and management of temporomandibular joint (TMJ) disorders, ensuring safe and effective orthodontic and restorative treatment planning.

Dentists will be able to:

Explain why MRI is superior to clinical examination and CBCT in diagnosing TMJ pathology.
Identify the key indications for TMJ MRI, including both dental and non-dental symptoms.
Recognize the limitations of poor imaging technique and reporting in TMJ diagnosis

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Is titanium still the gold standard for implants?

Are zirconia implants just hype from biological dentistry… or something more?

Do ceramic implants really integrate as well as titanium?

And should we already be offering patients a choice?

Zirconia implants are no longer a fringe concept—they’re entering mainstream conversations. In this episode, Dr. Pav Khaira returns to break down the science, clinical decision-making, and real-world application of zirconia vs titanium implants. From corrosion and osteoimmunology to occlusion and case selection, this is a practical, evidence-led discussion for clinicians navigating modern implant options.

https://youtu.be/-RCvf2KOdScWatch PDP264 on YouTubeProtrusive Dental Pearl: Thriving in Challenging Times???? Prioritize quality sleep—it sharpens decision-making, improves mood, and reduces irritability (6–7 solid hours beats longer, disrupted sleep).

➡️ Remember, stress comes from how we respond, not the situation itself—focus on what you can control and let go of the rest.

???? Lean on your support system and make time for reflection and gratitude—they help reframe pressure and build resilience.

Key Takeaways* Zirconia implants integrate just as well as titanium, with comparable clinical outcomes * Early healing may be slightly faster around zirconia, but long-term results are similar * Titanium can corrode over time, releasing particles linked to peri-implantitis * Zirconia does not corrode, removing this biological risk factor * Modern implant thinking focuses on osteoimmunology, not just osseointegration * Zirconia implants are often one-piece → no microgap and improved crestal bone stability * Surgical placement must be highly precise—zirconia is less forgiving than titanium * Guided osteotomy is strongly recommended for ceramic implants * Fracture risk in modern zirconia implants is low when manufactured correctly * Hot isostatic pressing significantly increases zirconia strength and reduces defects * Case selection is critical—limited bone or complex angulation may favour titanium * Zirconia implants are typically cement-retained only * Excess cement remains a risk factor for peri-implant disease → manage carefully * Zinc phosphate cement is useful due to radiopacity and bacteriostatic properties * Angled screw correction (titanium) is predictable only up to ~15 degrees * Patient preference for metal-free dentistry is a growing driver of zirconia demand

Episode Highlights* 00:00 Teaser * 00:49 Introduction * 02:32 Protrusive Dental Pearl: Advice for Dentists during challenging times * 05:14 Basics: What Are Implants Made Of? * 07:13 Osseointegration: Zirconia vs Titanium * 08:28 Why Zirconia? Biological Rationale * 11:13 Clinical Advantages of Zirconia Implant * 14:09 Zirconia Implants Limitations in Clinical Use * 17:45 Case Selection: When to Use Zirconia Implant * 19:16 Fracture Risk: Myth vs Reality * 21:30 Midroll * 24:51 Fracture Risk: Myth vs Reality * 25:29 Importance of Manufacturing Zirconia Implants * 27:49 Weaknesses & Clinical Considerations of Zirconia Implants * 30:49 Occlusal Programming for Implants * 32:24 Screw vs Cement Retention in Implants * 34:07 Angle Screw Correction (titanium Context) * 36:20 Cement Choices for Zirconia Implants * 38:27 Market Share & Future Trends of Zirconia Implants * 40:25 Learning Resources for Zirconia Implants * 41:51 Medico-Legal Considerations of Zirconia Implants * 47:37 Training & Education Pathways for Zirconia Implants * 48:25 Outro

Want to go deeper into implants?Explore Dr. Pav Khaira’s Academy of Implant Excellence— training designed to help you truly understand the why behind implant dentistry, not just follow protocols. Hands-on options, mentorship, and advanced training available.

✨Follow Academy of Implant Excellence on Instagram: https://www.instagram.com/academyofimplantexcellence

Mentioned resources from this Episode* Book: Zirconia: Material Properties and Surgical Principles for Dental Implants and Restorations

Want more????? Check out more episodes on implant complications and treatment planning

Implant Occlusion that Makes Sense – PDP 204
Implant Assessment for GDPs: from Space Requirement to Ridge Preservation – PDP052

PDPMainEpisodes

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 690 Implants

Aim: To improve understanding of zirconia implants, including biological considerations, clinical indications, limitations, occlusal principles, consent, and material-related decision-making.

Dentists will be able to –

Describe the clinical and biological considerations when comparing zirconia and titanium implants
Identify key case selection factors and limitations for zirconia implant treatment
Apply practical principles for occlusion, cementation, consent, and risk reduction in implant dentistry

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Is burnout inevitable in dentistry?

Why do so many high-achieving dentists still feel unfulfilled?

Are we too harsh on ourselves without even realising it?

And what if the way we speak to ourselves is the real problem?

In this episode, Jaz sits down with Dr Aditi Bhalla—a Prosthodontist and Integrative Psychotherapist, with over 15 years in dentistry and extensive training in mental health, mindfulness, and movement—to explore compassion-focused dentistry. They unpack burnout, perfectionism, fear-driven practice, and how understanding your mind could be the key to a sustainable, fulfilling career.

https://youtu.be/pNsW6AiWsWQWatch IC073 on YoutubeKey Takeaways

Burnout often stems from perfectionism, shame, and constant self-criticism
Many dentists tie their self-worth entirely to clinical performance
Childhood experiences can shape how we respond to stress and pressure
High-functioning anxiety is common but often goes unnoticed
NHS-style time pressure and fear of complaints drive chronic stress
Decision fatigue in dentistry significantly impacts performance and wellbeing
Social media amplifies comparison and feelings of inadequacy
There is a growing gap between expectations and real-world dentistry
Compassion requires courage, wisdom, and commitment—not weakness
Dentists are good at caring for patients but neglect self-care
Accepting positive feedback is as important as improving weaknesses
Emotional awareness is the first step to managing stress effectively
A “compassion toolkit” helps regulate emotions in real-time clinical scenarios
Sustainable dentistry requires prevention of burnout, not just coping strategies
Team culture improves when you recognise the human behind the role
Compassionate leadership still requires clear boundaries and accountability

Highlights of this episode:

00:00 Teaser
00:51 Introduction
07:50 What “Therapy” Means
11:43 Role of Childhood & Trauma
13:10 Therapists Need Therapy Too
14:40 Breakdown & Burnout in Dentistry
16:50 Causes of Burnout in Dentistry
19:50 Clinical Stress Factors
20:50 Decision Fatigue in Dentistry
23:35 Burnout in Modern Dentistry – Why More Now?
27:38 Midroll
30:59 Burnout in Modern Dentistry – Why More Now?
31:11 What is Compassion?
32:11 Lack of Self-Compassion in Dentistry
33:11 Three Directions of Compassion in Dentistry
35:11 Compassion Focused Dentistry (CFD)
39:11 Nervous System Awareness
41:31 Applying Compassion in DailyDental Practice
43:01 Compassion = Emotional Intelligence + Mindfulness
43:41 Compassion “Kit Bag”
45:11 Compassion in the Team
46:41 Creating a Compassionate Practice
51:51 Getting Started with Compassion
54:12 Outro

???? Want to improve your wellbeing and prevent burnout?Dr Aditi Bhalla runs free workshops and resources via the Dental Wellbeing Hub. You can also explore her work and sign up through her website: draditibhalla.com

LinkedIn: https://www.linkedin.com/in/draditibhalla/
Facebook: https://www.facebook.com/draditibhalla
Dental Wellbeing Hub Instagram: https://www.instagram.com/dentalwellbeinghub

InterferenceCast #BeyondDentistry

Want more?Check out the episode with Marco Maiolino on perfectionism in dentistry – Stop Being a Perfectionist – it’s OK to Fail – PDP184

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and D

AGD Subject Code: 770 Self-improvement

Aim: To explore the principles of compassion-focused dentistry and how emotional awareness, self-compassion, and team dynamics can improve clinician wellbeing and reduce burnout.

Dentists will be able to –

Recognise the role of emotional awareness and self-compassion in managing clinical stress
Identify key contributors to burnout in modern dental practice
Apply practical strategies to foster a compassionate and sustainable workplace

View Details

Are you sacrificing your health for your patients?

Are your neck and back quietly dictating how long you can practise?

Do you skip workouts because you “don’t have time”?

And what if your career ended—not by choice, but because your body gave up first?

In this episode, Jaz is joined by Fraser Smith, a sports scientist and nutrition expert, to break down what dentists actually need to do to stay healthy, pain-free, and practising for longer. From EMS training and realistic exercise routines to nutrition and injury prevention, this is a practical guide to protecting your most important asset—your health.

https://youtu.be/kQu7rDlzT8kWatch IC072 on YoutubeKey Takeaways

Health is a key pillar of career longevity in dentistry
Many dentists sacrifice exercise and sleep during high-stress periods
Short, consistent workouts are more sustainable than long, infrequent sessions
EMS can be a useful time-efficient adjunct but should not replace a full training programme
Strength, endurance, and mobility are all essential components of fitness
Most dentists should start with small, manageable exercise habits and build gradually
Deadlifts are beneficial but require proper technique and guidance
Reformer Pilates is a practical option for improving posture and mobility
Stretching provides short-term relief but must be combined with strengthening
Most musculoskeletal pain in dentists is due to repetitive strain and weakness
Movement and gradual strengthening are key to managing and preventing pain
Ignoring early pain increases the risk of chronic, persistent symptoms
Nutrition should be balanced and sustainable rather than extreme
Protein intake is often insufficient in active individuals
Supplements can support performance but should not replace a good diet
Long-term success depends on prioritising health as part of professional responsibility

Highlights of this episode:

00:00 Teaser
00:53 Introduction
05:40 What is EMS Training?
07:45 Get to know Fraser Smith
09:35 What’s the ideal health routine for Dentists?
11:56 Deadlifts for Dentists
15:01 Stretching & Posture Tips for Dentists
18:35 Midroll
21:56 Stretching & Posture Tips for Dentists
25:41 Balanced Nutrition
28:23 Protein Intake Suggestions
30:51 Back Pain Management
39:09 Outro

????For tailored support with strength, posture, and long-term health, check out Vive Fitness

Want more?

Check out episodes on health and longevity in dentistry: My Neck, My Back (Fix Your Posture While Removing Plaque!) – PDP220

InterferenceCast #BeyondDentistry

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Ultimate Education Plan, including Premium clinical walkthroughs and Masterclasses.

View Details

(This episode discusses suicide prevention and mental health. It does not include graphic details, but please listen with care. If this topic feels close to home, consider pausing and reaching out to someone you trust or a mental health professional.)

Why does dentistry have such high levels of stress and burnout?

Why do so many clinicians feel isolated despite working in busy practices?

What are the early warning signs that a colleague might be struggling?

And what can you actually do — practically — if someone is in crisis?

In this powerful and deeply important episode, Professor John Gibson shares his personal story and the mission behind the Canmore Trust. The conversation explores suicide prevention in dentistry, how to recognise warning signs, and the simple but life-saving actions every clinician should know.

https://youtu.be/F8uWxhn3B8kWatch IC071 on YouTubeKey Takeaways

Dentistry has a well-recognised issue with stress, burnout, and suicide risk
Suicide is always multifactorial — never caused by a single event
Toxic culture, including harassment and unrealistic expectations, contributes to distress
Social media comparison can amplify feelings of inadequacy and isolation
Dentistry is uniquely demanding — both intellectually and technically
Mental health stigma prevents open conversations within the profession
Neurodivergence is increasingly relevant and often underdiagnosed
Perfectionism is a key risk trait linked to suicidal thinking
Working below your moral standards creates significant psychological stress
Warning signs include changes in temperament, withdrawal, and isolation
Asking directly about suicide does not increase risk — it can save lives
Use the “double bounce” approach: ask the question twice if needed
If someone says yes, act immediately — hospital or emergency services
You are not responsible for managing the crisis alone
Early support includes sharing concerns and involving a trusted person
GP support can be transformative and should not be delayed

Highlight of this episode:

00:00 Teaser
00:51 Intro
04:16 John Gibson Introduction
07:15 Understanding the Scale of Suicide in Dentistry
09:59 Why Suicide Happens in Dentistry
11:13 Key Risk Factors of Suicide in Dentistry
12:09 Social Media and Comparison
12:52 Isolation
13:04 Difficulty of Dentistry
14:03 Mental Health Stigma
15:22 Neurodiversity
18:18 Perfectionism and Moral Conflict in Dentistry
21:44 Recognising Warning Signs of Suicide
21:46 Midroll
25:07 Recognising Warning Signs of Suicide
26:21 How to Approach a Suicidal Colleague
28:49 Double Bounce Technique
30:44 If the Answer is YES
33:36 Support and Resources for Dentists
34:12 Key Suicide Prevention Steps
37:40 Creating a Supportive Workplace
39:18 Reflective Space
40:00 Daily Positivity Practice
42:46 Canmore Trust Podcast
42:59 Outro

Learn more about mental health in Dentistry:

Check out more episodes on mental health, burnout, and wellbeing in dentistry.

PDP185 – Mental Health in Dentistry

IC040 – Overcoming Adversities

???? Support and resourcesIf this episode resonated with you or someone you know, explore the Canmore Trust for practical support and guidance:???? thecanmoretrust.co.uk

???? The Canmore Trust Podcast

They also offer helpful resources and podcasts focused on suicide prevention and mental well-being for healthcare professionals.

➡️General Dental Council – Mental Health and Well Being in Dentistry: A Rapid Evidence Assessment

InterferenceCast #Communication #BeyondDentistry

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B

AGD Subject Code: 770 Self Improvement (Mental Health / Stress Management)

Aim: To enhance clinicians’ understanding of suicide risk within dentistry, including contributing factors, warning signs, and practical approaches to supporting colleagues, fostering open conversations, and creating a mentally healthy workplace.

Dentists will be able to –

Recognise the multifactorial nature of suicide in dentistry and identify key contributing risk factors such as toxic culture, isolation, and stigma.
Identify behavioural and emotional warning signs of suicide in dental professionals and apply appropriate communication strategies, including direct questioning and empathetic support.
Implement practical steps to support colleagues in crisis and contribute to a workplace culture that prioritises mental health and wellbeing.

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You’ve spotted the signs—wear, scalloping, fragmentation, maybe even a low AHI—but what does that really mean?

When the data doesn’t match the symptoms, how do you move forward?

And how do you integrate airway into full mouth rehab without compromising function, stability, or predictability?

In this episode, Jaz is joined by Dr. Aston Parmar to explore the real-world application of airway dentistry. They discuss how to help patients own their problem, why sleep testing matters, and how airway influences diagnosis, treatment planning, and long-term outcomes.

https://youtu.be/-zVV1FAT0NIWatch PDP263 on YouTubeProtrusive Dental Pearl

Nasal Breathing and Simple Screening

Nasal airflow can be a major limiting factor in sleep quality.
Simple test: flare nostrils → if breathing improves, nasal resistance may be present.
Nasal dilators can be a cheap, low-risk intervention for selected patients.
Not all patients need mandibular advancement — sometimes the issue is nasal.
Second pearl: test snoring improvement by advancing the mandible.
If forward positioning reduces snoring sound → mandibular advancement may help.

Key Takeaways

Patients must own their problem before accepting treatment
Airway dentistry is about risk reduction, not cure
Apnea-Hypopnea Index (AHI) has limitations—context and patterns matter more than raw scores
Upper Airway Resistance Syndrome (UARS) is common but underdiagnosed
Sleep fragmentation can exist even with low AHI scores
Myofunctional therapy improves compliance and outcomes
Multi-night sleep testing provides more accurate insights
Collaboration with ENT specialists improves diagnostic accuracy
Airway is the bookend of full mouth rehab (start and end)
Dentistry should be airway-sympathetic, not just tooth-focused
Mandibular advancement devices are effective but require careful titration
Morning occlusal guides help reduce bite changes from appliances
Not all patients need the same pathway—risk stratification is key
Predictability in dentistry depends on understanding the whole system
The environment (airway, function, biology) matters more than the teeth

Highlights of this episode:

00:00 – Introduction to Upper Airway Resistance Syndrome
02:08 – Pearl: Nasal Breathing and Simple Screening
07:43 – Recap: Myofunctional Therapy and Indications
08:30 – Role of Myofunctional Therapy in Treatment Planning
09:40 – Patient Communication and Case Acceptance
23:20 – Sleep-Disordered Breathing Spectrum
23:50 – Apnea vs Hypopnea and Apnea-Hypopnea Index (AHI) Limitations
30:00 – Upper Airway Resistance Syndrome (UARS)
35:43 – Management of UARS
37:00 – Mandibular Advancement Devices (MAD)
39:00 – Maxillary Expansion and Surgical Options
41:00 – Treatment Pathway and ENT Involvement
44:00 – Risk Assessment in Full Mouth Rehab
59:30 – Airway-Sympathetic Dentistry
01:02:00 – Treatment Philosophy and Case Selection
01:07:00 – Airway as Bookends of Treatment
01:09:00 – Managing Side Effects of MAD
01:12:00 – Career Insight and Final Reflections

Want to learn more?

Watch part 1 of this episode: PDP262 – Implementing Sleep, Airway and Myo to Restorative Dentistry Part 1

Also, check out Stop Blaming Bruxism with Dr. Sandra Hulac – PDP142

????Master Airway Dentistry in PracticeJoin Dr. Aston Parmar’s course on 8th May in Cardiff

Learn how to screen, test, and manage airway patients
Understand real-world workflows and patient communication
Build confidence in integrating airway into your practice

???? Book via: www.dentalsleep.co.uk

???? Ergonomics Day – Dentistry Without Back Pain!

Join us Saturday, 13th June, Heathrow with Dr. Anikó Ball, world-leading ergonomics expert! Learn proper posture, positioning, and techniques to prevent back problems while practicing dentistry.

???? Hands-on workshop with a mobile dental chair???? Live camera demo on a big screen???? Can’t attend in person? Join online with live stream & replay

???? Early bird tickets even include a full event video!

???? Grab your spot now!

PDPMainEpisodes #CareerDevelopment #OrthoRestorative

This episode is eligible for 1.25 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcome C

AGD Subject Code: 730 – Oral Medicine, Oral Diagnosis, Oral Pathology

Aim

To provide dentists with a practical understanding of airway-focused dentistry, including sleep assessment, risk-based treatment planning, and the integration of airway considerations into full mouth rehabilitation.

Dentists will be able to:

Recognize the limitations of AHI and the importance of sleep fragmentation in diagnosis.
Understand the role of myofunctional therapy in improving airway function and treatment outcomes.
Apply a risk-based approach when integrating airway considerations into restorative and occlusal treatment planning.

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What do you actually do once you’ve screened a patient for airway or sleep-disordered breathing?

You suspect sleep apnea—but since we can’t diagnose it as dentists, how does that influence the care you provide?

What do you do with that information, and who should you be working with to help your patient?

And what if you want to implement airway into your practice—but you’re not in the right environment to do so?

In this episode, Dr. Aston Parmar joins Jaz to break down how to implement airway in everyday dentistry. Together, they explore what happens after screening, how it influences treatment planning, and how dentists can work with other professionals to deliver better care.

https://youtu.be/wGbgbW8muUIWatch PDP262 on YouTube Protrusive Dental Pearl

Use the Mallampati Score as a quick chairside airway screen: have the patient open wide and stick out their tongue. Grade 1 = low risk; higher grades indicate greater Sleep-Disordered Breathing risk.

⚠️ In TMD patients, limited opening can give falsely high scores.

✅ Always interpret alongside history and full exam.

Key Takeaways

Airway management is often overlooked in dental education.
Sleep testing can significantly improve patient outcomes.
Dentists should focus on airway health to enhance sleep quality.
Collaboration with orthodontists can benefit patient care.
Myofunctional therapy is crucial for both children and adults.
Early intervention before age six is vital for nasal breathing.
Tongue function plays a significant role in dental health.
Breathing patterns can affect orthodontic stability.
The Malampati score is a key indicator of sleep disorder risk.
Upper airway resistance syndrome can be difficult to diagnose.
Collaboration with myofunctional therapists enhances patient outcomes.
Understanding airway health is essential for total body health.
Inspiring the next generation of dental professionals is important.

Highlights of this episode:

00:00 Teaser
00:51 Introduction
04:03 Protrusive Dental Pearl: Mallampati Score
05:37 Meet Dr. Aston Parmar
09:51 Journey into Dentistry
17:10 Implementing Training in Practice
22:41 First Exposure to Airway Concept
30:18 South Wales Dental Sleep Clinic Model
30:21 Midroll
33:42 South Wales Dental Sleep Clinic Model
41:17 Myofunctional Therapy Explained
48: 51 Orthodontic Stability and Neutral Zone
54:52 Quickfire Screening Red Flags
01:02:55 Sleep Apnea Basics
01:04:23 Upper Area Resistance Syndrome (UARS)
01:08:53 Outro

Want more? Check out Airway Dentistry with Jeff Rouse – PDP229

???? Ergonomics Day – Dentistry Without Back Pain!

Join us Saturday, 13th June, Heathrow with Dr. Anikó Ball, world-leading ergonomics expert! Learn proper posture, positioning, and techniques to prevent back problems while practicing dentistry.

???? Hands-on workshop with a mobile dental chair???? Live camera demo on a big screen???? Can’t attend in person? Join online with live stream & replay

???? Early bird tickets even include a full event video!

???? Grab your spot now!

PDPMainEpisodes #CareerDevelopment #OrthoRestorative

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcome C

AGD Subject Code: 730 – Oral Medicine, Oral Diagnosis, Oral Pathology

Aim: To provide a practical, data-driven framework for identifying airway-related risks, understanding myofunctional therapy, and integrating sleep screening into routine dental assessment.

Dentists will be able to –

Recognize key airway and sleep-related risk factors during routine dental examinations.
Understand the role of myofunctional therapy in improving airway function and orthodontic stability.
Apply simple chairside screening methods to identify patients who may require further airway assessment.

View Details

Are AI receptionists here to take over your practice?

How do they actually work, and what can they do—or not do—for your team?

Could they make life easier for staff without replacing humans, or are they just a gimmick?

In this episode, award-winning dentist and marketing expert Dr. Grant McAree joins Jaz to break down AI receptionists. Together, they explore what an AI receptionist really is, how it integrates with your practice, and the compliance and legal considerations every dentist should know.

They also dive into the bigger picture—who these systems are really for, how patient interactions are managed, and a live demonstration of an AI receptionist in action that shows exactly what it can—and can’t—do for your practice.

https://youtu.be/Jx-0jOZG3lEWatch IC070 on YouTubeKey Takeaways:

AI receptionists are evolving to provide better patient interactions.
Data insights reveal significant gaps in patient communication.
The technology is designed to assist, not replace human receptionists.
AI can help streamline appointment bookings and patient inquiries.
Understanding patient needs is crucial for effective AI responses.
Customization of AI responses is essential for different practices.
The future of AI in dentistry looks promising but requires careful implementation.
AI should not be seen as a replacement but as a tool for efficiency.
Compliance and data storage are critical in patient interactions.
The integration of AI can lead to improved patient experiences.

YouTube Highlights:

00:00 Teaser
05:06 Meet Dr. Grant McAree
07:32 Grant’s Journey to AI
11:03 AI Gold Rush and Inequality
11:56 Interjection
14:01 AI Gold Rush and Inequality
15:59 Compliance and Legal Risks
18:42 What an AI Receptionist Does
20:54 Midroll
24:16 What an AI Receptionist Does
26:51 Comparing AI to Human Receptionists
32:47 Leads Data and Compliance
36:38 Future Adoption and Risks
42:46 Additional Features and Learning More
43:30 Jaz Call to AI Receptionist
46:01 Outro

Unlock the future of patient consultations! ????

Join my free course and learn how to use smart glasses + flamingo camera to give patients a live guided tour of their mouth—showing cracks, stains, and all the details in real time.

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✅ PDF guides and tutorials included

DM me FLAMINGO on Instagram or Click Here to enroll before I start charging! Don’t miss out on this wow-factor technology.

Check out RoboReception—an AI receptionist and lead tracker that captures interactions and streamlines practice workflow.

If you want to dive deeper into AI, check out Practical AI for Dentistry – Save Time, Achieve More

InterferenceCast #BeyondDentistry

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A

AGD Subject Code: 550 PRACTICE MANAGEMENT AND HUMAN RELATIONS

Aim

To understand the role, capabilities, compliance requirements, and practical integration of AI reception systems in dental practices.

Dentists will be able to –

Identify key functions and limitations of AI reception systems in dentistry.
Understand compliance and legal risks associated with AI in both NHS and private settings.
Recognize practical strategies for integrating AI to support staff without replacing them.

View Details

Can you claim parking expenses as a dentist?

What about a coffee machine for your practice—could that really be deductible?

Or investing in a MSc in Implantology—does that count as a tax write-off?

In this episode, chartered accountant Sebastian Stracey joins Jaz to answer all those “am I naughty if I claim this?” questions that dentists and associates always wonder about. Together, they cover what’s truly deductible, what isn’t, and some surprising exceptions you might not expect.

They also dive into the bigger picture—how principals and associates really compare in terms of income, stress, and responsibility—and Seb shares insights that might change the way you view your career path.

https://youtu.be/BW_TZ5iZ-B8Watch PDP261 on YouTubeProtrusive Dental Pearl

Check out our free Financial Resilience Webinar Replay on Protrusive Guidance, where Dr. Sunny Sadana and I discuss associate contracts, case acceptance, investing, and fee setting.

Key Takeaways:

Dentists often forget to claim mobile phone bills as expenses.
Home office usage can be claimed, especially for associates.
Keeping detailed mileage logs is crucial for claiming travel expenses.
Laundry and cleaning expenses for scrubs can be claimed.
Communication with your accountant is key to maximizing claims.
Continuing education expenses can be gray areas but may be allowable.
Gathering evidence for claims is essential to justify them to HMRC.
Specialization programs can be claimed if they build on existing knowledge.
Fixed fee services for accountants are beneficial for associates.
Always discuss your situation with your accountant to ensure compliance. Many new dentists struggle financially during their training.
Understanding tax obligations is crucial for financial stability.
VAT regulations can be complex, especially for cosmetic treatments.
It’s important to save for tax throughout the year, not just at the end.
Common misconceptions about tax deductions can lead to financial pitfalls.
Dentists should engage in financial education early in their careers.
Expense claims can be tricky, especially for gifts and personal items.
The distinction between personal and business expenses is vital for tax purposes.
Associates and principals have different financial realities in dentistry.
Communication and education about finances are essential for dental professionals.

Highlight of this episode:

00:00 Teaser
00:42 Introduction
02:06 Pearl: Free Financial Resilience Webinar Replay
04:45 Meet Sebastian Stracey
06:56 Common Missed Expenses
13:57 Home Internet Claims
16:49 Asking Accountants Questions
19:07 Claiming Masters Courses
26:31 Specialist Training Costs
27:30 Midroll
30:41 Specialist Training Costs
33:28 Saving for Tax Bills
36:36 VAT on Cosmetic Work
40:06 “Am I Naughty If?” Questions
49:10 Wild Expense Attempts
50:11 Ways Dentists Can Learn More About Tax and Finance
51:56 Associate vs Principal Numbers
53:39 Outro

Get expert financial guidance for individuals and businesses with Humphrey & Co—your trusted partners in taxes, planning, and business success

Learn strategies for career security, smart investing, and building wealth—watch Personal Finances for Dentists (IC068)

PDPMainEpisodes #BeyondDentistry

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B.

AGD Subject Code: 550 – Practice Management and Human Resources

Aim: To outline common allowable and non-allowable expense claims for dentists and highlight the importance of documentation, communication with accountants, and financial planning.

Dentists will be able to –

Identify commonly missed claimable expenses in dental practice.
Recognize expenses that are not allowable under tax rules.
Understand the importance of documentation and communication with accountants when claiming expenses.

View Details

Can AI really help you communicate better with patients?

What if you could audit your own consultations and discover which words, pauses, and stories increase treatment acceptance?

Dr. David Amador joins Jaz for a fascinating episode exploring how AI can transform the way we interact with patients. From auditing conversations to radiographic interpretation, they break down practical applications that improve both communication and patient care.

They also discuss how storytelling, patient trust, and ethical use of AI all come together to boost treatment acceptance — showing that AI isn’t here to replace us, but to make us better.

https://youtu.be/L38Hhu855RoWatch IC069 on YouTubeKey Takeaways

AI is transforming the way dental practices operate.
Storytelling is crucial for effective patient communication.
Building a strong team culture enhances practice success.
Data security is paramount when using AI tools.
Continuous training is essential for team development.
Patient engagement strategies can improve treatment acceptance.
AI tools can streamline administrative tasks and improve efficiency.
Understanding patient needs leads to better care outcomes.
Effective marketing requires a solid online presence and SEO.
Networking with other professionals can provide valuable insights.

Highlight of the episode

00:00 Teaser
00:34 Intro
02:23 Dr. Amador’s Background and Practice
08:14 Using AI for Decision Support
10:26 Leveraging AI for Communication and Training
15:57 Using AI for Patient Care and Diagnosis
21:37 Midroll 1
24:58 Using AI for Patient Care and Diagnosis
26:11 Leveraging AI for Dental Practice Efficiency
27:35 Midroll 2
30:20 Leveraging AI for Dental Practice Efficiency
32:44 Training and Scaling with AI Tools
33:45 Creating SOPs and Playbooks
36:53 Enhancing Patient Communication with Personalized Videos
40:36 Training and Data-Driven Growth
44:52 Outro

AI isn’t the future — it’s your next teammate.

Imagine: while you focus on patient care, AI records your consults, summarizes them, audits your communication, and helps interpret radiographs.

Plaud.ai makes note-taking automatic. Overjet makes diagnostics and patient communication crystal clear.

Check out Midtown Dental Studio — where cutting-edge technology meets genuine care.

If you found this episode valuable, don’t miss PS015: Communicating Fees, Treatment Plans, and More

InterferenceCast #CareerDevelopment #Communication

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and B

AGD Subject Code: 550 – Practice Management and Human Relations

Aim: To explore how artificial intelligence (AI) can be used to audit communication, enhance storytelling, and improve patient conversion while maintaining patient-centered care.

Dentists will be able to –

Explain how AI tools can support communication, diagnosis, and patient understanding in dentistry.
Demonstrate how storytelling and patient-centered communication influence treatment acceptance.
Evaluate the ethical, professional, and practical considerations of integrating AI into dental practice.

View Details

What is a prompt, and how do AI models actually work?

Which AI tools should you be using in dentistry?

Is it safe to put patient details into AI—and how can it help you save time and reduce stress?

In this episode, Dr. Daz Kasperek joins to make AI in dentistry tangible, even if you’ve never used it before. Together, we cover the basics: from getting started with prompts and AI models to understanding ethical considerations and practical ways AI can streamline your workflow.

They also explore the bigger picture—how AI can improve efficiency, enhance patient communication, and give clinicians more time to enjoy life outside the clinic.

https://youtu.be/cmin0h7GNyEWatch PDP260 on YouTube Protrusive Dental Pearl: A free AI tool called Dental Disrupt Smile Simulator lets you upload a smile photo and instantly generate a realistic smile makeover simulation for patient discussions. It runs as a custom GPT inside ChatGPT, created by Dr. Jason Lipscomb

Key Takeaways:

AI is revolutionizing the field of dentistry, particularly in diagnosis.
Prompt engineering is crucial for effective AI interactions.
Personalization of AI tools can significantly improve their utility.
AI can automate administrative tasks, potentially reducing the need for receptionists.
AI can enhance communication between dentists and patients.
The integration of AI in dentistry is still in its early stages.
AI can provide personalized recommendations for patient care.
Voice transcription is a more efficient way to interact with AI.
The future of dentistry will heavily rely on AI technologies. AI is revolutionizing image creation in dentistry.
Choosing the right AI model is crucial for effective use.
Patient confidentiality must be prioritized when using AI.
AI can transform administrative roles in dentistry.
AI can assist in personalized education and training.
The human connection in healthcare cannot be replaced by AI.
Job roles will evolve rather than disappear due to AI.
AI’s limitations highlight the importance of clinician expertise.

Episode Highlights:

00:00 Teaser
01:08 Introduction
03:05 Protrusive Dental Pearl – Smile Simulator
06:39 Meet Dr Daz Kasperek
07:16 AI Adoption and Inequality
16:58 Better Prompting with RCT (Role, Context, Task)
21:56 AI and Administrative Work in Dentistry
30:42 AI Notes in Practice
35:05 Midroll
38:26 AI Notes in Practice
38:49 Smile Simulator Demo
41:57 Choosing Your AI Stack
49:01 Patient Confidentiality and Data Safety
54:38 AI in Dentistry – What It Will Replace
01:01:56 What AI Cannot Replace
01:04:53 Endo AI Research and Thesis
01:07:10 Contact and Resources
01:08:17 Outro

If you enjoyed this episode, don’t miss “NEVER Write Notes Again! How I Use AI for Awesome and Efficient Dental Records – PDP181.”

PDPMainEpisodes #CareerDevelopment

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and C.

AGD Subject Code: 550 PRACTICE MANAGEMENT AND HUMAN RELATIONS

Aim: To provide dental professionals with a foundational understanding of artificial intelligence (AI) in dentistry, including its practical applications, limitations, and ethical considerations, to improve efficiency, patient communication, and clinical workflow.

Dentists will be able to:

Explain what AI is and the difference between an AI model and a prompt.
Identify key AI platforms and tools relevant to dentistry and personal use.
Apply AI safely in clinical practice while maintaining patient confidentiality.

View Details

Are you struggling to get your resin work looking flawless?

Wondering how to polish your composites so they shine like a pro?

Curious about practical tips you can implement immediately to level up your smile makeovers?

In this episode, Dr. Charles Brandon shares three game-changing secrets for mastering composite resin. From practical techniques you can apply right away to a conceptual tip that will completely transform the way you polish, Charles leaves no stone unturned.

Get ready for an episode packed with actionable advice, insider knowledge, and inspiration from a dentist whose resin work is truly next-level. Whether you’re refining your layering skills or aiming for that perfect finish, this episode is a must-listen.

https://youtu.be/dBlN_rbHnTIWatch PDP259 on YouTubeProtrusive Dental Pearl: Level up your resin veneers with the Perio Bur (code and more info here)— a long diamond bur for the slow-speed 1:1 handpiece that gives unmatched control, crisp shaping, and beautiful texture. If you use only one bur for finishing composite, make it this one.

Check out this video of Perio bur in Action on a Real Resin Veneer Case → protrusive.co.uk/periobur

Key Takeaways

The significance of patient communication and understanding their needs is highlighted.
Mistakes are seen as learning opportunities that contribute to growth in practice.
The role of mentorship in navigating challenges in aesthetic dentistry is discussed.
Aesthetic communication is crucial for patient satisfaction.
Patients are visually aided, not verbally aided.
Effective layering techniques can enhance composite work.
Practice on typodont models to build skills.
The polish is secondary to proper placement and finishing.
Understanding composite materials is key to success.
Start with two shades for layering to minimize complexity.
Courses should cover the entire process, not just techniques.
Self-teaching is a valuable way to improve skills.
Investing in oneself is essential for growth in dentistry.

YouTube Highlights:

00:00 Teaser
01:10 Introduction
02:05 Protrusive Dental Pearl – Using a Perio Bur
05:56 Dr. Charles Brandon’s Journey in Dentistry
11:42 Challenges and Reflections in Aesthetic Dentistry
19:08 Perfect Smile Secret #1: Build from the Bottom Up
26:08 Managing Temporaries During a Trial Smile
26:48 Midroll
30:09 Managing Temporaries During a Trial Smile
35:17 Freehand vs. Stent-Based Systems
39:19 Perfect Smile Secret #2: More Than Polish
44:23 Perfect Smile Secret #3: It’s Not the Composite
48:19 Practice and Continuous Learning
53:20 Course Offerings and Final Thoughts
56:00 Outro

Level Up Your Skills

Practice at home with a simple AliExpress setup (~$200) including a 1:5 & 1:1 handpiece plus micromotor.

Take it further with Dr. Charles Brandon’s composite veneer Masterclass and master the full process from design to finish.

If you enjoyed this episode, check out Minimal Preparation Veneers – PDP219.

PDPMainEpisodes #AdhesiveDentistry #CareerDevelopment

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C.

AGD Subject Code: 780 ESTHETICS/COSMETIC DENTISTRY

Aim: To equip dentists with practical techniques, workflows, and mindset strategies for delivering high-quality aesthetic dentistry using composite veneers, from patient communication and trial smiles to layering, polishing, and continuous skill development.

Dentists will be able to –

Explain the importance of patient communication, trial smiles, and expectation management in aesthetic dentistry.
Demonstrate a stepwise workflow for additive composite veneers, including mock-ups, trial duration, and handling of temporaries.
Apply layering, finishing, and polishing techniques effectively using minimal composite shades to achieve predictable aesthetic outcomes.

Cost:Access to this CE activity is included with an active Protrusive Guidance membership. Current membership pricing is available at www.protrusive.app.

Cancellation & Refund Policy:Memberships may be cancelled at any time. Access to CE activities remains active until the end of the current billing cycle. Subscription charges are non-refundable once processed. Full details are available at www.protrusive.app.

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Are you a high-earning dentist… living paycheck to paycheck?

Do you ever feel financially stretched – despite earning well?

Are you trapped in dentistry’s “golden handcuffs”?

And what would your life look like if you worked because you wanted to… not because you had to?

In this rare solo episode, Jaz steps away from occlusion and restorative dentistry to talk about something just as important: personal finances and career security for dentists.

After going deep down the money rabbit hole — reading books like Rich Dad Poor Dad, The Simple Path to Wealth, and I Will Teach You To Be Rich — Jaz shares how his upbringing, early career decisions, and financial education shaped his beliefs about wealth, freedom, and dentistry.

This isn’t financial advice.It’s a mindset shift.

And for many dentists, it might be the most important episode you hear this year.

https://youtu.be/4OXruGIdb_gWatch IC068 on YouTubeYour day list reflects your earning power.

The work you do each day quietly sets the limits of what you can earn.

Exams and single-surface composites create one kind of ceiling; comprehensive cases, ortho, rehab, sedation, and complex restorative work create another.

Upskilling changes that ceiling and gives you far more control over your financial future.

Want more mindset shifts like this?AskJaz — your on-demand dental brain — is built into the Protrusive App.

Key Takeaways

High income does not guarantee financial security.
Dentistry can become “golden handcuffs” without asset building.
Invest in yourself early — skill drives earning power.
Lifestyle creep quietly erodes freedom.
Financial independence means practicing because you want to.
Define your rich life and align spending accordingly.

Highlights of This Episode:

00:00 Why talk about money on a dental podcast?04:12 Perspective and gratitude as dentists10:45 The 45% paycheck-to-paycheck poll16:20 Associates vs principals — the reality22:34 Lifestyle creep explained27:18 Golden handcuffs in dentistry31:10 Growing up with financial scarcity40:02 Investing in yourself early in your career47:55 Index funds and financial resilience55:20 The 20% happiness illusion01:02:18 Defining your rich life01:08:42 Action steps and reflection

PersonalFinances

This episode isnot eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Ultimate Education Plan.

If you enjoyed this episode, check out IC022 – Income for Dentists and Jaz’s Top 10 Financial Literacy books inside Protrusive Guidance.

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Have you ever wondered how hypnotherapy can help your dental patients?

Can it really reduce anxiety, manage chronic pain, or even stop habits like cheek biting?

How can dentists integrate hypnotherapy into their care without stepping outside their scope of practice?

In this episode, Jaz and Dr. Rita Pais break down how hypnotherapy works, who can benefit, and practical ways dentists can incorporate it into patient care.

They also discuss real patient examples, from dental phobia to awake bruxism, showing how a minimally invasive talking therapy can make a real difference in improving habits, reducing stress, and enhancing overall patient outcomes.

https://youtu.be/ONnC_nP0iBQWatch PDP258 on YouTubeProtrusive Dental Pearl: How to Get Patients to Happily Accept a Mouth Prop – Use confident, directive communication paired with a simple analogy and a swallowing expectation to dramatically improve patient acceptance of mouth props.

Key Takeaways

Hypnotherapy combines hypnosis with therapeutic techniques for health outcomes.
Cognitive Behavioral Hypnotherapy (CBH) enhances treatment effectiveness.
Patients must be willing to try hypnotherapy for it to work.
Chronic pain management can benefit from relaxation techniques in hypnotherapy.
Hypnotherapy can address dental phobias and habits like nail-biting.
Awareness of habits is crucial for effective hypnotherapy.
Finding a qualified hypnotherapist is essential for successful treatment.
Science-based approaches in hypnotherapy are preferred by practitioners.
Success stories in hypnotherapy can be very rewarding for practitioners.
Hypnotherapy can be delivered online or in person, making it accessible.

Youtube Highlights

00:00 Teaser
00:59 Introduction
02:13 Protrusive dental pearl: How to Get Patients to Happily Accept a Mouth Prop
05:35 Dr. Rita Pais: Journey into Hypnotherapy
06:32 Hypnotherapy and Its Applications
08:39 Understanding Hypnotherapy and Pain
11:59 How Cognitive Behavioural Hypnotherapy Works
15:35 Midroll
18:56 How Cognitive Behavioural Hypnotherapy Works
20:41 Dental Indications for Hypnotherapy
24:41 Finding a Trusted Hypnotherapist
26:50 Mock Hypnotherapy Session: Patient Journey
30:51 Final Thoughts and Resources
32:28 Outro

For dentists looking to refer patients, The Hypnotherapy Directory is one available resource, though it lists all types of hypnotherapy.

For patients or colleagues interested in hypnotherapy referrals or collaboration, check out: Rita Pais Hypnotherapy

If you loved this episode, make sure to watch Hypnotize Your Patients with 3 Quick Techniques – IC015

This episode is eligible for 0.5 CE credit (Self-instruction) via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and C.

AGD Subject Code: 340 ANESTHESIA AND PAIN MANAGEMENT (Anxiolysis)

Aim: To provide dentists with a practical overview of hypnotherapy applications in dentistry, including cognitive behavioural hypnotherapy (CBH), patient selection, and habit/pain management.

Dentists will be able to –

Distinguish between hypnosis and hypnotherapy.
Explain how cognitive behavioural hypnotherapy integrates CBT and hypnosis.
Identify dental indications for hypnotherapy, including phobias, pain, and habits.

Cost:Access to this CE activity is included with an active Protrusive Guidance membership. Current membership pricing is available at www.protrusive.app.

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After watching this episode, you’ll understand exactly why owning your website matters. And here’s the good news: as a Protrusive community member, you can get 50% off your professional dental website – built specifically for associates who want to stand out.

???? Claim your exclusive discount: protrusive.co.uk/website

Do you really need your own website as an associate, or is a strong Instagram profile enough?

How do you build trust with patients before they even meet you?

And how can you ensure you are visible to the patients who are now using AI tools like ChatGPT to find their next dentist?

https://youtu.be/7StOMRLqFuIWatch IC067 on YouTubeIn this episode, digital marketing expert Rick O’Neill joins Jaz to discuss the evolving landscape of dental marketing. Together, they explore the “Zero Moment of Truth” and the 7–11–4 rule, explaining why a website is the only digital asset you truly own in a world of “rented” social media space.

They also dive into the future of search, covering how to optimize your presence for both Google and AI, and why authentic video content is the ultimate tool for bridging the “belief gap” with prospective patients.

Key Takeaways:

Having a purpose beyond profit is crucial for success.
The ‘I do, we do, they do’ model is effective for team growth.
Patient behavior has evolved; they research extensively before choosing a provider.
A personal website is essential for establishing credibility and trust.
Visual content, including professional photography, enhances personal branding.
Search engine optimization is vital for attracting local patients.
Social proof, such as patient testimonials, is more impactful than before-and-after photos alone.
Messaging is key; it should resonate with the target audience’s pain points.
Dentists have a responsibility to educate the public about their services.
Investing in digital marketing can yield measurable returns.

Highlights of this episode:

00:00 Teaser
00:47 Introduction
05:43 Introducing Rick O’Neill: Expert in Digital Presence
06:43 Insights from Richard Branson
10:15 Entry Into Marketing and Dentistry
13:25 Digital Assets for Associates and Practices
20:26 Key Elements of an Effective Associate Website
26:01 Search Optimization: Making Your Website Discoverable
26:48 Midroll
30:09 Search Optimization: Making Your Website Discoverable
32:40 Dentist’s Role in Content Creation
34:19 Importance of Social Proof in Dental Marketing
45:02 Building a Personal Brand with a Website
48:43 The Future of AI in Dental Marketing
52:35 Digital Solutions for Associates and Clinics
57:04 Resources for Principals and Associates
57:41 Outro

???? Special Community Offer: 50% Off!If you’re nodding along thinking “I need to get serious about my digital presence,” here’s your opportunity.

Protrusive community members get 50% off a professionally designed dental website

???? Head over to: protrusive.co.uk/websiteActivate your 50% discount and get your professional, patient-facing website up and running.

Check out my website to see what a modern associate website can look like.

Want more on building your dental brand? Don’t miss PDP037: Personal Branding for Dentists – Logos and Websites with Shaz Memon

InterferenceCast #CareerDevelopment #Communication

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 550 PRACTICE MANAGEMENT AND HUMAN RELATIONS

Aim: To understand the role of personal and practice websites in modern dentistry and how associates and principals can use digital tools to build trust, credibility, and patient engagement.

Dentists will be able to –

Explain why a personal website is valuable for dentists and associates.
Identify the key elements that make an associate website effective.
Describe strategies to use digital assets, SEO, and content for patient trust and conversion.

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Did Triman ever buy his own camera setup?

Has he figured out which niche or specialty he wants to pursue?

Are molar endodontics and surgical extractions still his fear procedures?

And how’s he getting on with those tricky fee discussions and private patient conversations?

Dr Triman Ahluwalia returns for another catch-up — one year after stepping into his first associate position. In this episode, Jaz follows Triman’s journey from new graduate to confident young clinician, exploring what’s changed and what lessons he’s learned along the way.

From building confidence in complex procedures to improving communication and investing in the right tools, this episode is packed with insights every fresh grad and early-career dentist can relate to.

https://youtu.be/gJNUM6JSLfEWatch IC066 on YouTubeTakeaways

Investing in photography can enhance documentation and patient engagement.
Confidence in discussing costs with patients improves with experience.
Mentorship is vital for growth and learning in dentistry.
Building a strong portfolio is essential for career development.
Choosing the right educational path depends on personal learning styles.
Communication with patients should focus on care rather than costs.
Dentistry offers diverse pathways for specialization and growth.

Highlights:

00:00 Teaser
00:30 Introduction
03:18 Patient Demographics and Practice Insights
06:04 Investing in Photography Equipment
10:13 Handling Complex Procedures and Referrals
13:20 Choosing the Right Courses for Career Growth
17:21 Communicating Costs and Building Confidence
18:32 Midroll
21:53 Communicating Costs and Building Confidence
27:31 Learning from Senior Colleagues and Mentorship
31:50 Building and Improving Your Dental Portfolio
33:56 Final Reflections and Advice for Young Dentists
38:41 Outro

????️ Connect with Dr. Triman Ahluwalia:

Instagram: @drtriman

LinkedIn: Dr Triman Ahluwalia

If you enjoyed this episode, don’t miss Triman’s earlier appearance — I Interviewed a New Grad 7 Months Apart – First Year of Practice (IC052)

InterferenceCast #Communication #CareerDevelopmentThis episode isnot eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Ultimate Education Plan, including Premium Clinical Walkthroughs and Masterclasses.

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What if you finally reach the peak of your career—only to have your body shut it down?

Why are so many dentists forced to cancel clinics, not because of burnout or skill, but because of crippling back pain?

And what if this “expected hazard of dentistry” didn’t actually have to be inevitable?

In this episode, Dr. Aniko Ball joins Jaz to challenge the long-held belief that chronic pain is just part of being a dentist. As an expert in dental ergonomics and the Alexander Technique, she reveals why so many clinicians are unknowingly damaging their bodies every single day—and how simple, overlooked changes can completely transform career longevity.

The mission for this episode was simple: deliver five genuinely life-changing, immediately actionable tips to protect your neck, back, and future. No fluff. No theory for theory’s sake. Just practical changes you can implement straight away—starting from your very next clinic session.

If your health matters to you as much as your dentistry, this is an unmissable episode.

https://youtu.be/u7hEOPpEsGAWatch PDP27 on YoutubeProtrusive Dental Pearl: Cut toxic noise, protect time for your health, and optimize the small habits you repeat daily. You only rotate ~10–13 meals—upgrade those, move a little more, sleep a little better. Small, consistent upgrades compound into an unrecognisable year.

Key Takeaways:

Back pain in dentistry is not inevitable—it is largely the result of cumulative postural habits.
Most dental pain comes from holding positions the body was never designed to hold, not from single traumatic events.
Lifting the elbow or shoulder for prolonged periods activates movement muscles, guaranteeing shoulder and upper back pain.
A finger rest must be used on the non-dominant hand holding the mirror, not just the dominant hand.
Hovering the mirror is equivalent to holding the arm raised against gravity.
The spine is not designed for sustained bending or twisting, even slightly.
Staying vertical is critical—move the patient and the chair, not your spine.
Traditional loupes often force neck flexion; refractive loupes or microscopes allow upright posture and straight-ahead vision.
Stool height matters: hips slightly higher than knees, feet flat, heels fully released into the floor.
If leg weight isn’t given to the floor, the lower back absorbs the load instead.
Habits outside the clinic—especially looking down at a mobile phone—train the same harmful postural patterns used in dentistry.
Postural change feels strange at first because bad habits feel comfortable, even when they are damaging.
Real change requires habit interruption, repetition, and support over several weeks.
Your body is your most important instrument—protecting it protects your career.

Highlights:

00:00 Teaser
00:52 Introduction
03:36 Pearl – Optimizing Small Habits
07:06 Interview with Dr. Aniko Ball: Her Journey on Ergonomics and Dentistry
10:00 Challenging Misconceptions in Dentistry
17:42 Common Mistakes and Practical Tips for Better Posture
28:29 Importance of Refractive Loupes and Microscopes
29:53 Midroll
33:14 Importance of Refractive Loupes and Microscopes
34:18 Communicating with Patients for Better Ergonomics
38:06 The Science of Habit Change and Neuromuscular Training
42:40 Optimizing Dental Stool Height for Better Ergonomics
47:14 The Impact of Mobile Phone Usage on Posture
50:53 Key Posture and Ergonomic Takeaways
53:35 Full-Day Ergonomics Workshop
59:13 Outro

???? This episode is the introduction.The real transformation happens in the room.

???? Join Dr. Aniko Ball for a full-day, full-demonstration workshop and learn how to make your body—and your back—unbreakable.

???? Saturday 13th of June — save the date.

???? protrusive.dental/unbreakable

If this episode resonated with you, My Neck, My Back (Fix Your Posture While Removing Plaque!) – PDP220 is the perfect next watch.

PDPMainEpisodes ##BeyondDentistry #CareerDevelopment

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C.

AGD Subject Code: 130 ELECTIVES

Aim: To help dentists reduce cumulative musculoskeletal trauma by understanding how posture, habits, and equipment choices directly affect spinal, shoulder, and long-term career health.

Dentists will be able to –

Identify common postural habits in dentistry that lead to cumulative trauma and chronic pain.
Apply practical ergonomic principles to reduce strain on the spine, shoulders, hips, and neck.
Modify daily habits, including non-clinical activities, to support long-term musculoskeletal health.

Cost:Access to this CE activity is included with an active Protrusive Guidance membership. Current membership pricing is available at www.protrusive.app.

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When should you attempt to save the root filled molar that everyone else thinks is doomed?

What are the key steps to safely remove, treat, and replant a tooth without causing fractures or resorption?

And how do you manage patient expectations and post-op care to maximize success?

In this episode, Dr. Samuel Kratchman and Dr. Shivakar join Jaz to explore intentional tooth replantation—a procedure that rarely gets the spotlight but can completely change treatment options for challenging cases.

They cover everything from case selection and imaging, to managing crowns and fragile teeth, to simple tools and techniques that make this procedure predictable and accessible.

They also dive into patient communication, consent, and how to include this procedure as part of your everyday dental armamentarium, giving you the confidence to consider it when the right case comes along.

https://youtu.be/SjJTzbJ_AXsWatch PDP256 on YouTubeKey Takeaways:

Intentional replantation is a viable alternative to extraction.
The success rate of intentional replantation is documented at 88-89%.
Patient education is crucial for successful treatment outcomes.
The periodontal ligament must be kept moist during the procedure.
Imaging is essential for understanding tooth anatomy before replantation.
The procedure can be performed atraumatically with proper technique.
Replantation can be a last chance for teeth that are difficult to replace with implants.
A mindset shift is needed in dentistry to prioritize saving natural teeth. Apical infections are often linked to the root tip and surrounding tissue.
A good coronal seal is essential before any restorative work.
Common complications include ankylosis and resorption.
Inflammation can aid in the extraction process by serving the ligament.
Post-operative care is vital for successful recovery.

Highlights:

00:00 Teaser
00:48 Introduction
03:27 Pearl: PDL is everything
04:54 Interview with Dr. Shivakar Mehrotra
07:03 Interview with Dr. Samuel Kratchman
11:01 Terminologies and Success Rates of Replantation
16:03 Indications of Replantation
22:29 Evaluating Radiographs and Clinical Factors
28:48 Case Studies and Practical Applications
30:51 Midroll
34:12 Case Studies and Practical Applications
38:08 Management of Apical Infection
40:35 Curveball Scenario: Combined Endodontic and Restorative Challenge
45:57 Replantation Success Rates and Complications
51:06 Radiographic Signs and Extraction Techniques
56:03 Postoperative Care and Instructions
59:49 Final Thoughts and Resources
01:02:14 Outro

???? First replantation case coming up? Do your homework! ????

Before you touch that tooth:???? Read the published protocols

INTENTIONAL REPLANTATION by Dr. Samuel Kratchman
Retention and Healing Outcomes after Intentional Replantation

???? Review systematic reviews

Clinical outcome of intentional replantation with preoperative orthodontic extrusion: a retrospective study by Cho et al
A Systematic Review of the Survival of Teeth Intentionally Replanted with a Modern Technique and Cost-effectiveness Compared with Single-tooth Implants by Anshul Mainkar

Keep the learning going! Check out PDP061: Surgical Extrusion for ‘Hopeless’ Teeth.

PDPMainEpisodes #EndoRestorative #OralSurgeryandOralMedicine

This episode is eligible for 1 CE credit (Self-instruction) via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C.

AGD Subject Code: 070 ENDODONTICS (Surgical treatment)

Aim: To understand the indications, technique, and outcomes of intentional replantation for teeth with failed endodontic treatment, emphasizing atraumatic removal and predictable long-term success.

Dentists will be able to –

Identify teeth suitable for intentional replantation based on anatomy, root morphology, and prior treatment.
Explain the procedural workflow, including atraumatic extraction, extraoral root-end management, and replantation techniques.
Counsel patients effectively on prognosis, risks, and postoperative care.

Cost:Access to this CE activity is included with an active Protrusive Guidance membership. Current membership pricing is available at www.protrusive.app.

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Are posterior tooth contacts really harmless?

Could group function and non-working side interferences be driving muscular TMD, headaches, and facial pain?

And can digital occlusal data change how we approach bite adjustment?

Dr. Jeremy Bliss joins the podcast to tackle one of the most controversial topics in dentistry: Selective Grinding/Equilibration for TMD but specifically Disclusion Time Reduction (DTR). With a strong focus on restorative technology, lasers, and T-Scan analysis, Jeremy brings a practical and experience-driven perspective to occlusion and bite therapy.

This episode breaks DTR down from the very beginning—what it is, how it differs from traditional equilibration, and why reducing posterior tooth contact during excursive movements may help certain susceptible patients. The conversation also explores canine guidance vs group function, macro vs micro occlusion, and where DTR fits within evidence-based dentistry when conservative care has failed.

https://youtu.be/TMa11nh7VIUWatch PDP255 on YouTubeProtrusive Dental Pearl: Don’t buy advanced occlusal or motion-tracking tech unless your type of dentistry, training, lab support, and local backup can fully use the data—otherwise it’s just a Ferrari stuck in traffic.

Key Takeaways: Disclusion Time Reduction (DTR) & T-Scan

T-Scan: Provides objective data on tooth contact timing and force—impossible to see with the eye or articulating paper.
EMG: Tracks temporalis and masseter activity to show how muscles respond to occlusion.
Goal of DTR: Reduce posterior tooth contact during excursions, shifting contact to canines to relax muscles.
Patient Selection: Best for symptomatic muscular TMD; requires sufficient canine/incisal overlap.
Clinical Benefits: Reduces headaches, migraines, muscle tension, parafunctional damage, and progressive tooth wear.
Procedure: Conservative enamel adjustments (0.5–0.75 mm), guided by T-Scan; posterior teeth should disclude in <0.5 sec.
Implant Care: Prevent early loading to protect bone and restorations.
Evidence: Supported by systematic review and clinical cases; improves outcomes over traditional occlusal adjustments.

Highlights:

00:00 Teaser
00:53 Introduction
09:51 Pearl: Buying Advanced Technologies
11:53 Interview with Dr. Jeremy Bliss
18:08 Introduction to Digital Occlusal Analysis
22:46 Challenges and Controversies in TMD Treatment
26:09 Explaining T-Scan and Its Benefits
32:42 Understanding the Anatomy and Physiology of DTR
36:25 Techniques and Tools for DTR
38:14 Midroll
41:35 Techniques and Tools for DTR
44:19 The Impact of DTR on Muscle Tension and Pain
48:43 Bruxism Cessation After DTR
49:50 Importance of EMG in DTR
52:05 Case Study: A Life-Changing DTR Treatment
56:59 Conclusion and Future Directions
01:00:46 Outro

Systematic ReviewEffectiveness of T-scan Technology in Identifying Occlusal Interferences and its Role in the Management of Temporomandibular Disorders: A Systematic Review

Individual Practice Contact: blissdental.co.uk – contact directly via the website form for information about DTR or patient referrals.

DTR Treatment for TMD with Dr Jaz Gulati in Richmond, London

PDPMainEpisodes #OcclusionTMDandSplints #CareerDevelopment

To learn more about Disclusion Time Reduction, check out: Occlusograms are Lying To Us! Don’t Trust the ‘Heat Map’ – PDP247

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 180 OCCLUSION

Aim: To understand the principles and clinical applications of digital occlusal analysis and Disclusion Time Reduction (DTR) for managing occlusion-related muscular pain, TMD, and improving restorative dentistry outcomes.

Dentists will be able to:

Explain the concept of disclusion time and its impact on masticatory muscles.
Describe how T-Scan and EMG are used to assess occlusal force, timing, and muscle activity.
Identify appropriate patients for DTR and apply objective data to guide safe occlusal adjustments.

Cost:Access to this CE activity is included with an active Protrusive Guidance membership. Current membership pricing is available at www.protrusive.app.

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When are antibiotics truly indicated in dentistry?

How do you manage the patient who’s begging for a prescription?

And what impact are we having on the gut every time we prescribe unnecessarily?

In this episode, Dr. Jeremy Lenaerts joins Jaz to explore the world of antibiotics in dentistry. Together, they cover when to prescribe, when not to, and why analgesics or local measures are often the better option.

They also dive into the bigger picture—antibiotic resistance, gut health, and how to navigate those tricky conversations when patients demand antibiotics for the wrong reasons.

https://youtu.be/-Q4hvl-8vpUWatch PDP254 on YoutubeProtrusive Dental Pearl? Save time and avoid confusion with a ready-made Antibiotics Cheat Sheet that combines the best guidelines into one resource. It covers:

True indications and contraindications
Drug interactions
First, second, and third-line choices
Doses and duration

???? Download it or find it in the Protrusive Vault if you’re a Protrusive Guidance member.

Key Takeaways

Antibiotics are often overprescribed in dentistry, with 80% deemed inappropriate.
The gut microbiome plays a crucial role in overall health and can be negatively impacted by antibiotics.
Educating patients about the risks of antibiotics is essential for informed consent.
Local measures should be prioritized over antibiotics for dental infections.
Antibiotics can lead to antibiotic resistance, affecting both individual and public health.
The gut microbiome is increasingly recognized as a separate organ essential for health.
Dentists should consider the long-term effects of antibiotics on gut health when prescribing.
Patient communication is key in managing expectations around antibiotic prescriptions.
A balanced diet rich in fiber and fermented foods supports gut health.
Dentists must navigate the tension between patient demands and clinical guidelines.

Highlights of this episode:

00:00 Teaser
00:37 Intro
02:25 Protrusive dental podcast
04:10 Dr. Jeremy’s Journey into Dentistry
07:47 Antibiotic Use in Dentistry
10:28 True Indications for Antibiotics
14:12 Impact of Antibiotics on Gut Health
21:09 Clinical Scenarios and Best Practices
26:09 Managing Severe Dental Swellings
26:28 Midroll
29:49 Managing Severe Dental Swellings
33:39 Techniques for Anesthetizing Abscesses
38:06 Handling Cellulitis and Systemic Infections
42:58 Dosage and Safety of Local Anesthetics
44:58 Dealing with Dry Sockets and Retreated Teeth
47:43 Outro

Updated SDCEP Guidance

For clinicians in the UK, Drug Prescribing for Dentistry is now available through the dedicated website SDCEP Dental Prescribing.

Please note that SDCEP no longer provides updates to the printed guidance, and the Dental Prescribing app is no longer supported or updated—it should be deleted from all devices. The SDCEP Dental Prescribing website is now the authoritative source for the most up-to-date information on prescribing in dental practice.

We are also providing the 2016 PDF version of Drug Prescribing for Dentistry for reference, but users should be aware that this document is no longer maintained and may not reflect the latest clinical guidance.

Download the 2016 PDF here.

If you enjoyed this episode, you’ll also find value in Prescribing Antifungals as a GDP – Diagnosis and Management (PDP151)

PDPMainEpisodes #Communication #BreadandButterDentistry #CareerDevelopment

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C and D.

AGD Subject Code: 340 (Prescription medication management)

Aim: To enhance clinicians’ confidence in the rational prescribing of antibiotics in dentistry, with an understanding of when they are indicated, when they are not, and the broader impact on antimicrobial resistance and gut health.

Dentists will be able to –

Identify the true clinical indications for antibiotic use in dentistry.
Recognize when local measures (drainage, extraction) are preferable to antibiotics.
Explain the impact of antibiotic use on antimicrobial resistance and the gut microbiome.
Apply current guidelines (e.g., SDCEP) in clinical scenarios involving dental infections.

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Can adults really expand their maxilla?

Is treating sleep apnea with a CPAP or mandibular advancement device only MASKING the problem?

How does craniofacial anatomy influence airway health, and what should dentists look for?

Dr. Dave Singh joins us to dive into CranioFacial Sleep Medicine. He breaks down how structural issues—like a narrow maxilla, high-arched palate, or limited tongue space—can be root causes of sleep-disordered breathing, rather than just treating symptoms.

The episode also touches on controversies in orthodontics and presents evidence supporting interventions once thought impossible in adults.

https://youtu.be/WUyeOjKquJUWatch PDP253 on YoutubeProtrusive Dental Pearl: Obstructive Sleep Apnea is NOT just a “fat old man disease.” If you’re not screening every patient for sleep and airway issues, you’re missing a huge piece of their overall health. Snoring, bruxism, and craniofacial anatomy are all connected, and understanding these links can transform the way you approach patient care.

Key Takeaways:

Mandibular advancement appliances are not a universal solution. While effective for some patients, they often fail to address the underlying causes of airway collapse.
Craniofacial sleep medicine focuses on airway etiology, not just symptom control, by identifying why the mandible, tongue, and airway behave as they do during sleep.
The cranial base plays a foundational role in facial growth, jaw position, and airway size, directly influencing sleep apnea risk.
A retruded mandible is frequently due to developmental and epigenetic factors, rather than being an isolated mandibular issue.
Sleep apnea has multiple endotypes—including craniofacial, neurologic, metabolic, and myopathic—requiring individualized treatment planning.
Bruxism is not a reliable airway-opening mechanism and may be a primitive physiological response to hypoxia rather than a protective behavior.
Tooth wear can be an early indicator of sleep-disordered breathing, and should prompt clinicians to screen beyond restorative concerns.
Upper Airway Resistance Syndrome (UARS) can occur even when the apnea-hypopnea index (AHI) is low, particularly in non-obese patients with fatigue, pain, and poor sleep quality.
Palatal expansion should be understood as a 3D craniofacial intervention, aimed at improving nasal airflow and airway function—not merely widening the dental arch.
Effective care depends on an integrated, multidisciplinary approach, involving dentists, orthodontists, sleep physicians, ENTs, and myofunctional therapists.

Youtube Highlights:

00:00 Teaser
01:01 Introduction
02:56 Pearl: Debunking Myths About Sleep Apnea
04:27 Interview with Professor Dave Singh: Journey and Insights
13:23 Craniofacial Development
18:53 Epigenetics and Orthodontic Controversies
25:52 Diagnosis and Treatment of Sleep Apnea
32:49 Understanding Upper Airway Resistance Syndrome
34:17 Midroll
37:38 Understanding Upper Airway Resistance Syndrome
39:45 Diagnosing Sleep Disorders and Treatment Modalities
43:58 Exploring Bruxism and Its Hypotheses
45:19 CPAP and Alternative Treatments for Sleep Apnea
48:12 Managing Upper Airway Resistance Syndrome
55:11 Integrative Approach to Sleep Disorder Management
57:17 Diagnostic Protocols and Imaging Techniques
01:02:25 The Importance of Proper Device Fit and Function
01:07:16 Upcoming Events and Further Learning Opportunities
01:09:56 Outro

✨ Don’t Miss Out: Practical, anatomy-based approaches to sleep and airway management for dentists and specialists

???? Event: Introduction to Craniofacial Sleep Medicine

???? Location: Marriott Hotel, London Heathrow

???? Course Price: £2,495

???? Early Bird Registration: £1,996

????️ Discount Code: Use “earlybird20” at checkout

???? Learn More: Visit REMA Sleep for details on courses, devices, and craniofacial sleep medicine resources.

???? Try Protrusive AI aka AskJaz today: Explore clinical reasoning and educational support directly within the Protrusive Guidance App!

If you loved this episode, watch 5 Airway Patients In Your Dental Practice Right Now with Dr Liz Turner – PDP226

PDPMainEpisodes #OcclusionTMDandSplints #BreadandButterDentistry

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcome C.

AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Sleep medicine)

Aim: To understand the craniofacial and dental considerations in managing sleep-disordered breathing, including the role of mandibular advancement, palatal expansion, and integrative dental approaches in sleep medicine.

Dentists will be able to –

Describe the craniofacial factors contributing to sleep-disordered breathing and upper airway resistance syndrome (UARS).
Explain the mechanisms, indications, and limitations of mandibular advancement devices and palatal expansion in dental sleep medicine.
Integrate diagnostic findings, craniofacial assessment, and interdisciplinary collaboration to formulate individualized treatment plans for patients with sleep-disordered breathing.

View Details

Happy New Year, Protruserati ✨

As 2025 comes to a close, we wanted to pause and reflect by revisiting the moments that genuinely shaped how we practise, think, and show up in the clinic.

This Best of 2025 episode starts with restorative and aesthetics, moves through digital workflows, endo, paediatrics, surgery, communication, and finishes with what sustains us over a long career. These are the clips that made me pause, rethink, and quietly adjust how I work – and I hope they do the same for you.

Some of the ideas you’ll hear in this episode include:

Predictable ways to manage wear and space without over-treating
Small restorative and material choices that have a big impact long-term
Practical digital workflows that genuinely improve accuracy and efficiency
Endo fundamentals that reduce stress and increase consistency
Clear clinical judgement for paediatrics, surgery, and medical emergencies
Communication habits that build trust without using jargon
Simple, sustainable ways to protect your body, health, and curiosity

https://youtu.be/rsOxnzlYUkcWatch the Best of 2025 on YouTubeAlso, AskJaz is here!????AskJaz (JazAI) is built to solve a simple problem: knowing what to do next without digging through endless content. Need quick guidance on a tricky case? Not sure which cement to use? Need help with a lab prescription? AskJaz has you covered.????

It provides 24/7 support, allowing you to ask questions at any time and receive clear, direct responses. You can even talk to Jaz in your own language, making the guidance easier to understand and apply—especially in fast-paced clinical situations.

AskJaz is available by upgrading to the Ultimate Clinical Education Plan, where it’s currently included. This gives you full access to AskJaz alongside premium masterclasses, CPD features, and advanced clinical resources inside the app.

If you join or upgrade on or before January 11, AskJaz is included with your Ultimate membership for as long as your account remains in good standing.

From January 12, a new Ultimate+ Plan will launch at a higher price—and that will be the only way new members can access AskJaz.

So if you’ve been thinking about upgrading or joining the app, this is a very good moment.

A Heartfelt Thank YouTo every guest who sat down with me this year and shared their knowledge, their stories, their hard-won wisdom — thank you. You made us all better clinicians.

And to you — for listening, for questioning, for caring enough to keep learning even when you’re exhausted, even when the day’s been long, even when it feels like there’s always more to know.

You’re the reason this podcast exists. You’re the reason I keep doing this.

Thank you for being here. Thank you for being part of this community. Thank you for showing up, year after year.

Here’s to 2026. Here’s to more conversations. Here’s to all of us getting just a little bit better.

Until next year, keep learning, keep caring, and keep doing the dentistry that makes you proud.

View Details

Do your patients really have two bites?

Does their bite change when they lie down? When they sleep?

And how can you explain centric relation, posture, and deprogramming in a way that patients actually understand?

Dr. Bobby Supple joins Jaz for a powerful episode unpacking one of the most misunderstood topics in occlusion: the daytime chewing bite versus the nighttime airway bite. After spending days with Bobby in his New Mexico clinic, Jaz saw firsthand how simply and elegantly Bobby communicates concepts that usually leave patients — and dentists — confused.

Together, they explore why bite discrepancies exist, what happens when the condyles fully seat, and how aligning Bite One and Bite Two over time can transform patient comfort and restorative outcomes.

https://youtu.be/EC_qxUF7GxIWatch PDP252 on YouTubeProtrusive Dental Pearl

When assessing abfractions, always check the patient’s bite in two positions: seated upright and lying back.
Posture subtly shifts the condylar position and can change how forces load the tooth.

Want more gems like this? AskJaz — your on-demand dental brain, will be soon baked right into the Protrusive App.

Key Takeaways:

Every patient has two bites — their upright chewing bite and their horizontal airway bite.
Posture changes the condylar position more than we realise.
Clear communication can make complex occlusion concepts instantly understandable.
Aligning Bite One and Bite Two over time leads to healthier joints and more predictable dentistry.

Highlights of this episode:

03:36 Pearl – Assessing Abfractions
06:47 Dr. Bobby Supple’s Journey to Dentistry
10:46 Confusion Around Centric Relation
13:22 Exploring T-Scan Technology
21:40 The Evolution of Digital Occlusion
27:05 Effect of Sitting vs. Reclined Position
32:03 Airway and Skeletal Asymmetry
37:19 Bite Philosophy and Treatment
42:10 Orthotics and Long-term Care
52:13 Preventive Dental Care
58:18 Ask Jaz AI (Beta Launch)

???? Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES).

????️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician” ???? February 18–19, 2026 · Chicago, Illinois

Papers & Literature: Dr. Bobby’s Top Picks

Evolving digital patterns

Introduction to force scanning

5 ways to use T-Scan

Digital Occlusion–From paper marks to digital force mapping

Discover Dr. Robert Kerstein’s guide to Measured Digital Occlusion and T-Scan technology.

Dive deeper into occlusion with Dr. Bobby Supple on Occlusion Wars II: Beyond Teeth – PDP101

PDPMainEpisodes #OcclusionTMDandSplints #BestofProtrusive

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C

AGD Subject Code: 180 OCCLUSION

Aim: To enhance clinicians’ understanding of the “two bites” concept, the role of condylar position in occlusal health, the use of T-Scan in diagnosing occlusal force patterns, and the long-term prevention-based approach to managing occlusal stress, abfractions, and TMJ remodeling.

Dentists will be able to –

Explain the concept of patients having “two bites” (MIP bite vs. airway/postural bite) and describe how posture influences mandibular position.
Identify occlusal stress patterns using clinical examination and digital tools (e.g., T-Scan) to recognise overloads that may contribute to abfractions, cracks, or TMJ symptoms.
Apply a long-term, preventive approach to occlusal management that aims to harmonise daytime and nighttime bites while supporting joint remodeling through appropriate orthotic therapy.

View Details

How do you balance a high-performance dental career with being an effective parent?

What strategies help you stay sane amidst the organized chaos of family life?

How can showing up as your best self benefit both your patients and your children?

Dr. Shandy Vijayan and Dr. Raabiha Maan join Jaz in this nonclinical episode to share their experiences of parenthood in dentistry. From the unique perspectives of two dentist-moms and the dad viewpoint, they discuss the real-life challenges of raising children while maintaining personal well-being.

They also share practical tips, book recommendations, and actionable strategies for self-care and emotional regulation—helping you create a balanced family life while thriving in your career.

During the episode, Jaz also mentions KARRI — a fun, screen-free voice messenger that helps kids stay safely connected with parents and friends, without social media or internet access.

Loved by kids. Trusted by parents. Get 50% off via: www.protrusive.co.uk/karri

https://youtu.be/F-Tp83_tucoWatch IC065 on YoutubeKey Takeaways

Life comes in “seasons”; early parenting (~0–8 yrs) is intense but temporary.
Reduce clinical load early to focus on children; career focus increases after ~12 yrs.
Prioritize time with kids over tasks; coordinated parenting schedules help.
House help significantly reduces stress, frees energy for quality interactions.
Support networks (family, in-laws, professional communities) are essential.
Grandparents: allow flexibility; avoid micromanaging childcare.
Returning to work: stress, costs (GDC, indemnity, childcare), skill gaps, guilt.
Dentistry = high-performance + emotional labor; manage energy carefully.
Quick mental reset between work/home recommended; part-time can boost longevity.
Parent happiness + strong parental relationship = major factor in kids’ emotional regulation.
Run family like a small business: systems, schedules, clear roles.
Self-regulation, EQ, and self-care benefit family, patients, and professional life.

Highlights of this episode:

00:00 Teaser
01:00 Intro
02:50 Shandy’s Story: Juggling Multiple Clinics
08:11 Raabiha’s Story: Managing a Practice and Family
08:58 Interjection
16:03 Raabiha’s Story: Managing a Practice and Family
18:17 Life Seasons and Reducing Clinical Commitment
21:05 The Value of Help and Support Networks
27:00 Financial and Emotional Challenges in Dentistry
33:03 Midroll
36:22 Financial and Emotional Challenges in Dentistry
36:24 Balancing Work and Home Life
42:26 Time Management and Setting Boundaries
46:51 Self-Care and Emotional Regulation
53:53 Upcoming Wellness Event
59:01 Final Thoughts and Future Ideas
59:49 Outro

Ready to take the next step?

Check out this great resource for new dentists and trainees: Dentistry in a Nutshell
Join the community at the Dental Mums Network to connect with dentist‑parents balancing clinical work and family life.

Revive 2026 – A Wellness Event Like No Other (6 hours CPD)

???? Saturday 24th January 2026

???? Leonardo Royal Hotel, St Paul’s, London

Revive 2026 is your invitation to pause, breathe, and reconnect- a full-day experience designed for women in dentistry who are ready to start the year with purpose, calm, and clarity.

Loved this? Dive deeper into Parenthood and Dentistry – IC025 (Even If You’re Not a Parent!)

InterferenceCast #BeyondDentistry #Communication

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcome: B

AGD Subject Code: 770 SELF IMPROVEMENT

Aim: To explore strategies for managing work-life balance in dentistry, focusing on early parenthood, emotional regulation, and professional sustainability.

Dentists will be able to –

Describe key challenges dentists face balancing clinical practice with early parenthood.
Identify practical strategies for maintaining emotional energy, setting boundaries, and creating support networks.
Apply approaches to integrate self-care, household management, and EQ development to enhance personal and professional well-being.

View Details

Thinking of moving to the USA as a dentist?

Wondering what exams, applications, and documents you’ll need to practice or specialize there?

Curious about how much it costs — and what life as a dentist in the States is really like?

Dr. Hazel Kerr and Dr. Dorrin Reyhani join Jaz for a deep dive into everything you need to know about moving to America as a dentist. Both UK-trained and now faculty at UPenn, they share their personal journeys and break down the full pathway — from exams like the INBDE and TOEFL, to transcripts, personal statements, and application timelines.

They also discuss what it’s like working in the US compared to the UK, including earning potential, patient culture, and training opportunities. Whether you want to complete an advanced standing program, pursue a specialty, or bring your skills back home, this episode gives you a clear roadmap to make it happen.

https://youtu.be/Ro9dljETKpcWatch IC065 on YouTubeKey Takeaways

The journey to becoming a dentist varies significantly by country.
Specializing in dentistry can open more opportunities than general practice.
Board certification enhances professional status and may offer insurance benefits.
International dentists have specific routes to practice in the US.
Scholarships can significantly reduce the financial burden of dental education.
Teaching positions can provide pathways to practice without additional costs. Faculty primarily teach and supervise dental students in clinics.
Early preparation for the INBD exam is crucial for success.
Clinical experience and a strong portfolio are essential for applications.
Networking and externships can enhance application prospects.
Understanding the application process can alleviate stress for international students.
Cultural differences impact how dental care is valued and perceived.

Highlights of this episode:

00:00 Teaser
00:55 Introduction
04:15 Journey to Specialization
12:49 Understanding the Certification and Board Process
15:35 Exploring Different Routes for International Dentists
18:17 Financial Considerations and Scholarships
25:48 US Difficulty and Competitiveness
29:35 Choosing Between General and Specialty Routes
31:11 Navigating State-Specific Licensing
33:28 Teaching and Clinical Responsibilities
35:03 Midroll
38:24 Teaching and Clinical Responsibilities
43:01 Application Process and Exams
52:07 Residency and Career Pathways
57:39 Application Portals
01:00:35 Work Experience Before Specialization
01:03:22 Why Dentists Choose to Work in the US
01:09:36 Finishing the Program and Looking Ahead
01:12:01 Outro

If you enjoyed this episode, you’ll definitely be inspired by The American Dental Dream – PDP002.

InterferenceCast #CareerDevelopmentThis episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Ultimate Education Plan.

View Details

You’re doing a routine exam when you spot it – a stained hairline crack snaking across the marginal ridge of a molar. Your patient hasn’t mentioned any symptoms… Yet.

Should you sound the alarm? Monitor and wait? Jump straight to treatment?

Cracked teeth are one of dentistry’s most misunderstood diagnoses. Colleagues debate whether to crown or monitor. And that crack you’re staring at? It could stay dormant for years—or spiral into an extraction by next month.

So what separates the teeth that crack catastrophically from those that quietly hold together?

In this episode, I am joined by final-year dental student Emma to crack the code (pun intended) on cracked tooth syndrome.

We break down the easy-to-remember “position, force, time” framework to help you spot risk factors before disaster strikes, and share a real-world case of a 19-year-old bruxist whose molar was saved by smart occlusal thinking.

If you’ve ever felt uncertain about diagnosing, explaining, or managing cracked teeth, this episode will change how you think about every suspicious line you see.

https://youtu.be/mU8mM8ZNIVUWatch PS019 on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Risk factors include large restorations and bruxism.
Occlusion plays a significant role in tooth health.
Diet can impact the integrity of teeth.
Every patient presents unique challenges in treatment.
Communication about dental issues is key for patient care.
Certain teeth are more prone to fractures due to their anatomy.
The weakest link theory explains why some patients experience more dental issues.
Patient history is crucial in predicting future dental problems.
The age and dental history of a patient influence treatment decisions.
Understanding occlusion is essential for diagnosing and treating cracked teeth.
The location of a tooth affects the force it experiences during chewing.
Bruxism increases the risk of tooth fractures.
Tooth contacts and forces play a critical role in diagnosing issues.
Opposing teeth can provide valuable insights into tooth health.
Effective communication is essential in managing cracked teeth.
Stains on teeth can indicate deeper issues with cracks.
Monitoring and documenting cracks over time is crucial for patient care.

Highlights of this episode:

00:00 Teaser

00:49 Intro

03:25 Emma’s Dental School Updates

07:18 What is Cracked Tooth Syndrome (CTS)?

10:02 Crack Progression and Severity

12:45 Risk Factors

14:54 Position–Force–Time Framework

21:53 Which Teeth Fracture Most Often?

25:32 Midroll

28:53 Which Teeth Fracture Most Often?

30:37 The Weakest Link Theory

34:05 Diagnostic Tools

37:56 Treatment Planning

39:42 Case Study – High Force Patient

47:27 Communication and Patient Management

51:03 Key Clinician Takeaways

53:03 Conclusion and Next Episode Preview

53:42 Outro

Check out the AAE cracked teeth and root fracture guide for excellent visuals and classification details.

Literature review on cracked teeth – examines evidence around risk factors, prevention, diagnosis, and treatment of cracked teeth.

Want to learn more about cracked teeth? Have a listen to PDP028 and PDP098 – both packed with practical tips and case-based insights.

BreadAndButterDentistry #PDPMainEpisodes #OcclusionTMDandSplints

This episode is eligible for 0.75 CE credits via the quiz on Protrusive Guidance.

This episode contributes to the following GDC development outcomes:

Outcome C

AGD Subject Code: 250 – Operative (Restorative) Dentistry

Aim: To help dental professionals understand the causes, diagnosis, and management of cracked teeth through a practical, evidence-based approach. It focuses on identifying risk factors using the Position–Force–Time framework and improving patient outcomes through informed communication and tailored treatment planning.

Dentists will be able to:

Explain the aetiology and progression of cracked tooth syndrome
Identify high-risk teeth and patient factors—such as restoration design, occlusal contacts, and parafunctional habits—that predispose to cracks
Communicate effectively with patients about the significance of cracks, prognosis, and monitoring options, improving patient understanding and consent

Click below for full episode transcript:Teaser: Sometimes, you have a tooth position problem. Sometimes you have a tooth force problem, and sometimes you have a tooth contact time problem. So time, force, position. A crack is an end product of overload. So risk factors for cracked teeth, right?

Teaser: So if we think, again, that is to do with overload, right? When you have a patient who’s got large amalgam restorations, MOD, I don’t remember the last time I removed an amalgam and I didn’t see a crack underneath.

Why is it that maxillary premolars are more likely to crack than mandibular premolars? This is really fascinating. If all you do is remove the crack and put a composite, the composite will also fail through overload eventually. So you must change something about the environment to reduce the crack propagation.

Jaz’s Introduction: I’ve been involved in dental communities for many years now. I run my own community, the Protruserati, Protrusive Guidance. And one of the questions that keep propping up week by week, month by month, year by year… it’s just all seasons, all time, is about cracked teeth management, diagnosis, cracked tooth syndrome, and getting very patient specific, describing the symptoms and signs, and all the discussions are about cracked teeth.

So there’s still obviously some uncertainty about the best way to diagnose and manage cracked teeth, which is why we created this episode. I know it’s part of the PS, Protrusive Student series, but honestly, the way I ended up explaining cracks in my philosophy and the way I think about how cracks form and how the management very much depends on so many patient factors is pretty unique, I think. I don’t think I’ve ever spoken about cracks in this way, and I think it ended up being a really wholesome episode. Again, thanks to some wonderful questions from our student, Emma.

Now, alongside this episode in the show notes, we’ve put together some essential reading and some great PDF, excellent data and visuals on cracked teeth, and I mentioned a good review, literature review on cracked teeth. That’s also referenced in the show notes. If you are watching or listening on Protrusive Guidance, just scroll below and download it.

And if you haven’t yet joined the community, what are you waiting for? We’re waiting for you on protrusive.app. I really enjoyed recording this episode, Emma, and I hope you enjoy listening or watching it. Oh, and this episode is eligible for CE. There was so much substance. So whether you’re gonna collect CPD hours or CE credits, whoever you are in the world, this episode is eligible again through the Protrusive Guidance app. Let’s catch the main episode.

Main Episode:Emma, the Protrusive Student. Welcome back to the Protrusive Dental Podcast. It’s so nice to have you. We’re talking about cracked teeth today. Look, I can talk about cracked teeth for days. It’s something when I, in the early episodes, one of the early episodes, it’s titled I Hate Cracked Teeth.

I still hate cracked teeth. We all hate cracked teeth. No one likes cracked teeth. But you know what? Over the years, I’ve learned so much about cracked teeth, and now I’ve got some things to share with you and I’m really excited to share with you that will really change how you approach cracked teeth and how you communicate cracked teeth and all that kind of good stuff.

But what I wanna start with is what’s more important to you as a student? You are connected to students and young dentists better than I am. You are right there in the trenches, okay? Like asking these questions that no one wants to ask anymore because they’re afraid to ask, right?

Because, hmm, maybe I should know this already, but you have no fear, no shame because you’re a student, it’s fine. So it’s cool. Like, you don’t have to know everything. And so you are in a position to ask, to represent everyone and ask those questions. So firstly, Emma, tell us, give us an update. How’s final year going at uni?

[Emma]Yeah, final year’s going good. Just the same as when I caught up with you a couple weeks ago. It’s just our finals are out the way, so I’ve got a lot more time in the evening to sort of decompress and focus on the things that I know will be in my book the day after. If I’ve got a crown prep or something or something that I need to look up on, I know what I’m gonna be doing.

I can go home and I can focus on that for the next day rather than stressing about exams. But it’s good. It’s going really well....

View Details

Are you confident in spotting a child at risk of neglect?

Do you know what to do if you witness abuse in your practice?

How can you raise concerns safely while protecting both the child and your team?

This episode with Dr. Christine Park provides tangible actions, practical scripts, and clear guidance for managing challenging scenarios—like seeing an adult hit a child in the waiting room or recognizing neglect in the dental chair. These are situations dental school rarely prepares us for.

Every practice needs clear protocols for safeguarding. This episode acts as a North Star, helping you stay compliant while ethically doing the right thing. If you treat children, you must listen to this episode and share it with every colleague who treats children.

https://youtu.be/-kYs23Xa4LsWatch PDP251 on YouTubeProtrusive Dental Pearl: Find the phone number of your local child safeguarding board / social services. Verify it, then display it where you and your team can quickly access it.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Dentists are trained observers of family dynamics.
Recognizing normal behavior is key in dental care.
Unconscious observations can guide professionals.
Feeling uncomfortable about a situation is a valid signal.
Empowerment comes from trusting your instincts.
Dental care professionals see many aspects of families.
It’s important to act on uncomfortable feelings.
Observation skills are crucial for effective care.
Children’s interactions reveal much about family health.
Awareness of discomfort can lead to better outcomes.

Highlights of this episode:

00:00 Teaser

00:59 Intro

02:40 Pearl – Child Protection Hotline

05:23 Dr. Christine Park’s Background and Expertise

08:37 The Role of Dentists in Safeguarding Children

11:19 Practical Scenarios and Guidelines for Safeguarding

15:35 Recognizing Silent Cases of Neglect

17:29 Team Collaboration and Support in Safeguarding

21:58 Guidelines and Policies for Effective Safeguarding

22:03 Midroll

25:24 Guidelines and Policies for Effective Safeguarding

28:32 Handling a Tough Safeguarding Scenario

32:18 Dealing with Poor Oral Hygiene and Neglect

39:12 Managing Parental Reactions and Consent

43:08 The Importance of Safeguarding in Dentistry

45:34 Further Guidance and Resources

46:10 Outro

???? Safeguard your young patients with confidence!

Catch Dr. Christine Park at the Scottish Dental Show in June or via her NES webinars.

Check out the BSPD guidelines on dental neglect —an essential resource for any dentist treating children

✉️ Get in Touch with Dr. Christine:

General: Christine.park@glasgow.ac.uk
Patient-info: Christine.park7@nhs.scot

If you loved this episode, don’t miss How to Manage Children in Dental Pain – Paediatric Emergencies – PDP159

PDPMainEpisodes #Communication #CareerDevelopment

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and D.

AGD Subject Code: 430 PEDIATRIC DENTISTRY (Identification and reporting of child abuse)

Aim: To equip dental professionals with practical knowledge and skills to recognize, respond to, and appropriately escalate safeguarding concerns involving children in dental practice.

Dentists will be able to –

Identify key signs and red flags of child neglect, abuse, or welfare concerns in dental patients.
Apply clear communication strategies to discuss concerns with parents/caregivers and involve relevant authorities.
Follow practice-based and multi-agency procedures for safeguarding, including documenting observations and escalation.

Click below for full episode transcript:Teaser: We're so well trained in observing, and we're really, really good at knowing what normal is. We know what looks normal to us, and even if we are not consciously aware of what we're seeing, there is always an unconscious part of us. If we see something that doesn't feel right, it will feel uncomfortable.

Teaser:The worst thing is if a dentist or a nurse gets left to deal with it on their own at half past four on a Friday afternoon, when they can’t get through to anybody, and all the rest of the practice are going, not my problem, I’ll see you later.

What do I want that child to think about in years to come? When they’re grown up and they’re an adult and they can look back, do I want ’em to look back and say, that dentist Christine, she saw me and knew I needed help and did X, Y, Z, or, that dentist saw me and knew I needed help and did nothing.

And never want any of my dental colleagues to be the last health professional to see a child that something then horrific happens to.

Jaz’s Introduction: If you treat children, it is your duty to listen to this episode in full, because this is one of those times you get to change a child’s life. You get to potentially save a life, or at the very least, change the entire trajectory of a child’s life.

Safeguarding of children is one of the recommended topics from our regulator, and there’s a really good reason for that. We, as dentists, are in a phenomenal position to be able to look out for nuances and really safeguard the children. They only see their medical doctor when there’s a problem, but they see us more regularly.

And if you treat children, it should be part of your personal development plan to safeguard them. And this episode will give you CPD for that. But forget the CPD, because more importantly, when you see an adult hitting a child in the waiting room, or you see a neglected child in your dental chair and you need to raise concerns, this episode will give you tangible actions, scripts to follow, and good, safe guidance on how to manage these really tricky scenarios, which dental school just does not prepare us for.

This episode with Dr. Christine Park will give you the tools you need to manage these tough scenarios. Now, it’s not a very common thing, thankfully. It’s a bit like mouth cancer. We do screening for mouth cancer every single patient, and we hope not to find it, but when we do find it or are concerned, we refer, we get some expert advice, and we should be doing the same when it comes to safeguarding children.

Every practice needs to have clear protocols in place, and this episode is a great North Star to follow, to help us stay compliant, but also ethically do the right thing. So if you treat children, you must, must, must listen to this episode and share it with every colleague that treats children.

Dental PearlHello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode I give you a Protrusive Dental Pearl. It’s a very important actionable step I’m giving you for this episode’s pearl. Now, most of us under our computer or near our workstation, we have the phone number to call if the service stops working.

Or if we need IT support, and this is almost like universal for all dental practices I’ve worked in. Now, what all practices don’t have is a phone number for when you are concerned about the wellbeing of a child, when you need to do some safeguarding for children, the phone number of social services near you, or a safeguarding authority for children near you.

Do you have that phone number easy to find somewhere? And I think it’s our duty to have that number easy to reference. It’s a bit like when a dental trauma comes in, we refer to the guidelines, we follow the steps. Well, sometimes with these high-octane, adrenaline-pumping, tough conversations that we have with parents, we need a quick reference of a phone number to call for help, as well as discussing it with the lead nurse, practice manager, the other dentist.

Because when safeguarding and children is concerned, it is an entire practice issue, and it is a community-wide issue. So my top tip is have the phone number. Have a phone number of your local safeguarding authority, and you have to do a bit of work. I would say ask ChatGPT, then verify that what ChatGPT is telling you is correct. You need a local contact to get advice. And I think it’s our ethical duty to do so.

Anyway, let’s check out the main episode with Dr. Christine Park, who really breaks it down. Well, we have scripts. We have tangible actions for you to better look after children. I really hope you never have to use these scripts, but when you do, you’ll be way more prepared and you’ll be able to really help children and change their entire life. Enjoy the learning. I’ll catch you in outro.

Main Episode:Dr. Christine Park, welcome to the Protrusive Dental Podcast. So nice to have you smiling. You’ve got the a nice...

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Let’s be honest – the occlusion after Aligner cases can be a little ‘off’ (even after fixed appliances!)

How do you know if your patient’s occlusion after aligner treatment is acceptable or risky?

What practical guidelines can general dentists follow to manage occlusion when orthodontic results aren’t textbook-perfect?

Jaz and Dr. Jesper Hatt explore the most common challenges dentists face, from ClinCheck errors and digital setup pitfalls to balancing aesthetics with functional occlusion.

They also discuss key strategies to help you evaluate, guide, and optimize occlusion in your patients, because understanding what is acceptable and what needs intervention can make all the difference in long-term treatment stability and patient satisfaction.

https://youtu.be/e74lUbyTCaAWatch PDP250 on YouTubeProtrusive Dental Pearl: Harmony and Occlusal Compatibility

Always ensure restorative anatomy suits the patient’s natural occlusal scheme and age-related wear. If opposing teeth are flat and amalgam-filled, polished cuspal anatomy will be incompatible — flatten as needed to conform.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Common mistakes in ClinCheck planning often stem from occlusion issues.
Effective communication and documentation are crucial in clinical support.
Occlusion must be set correctly to ensure successful treatment outcomes.
Understanding the patient’s profile is essential for effective orthodontics.
Collaboration between GPs and orthodontists can enhance patient care.
Retention of orthodontic results is a lifelong commitment.
Aesthetic goals must align with functional occlusion in treatment planning.
Informed consent is critical when discussing potential surgical interventions. The tongue plays a crucial role in orthodontic outcomes.
Spacing cases should often be approached as restorative cases.
Aligners can achieve precise spacing more effectively than fixed appliances.
Enamel adjustments may be necessary for optimal occlusion post-treatment.
Retention strategies must be tailored to individual patient needs.
Case assessment is vital for determining treatment complexity.

Highlights of this episode:

00:00 Teaser

00:59 Intro

02:53 Pearl – Harmony and Occlusal Compatibility

05:57 Dr. Jesper Hatt Introduction

07:34 Clinical Support Systems

10:18 Occlusion and Aligner Therapy

20:41 Bite Recording Considerations

25:32 Collaborative Approach in Orthodontics

30:31 Occlusal Goals vs. Aesthetic Goals

31:42 Midroll

35:03 Occlusal Goals vs. Aesthetic Goals

35:25 Challenges with Spacing Cases

42:19 Occlusion Checkpoints After Aligners

50:17 Considerations for Retention

54:55 Case Assessment and Treatment Planning

58:14 Key Lessons and Final Thoughts

01:00:19 Interconnectedness of Body and Teeth

01:02:48 Resources for Dentists and Case Support

01:04:40 Outro

Free Aligner Case Support!Send your patient’s case number and get a full assessment in 24 hours—easy, moderate, complex, or referral. Plus, access our 52-point planning protocol and 2-min photo course. No uploads, no cost.

[Get Free Access Now]

Learn more at alignerservice.com

If you enjoyed this episode, don’t miss: Do’s and Don’ts of Aligners [STRAIGHTPRIL] – PDP071

PDPMainEpisodes #OcclusionTMDandSplints #OrthoRestorative

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and C.

AGD Subject Code: 370 ORTHODONTICS (Functional orthodontic therapy)

Aim: To provide general dentists with practical guidance for managing occlusion in aligner therapy, from bite capture to retention, including common pitfalls, functional considerations, and case selection.

Dentists will be able to –

Identify common errors in digital bite capture and occlusion setup.
Understand the impact of anterior inclination and mandibular movement patterns on occlusal stability.
Plan retention strategies appropriate for aligner and restorative cases.

Click below for full episode transcript:Teaser: The one thing that we always check initially is the occlusion set correct by the aligner company. Because if the occlusion is not set correctly, everything else just doesn't matter because the teeth will move, but into a wrong position because the occlusion is off from the beginning. I don't know about you, but if half the orthodontists are afraid of controlling the root movements in extraction cases, as a GP, I would be terrified.

Teaser:I don’t care if you just move from premolar to premolar or all the teeth. Orthodontics is orthodontics, so you will affect all the teeth during the treatment. The question’s just how much. Imagine going to a football stadium. The orthodontist will be able to find the football stadium.

If it’s a reasonable orthodontist, he’ll be able to find the section you’re going to sit in, and if he’s really, really, really good, he will be able to find the row that you’re going to sit in, but the exact spot where you are going to sit… he will never, ever be able to find that with orthodontics.

Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati. Welcome back to your favorite dental podcast. I’m joined today by our guest, Dr. Jesper Hatt. All this dentist does is help other dentists with their treatment plans for aligners. From speaking to him, I gather that he’s no longer practicing clinically and is full-time clinical support for colleagues for their aligner cases.

So there’s a lot we can learn from someone who day in day out has to do so much treatment planning and speaking to GDPs about their cases, how they’re tracking, how they’re not tracking, complications, and then years of seeing again, okay, how well did that first set of aligners actually perform? What is predictable and what isn’t?

And as well as asking what are the most common errors we make on our ClinChecks or treatment plan softwares. I really wanted to probe in further. I really want to ask him about clinical guidelines for occlusion after ortho. Sometimes we treat a case and whilst the aesthetics of that aligner case is beautiful, the occlusion is sometimes not as good.

So let’s talk about what that actually means. What is a not-good occlusion? What is a good occlusion? And just to offer some guidelines for practitioners to follow because guess what? No orthodontist in the world is gonna ever get the occlusion correct through ortho. Therefore, we as GPs are never gonna get a perfect textbook occlusion, but we need to understand what is acceptable and what is a good guideline to follow. That’s exactly what we’ll present to you in this episode today.

Dental PearlNow, this is a CE slash CPD eligible episode and as our main PDP episode, I’ll give you a Protrusive Dental Pearl. Today’s pearl is very much relevant to the theme of orthodontics and occlusion we’re discussing today, and it’s probably a pearl I’ve given to you already in the past somewhere down the line, but it’s so important and so key.

I really want to just emphasize on it again. In fact, a colleague messaged me recently and it reminded me of this concept I’m about to explain. She sent me an image of a resin bonded bridge she did, which had failed. It was a lower incisor, and just a few days after bonding, it failed. And so this dentist is feeling a bit embarrassed and wanted my advice.

Now, by the way, guys, if you message me for advice on Instagram, on Facebook, or something like that, it’s very hit and miss. Like my priorities in life are family, health, and everything that happens on Protrusive Guidance. Our network. If you message me outside that network, I may not see it. The team might, but I may not see it.

It’s the only way that I can really maintain control and calm in my life. The reason for saying this, I don’t want anyone to be offended. I’m not ignoring anyone. It’s just the volume of messages I get year on year, they’re astronomical. And I don’t mind if you nudge me. If you messaged me something weeks or months ago and I haven’t replied, I probably haven’t seen it. Please do nudge me.

And the best place to catch me on is Protrusive Guidance. If you DM me on Protrusive Guidance, home of the nicest and geekiest dentists in the world, that’s the only platform I will log in daily. That’s our baby, our community. Anyway, so I caught this Facebook message and it was up to me to help this colleague.

And one observation I made is that the lower teeth were all worn. The upper teeth were really worn, but this resin bonded bridge pontic, it just looked like a perfect tooth. The patient was something like 77 or 80. So it really made me think that, okay, why are we putting something that looks like a 25-year-old’s tooth in a 77-year-old? But even forgetting age and stuff, you have t...

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Do you have a “hopeless” retained root you’re ready to extract?

Think implants, dentures, or bridges are the only way forward?

What if there’s a way to save that tooth — predictably and biologically?

In this episode, Dr. Vala Seif shares his experience with the Surgical Extrusion Technique — a game-changing approach that lets you reposition the root coronally to regain ferrule and restore teeth once thought impossible to save.

Jaz and Dr. Seif dive into case selection, atraumatic technique, stabilization, and timing, all guided by Dr. Seif’s own SAFE/SEIF Protocol, developed from over 200 successful cases.

https://youtu.be/2TyodqgAP9wWatch PDP249 on YouTubeProtrusive Dental Pearl: When checking a ferrule, consider height, thickness, and location of functional load. Upper teeth: prioritize palatal ferrule. Lower teeth: prioritize buccal. Tip: do a partial surgical extrusion, rotate the tooth 180°, then stabilize.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Surgical extrusion is a technique-sensitive procedure that requires careful planning.
Case selection is crucial for the success of surgical extrusion.
A crown-root ratio of 1:1 is ideal for surgical extrusion.
Patients are often more cooperative when they see surgical extrusion as their last chance to save a tooth.
Surgical extrusion can be more efficient than orthodontic extrusion in certain cases.
The importance of ferrule in dental restorations cannot be overstated.
Proper case selection is crucial for successful outcomes.
Atraumatic techniques are essential for preserving tooth structure.
The ‘Safe Protocol’ offers a structured approach to surgical extrusion.
Patient communication is key to managing expectations.
Flowable composite is preferred for tooth fixation post-extraction.
Understanding root morphology is important for successful extractions.

Highlights of this episode:

00:00 Surgical Extrusion Podcast Teaser
01:07 Introduction
02:38 Protrusive Dental Pearl
05:53 Interview with Dr. Vala Seif
08:57 Definition and Philosophy of Surgical Extrusion
15:30 Indications, Case Selection, and Root Morphology
21:37 Comparing Surgical and Orthodontic Extrusion
25:54 Crown Lengthening Drawbacks
28:39 Occlusal Considerations
33:53 Midroll
37:16 Definition and Importance of the Ferrule
43:07 Clinical Protocols and Fixation Methods
01:00:01 Post-Extrusion Care and Final Restoration
01:05:04 Learning More and Final Thoughts
01:09:29 Outro

Further Learning:

Instagram: @extrusionmaster — case examples, papers, and protocol updates.
Online and in-person courses in development (Europe + global access).

Loved this episode? Don’t miss “How to Save ‘Hopeless’ Teeth with the Surgical Extrusion Technique” – PDP061

PDPMainEpisodes #OralSurgeryandOralMedicine #OrthoRestorative

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C.

AGD Subject Code: 310 ORAL AND MAXILLOFACIAL SURGERY

Aim: To understand the biological and clinical principles of surgical extrusion as a conservative alternative to orthodontic extrusion or crown lengthening for managing structurally compromised teeth.

Dentists will be able to –

Identify suitable clinical cases for surgical extrusion, including correct root morphology and crown–root ratios.
Describe the step-by-step SAFE Protocol for atraumatic surgical extrusion, fixation, and timing of endodontic treatment.
Evaluate the advantages, limitations, and biomechanical considerations of surgical extrusion compared with orthodontic extrusion and crown lengthening.

Click below for full episode transcript:Teaser: I always had a problem with extracting teeth. Not a problem technically, ethically. If highly damaged teeth get properly treated and correctly maintained, they are always going to outlive implants.

[Teaser]So what I’m referring to here is that the most sophisticated and complicated solutions are not always the smartest one. It’s not about most expensive. It’s not about most advanced. It’s not about most complicated. It’s about the best possible for the patient. We must keep that in mind that there is no such thing as a master key that opens up all of the doors for us.

Surgical extrusion, over the years… it actually was presented to dentistry in the early eighties. They were really trying to work on surgical extrusion. And guess who comes out? I have done over 200 cases with a follow-up of up to six, seven years. That is something that you can rely on. In such cases, I take out the tooth and rotate it and put it back in.

No way.

Jaz’s Introduction: Yeah, so you have a retained root and you think this is hopeless and you’re headed towards an implant, denture, a bridge or whatever. But then this episode comes along and reminds you about the power of the surgical extrusion technique. In plain terms, you are partially extracting the root, and now you have the most important thing in restorative dentistry. You have ferrule, you have tooth structure, you can now crown. Whereas before everything was subgingival and it was impossible to restore.

Hello, Protruserati, I’m Jaz Gulati and welcome back to your Favorite Dental Podcast. This is the podcast where you make dentistry tangible and make you fall in love with dentistry again.

Four years ago, with Dr. Peter Raftery, the endodontist, we spoke about this very topic, the surgical extrusion technique. I’ll put that episode in the show notes ’cause that was really valuable as well. But in this episode it is special because it’s an update from someone who’s done more than 200 cases.

So what he believes, and what I also believe, is he is the most experienced clinician in the world when it comes to the surgical extrusion technique. I haven’t seen anywhere in the literature the kind of numbers that he’s done—so, so much.

We can learn from Dr. Vala Seif from Iran, and Protruserati, you’re gonna absolutely love him, right? His storytelling, his analogies. I actually really geeked out and had a great time, and I know you’re gonna love him. Even all the way to the end, the last few seconds, he still gave another tip of how to stop bleeding when you do this technique so you can then add your composite splint to secure the root. He’ll give you that right at the very end. So make sure you don’t miss any of this episode.

Dental PearlNow, every PDP episode I give you a Protrusive Dental Pearl. This one’s an occlusion conceptual one, a biomechanical one when it comes to restorative dentistry, but it’s also very relevant to this episode ’cause a really cool, fascinating technique was advised by Dr. Seif, which I really am excited to share with you.

So firstly, conceptually, the pearl I’m giving is to remember the following: that when you have supragingival structure all the way around 360 degrees, we call that the ferrule. Something a crown can grab onto, and it’s important that this ferrule is as tall as possible vertically—ideally two millimeters plus—but it’s also important that the tooth structure remaining is thick because if it’s very, like, if it’s paper thin, that’s not really a ferrule, that’s not really contributing biomechanically.

Now the conceptual pearl I’m giving to you is to think about the position of the ferrule. If you have three millimeters on the palatal side and one millimeter on the buccal side, then this is still pretty good, especially for upper teeth, because the location of the ferrule is actually really important.

Think of the way that the upper incisors are loaded in a class one and class two patient. When a patient is chewing, the palatal of the upper incisors is taking load in clenching, is taking load in mastication and chewing as the food is pushed into centrals, and as you are cutting and incising, the crown is kind of going in a buccal direction.

The tooth, the crown of an upper incisor, is heading in a buccal direction, and so it is trying to grip onto that palatal tooth structure. And in a lower incisor, the buccal part of tooth structure is gonna be under more strain because the lower incisor is trying to bend inwards.

So why is this important? Well, pragmatically speaking, if you have a scenario where you’re trying to restore a canine and you’ve got lots of tooth structure palatally and not very much tooth structure buccally, then probably you’re gonna still be okay because that palatal tooth structure for an upper tooth, that’s usually more valuable and more precious. It just helps us to remember how teeth are loaded in a biomechanical way.

Now, the absolutely fascinating thing that Dr. Vala Seif spoke about is: let’s say you have a scenario where we have a retained root, like a crown–root fracture, and let’s say you have loads of tooth structure bucca...

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Are you confident in replacing a single missing central incisor?

When is a denture the right option — and when should you consider a bridge or implant instead?

Why is the single central incisor one of the hardest teeth to replace to a patient’s satisfaction?

In this Back to Basics episode, Jaz and Protrusive Student Emma Hutchison explore the unique challenges of replacing a single central incisor. They break down when each option — denture, resin-bonded bridge, conventional bridge, or implant — is appropriate, and the biological and aesthetic factors that influence that decision.

They also share key communication strategies to help you manage expectations, guide patients through realistic treatment choices, and avoid disappointment when dealing with this most visible and demanding tooth.

https://youtu.be/czjPQxKpwPwWatch PS018 on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Replacing a single central incisor isn’t just about technical skill — it’s about communication and case selection.
Success comes from helping patients understand that a restoration replaces a tooth’s function and appearance, not nature itself.
Clear conversations about expectations, limitations, and maintenance are what turn a difficult aesthetic case into a satisfying long-term result.

Highlights of this episode:

00:00 Teaser

00:28 Intro

01:56 From Dental Nurse to Final-Year Student

07:38 Challenges and Considerations in Replacing Central Incisors

12:51 Patient Communication and Treatment Planning

18:33 Discussing Treatment Options and Enamel Considerations

21:16 Communicating Options and Guiding Patient Decisions

25:51 Choosing Between Fixed and Removable Options

27:10 Midroll

30:31 Choosing Between Fixed and Removable Options

31:05 Handling Old Crowns and Patient Communication

34:17 Conventional vs. Resin-Bonded Bridges

37:57 Occlusal Load, Function, and Implant Considerations

43:40 Digital Workflow in Dentistry

45:54 Managing Aesthetic Expectations

48:34 Final Thoughts and Recommendations

52:59 Outro

???? Want to feel confident with prosthodontics?

Explore these essential follow-ups to this episode:

Dentures vs Bridges with Michael Frazis
Crowns vs Onlays with Alan Burgin
Dentures with Finlay Sutton
RBB Masterclass on the Protrusive Guidance App

Quick, practical lessons to sharpen your planning, communication, and anterior aesthetics — all in your pocket.

ProsthoPerio #OcclusionTMDandSplints #Communication #BreadandButterDentistry

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C.

AGD Subject Code: 610 – Fixed Prosthodontics

Aim: To provide a clear, clinical overview of replacing a single missing incisor — focusing on when to choose a denture, bridge, or implant, and how to communicate realistic expectations.

Dentists will be able to –

Identify the key biological, functional, and aesthetic challenges in replacing a central incisor.
Compare the indications, advantages, and limitations of dentures, resin-bonded bridges, conventional bridges, and implants.
Communicate realistic outcomes, limitations, and maintenance expectations effectively to patients.

Click below for full episode transcript:Teaser: Have you heard of something called central dominance?

Teaser:No.

So in the face, the central incisors should be the star of the show, should be in the middle, and the centrals should be like twins. When we lose a central incisor, we have to discuss how was that central incisor lost, and most common cause is trauma. The most important predictor success of a resin bonded bridge is the same as it is for veneers. If you’re not sure what the treatment plan should be, you probably haven’t asked a patient enough questions.

Jaz’s Introduction:Welcome to this Back to Basics episode on replacing the single central incisor, why the single central incisor is the most important tooth, obviously, but so that we can just go a little bit deeper into this topic rather than talking about replacement options in general, which you’ve already done on the podcast.

There are certain features which are very special when you’re replacing the central incisor and why it is regarded as the most difficult treatment to deliver in terms of patient satisfaction expectations. We’re joined by the Protrusive student, Emma Hutchison, where we’re gonna go into the basic overview of decision making.

When is a denture appropriate? Is it ever appropriate for an incisor? How about bridges and what type, and what are the implant considerations, and actually choosing between these options? I think one of the biggest takeaways you might get from this is communication. There’s a specific way I communicate to patients about this, and that’s what I think you’ll probably take away the most from this episode.

Hello Protruserati. I’m Jaz Gulati and welcome back to the student edition of your favorite dental podcast. I know we call it Protrusive Students, but young practitioners or those returning back to work often find these episodes very valuable. Of course, we’ve got so much more where this came from.

We’ve got all sorts of genres and topics covered in Protrusive Podcast and recently on YouTube. We’ve done the playlist so you can actually pinpoint the different themes of the podcast. On our app, Protrusive Guidance, head over to protrusive.app if you’re interested in that. It’s the community of the nicest and geekiest dentists in the world. We put some extra videos, not on YouTube, on there as well. Let’s now join Emma, and I’ll catch you in the outro.

Main Episode:Emma Hutchison, the Protrusive Student, welcome back. How are you doing? How is clinics going? Final year, you’ve done your exams, but it’s the actual more clinical exposure. How’s everything going?

[Emma] Mm-hmm. Yeah, it’s going good. So as I was saying last time, it’s just more, lots more experience this year, which is good. So I’m up in Falkirk in Scotland every second week, just Monday till Friday, nine till five, seeing about four or five patients a day. And then the other second week I’m in Glasgow doing more specialized stuff, watching some consultants in restorative and things. So it’s good. It’s good. Just plodding along quite nicely, which is good.

[Jaz] Good. And you obviously have been a dental nurse. So once you’re seeing four to five patients a day, you have this extra level of insight that maybe your colleagues don’t have. Like, in the real world it’s 30, 40 patients sometimes, sometimes 12, sometimes one. Like, it’s such a variation.

‘Cause obviously you’ve been an implant nurse as well. So what advice do you want to give to your colleagues who are maybe listening to this and they’re seeing these four to five patients, and you want to prepare them for the real world? What would you say with your very unique perspective?

[Emma] Yeah, I think when I was working as an implant nurse, I remember speaking to the dentist I was working with and he was saying why he moved to private dentistry initially is just because the real life just isn’t like the gold standards that you’re taught at dental school. In the NHS especially, you’re time restricted.

So I think I do have that in the back of my head. I know that I won’t have the luxury of such long appointments when I graduate. So yeah, I’m just getting myself prepared for the real world. ‘Cause I am gonna do VT or DFT so that I can work in the NHS to start off with and then see where I go from there.

But I do know that in the back of my mind it’s gonna get a lot busier as soon as I start VT practice. So yeah, just that you’re not gonna have the best materials that you do in dental school. I know in Glasgow anyway, we tend to have really quite good materials. Good rubber dam. I know I’ve spoke to you about things like that before, and just that it might not be like that in the real world when I graduate and get out there and start working.

So just to prepare myself for that. I’m aware of it, it’s fine. And I’m just trying to relish the opportunities that I have at the moment and the staff around me that I have as well. I think that’s one thing.

[Jaz] You’ve gotta be like a leech, Emma. You’ve gotta be like a leech, like a sponge.

[Emma] And just ask all the questions whilst you have all these specialists and consultants around you and just take note of everything that they’re saying. Especially the way that people communicate with their patients and pick up little things that they’re saying to their patients and make it your own. So I’m trying not to wish away my last year, so that’s good.

[Jaz] No, enjoy it. Enjoy the comfort and the bu...

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What if one bad decision completely changed the course of your career?

In this exclusive, members-only episode, Jaz sits down with a fellow dentist from our community who shares his raw, honest story about a moment of misjudgment — committing fraud — and the painful lessons that followed.

This isn’t about blame. It’s about insight, accountability, and redemption.

From the shock of investigation and court hearings, to the struggle of rebuilding trust and identity, this conversation shines a light on what really happens behind closed doors when things go wrong.

The aim of this podcast was to hopefully deter colleagues from temptation which can affect anyone at any time.

https://youtu.be/QF-UNrlYjcwWatch PDP248 on YouTubeHow to Watch the Full Episode This is a members-only podcast episode due to its sensitive nature.

You can access it by creating a free Community account at: https://www.protrusive.app

Highlights of this episode:

00:00 Teaser

00:49 Introduction

05:49 End Screen

Love this episode? Don’t miss Divorce, Alcohol and Rough Patches – Overcoming Adversities (IC040)

PDPMainEpisodes #BeyondDentistry

This episode is eligible for 0.5 CE credits via the Quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and D

AGD Subject Code: 555 Ethics in Dentistry

Aim: To reflect on the ethical, professional, and emotional lessons learned from a real-life case of dental fraud, highlighting accountability, insight, and rehabilitation while identifying practical steps to prevent similar incidents.

Dentists will be able to –

Recognise how workplace pressures, lack of mentorship, and poor oversight can lead to ethical lapses.
Understand the legal, professional, and emotional consequences of dishonesty and poor record keeping.
Identify support systems, coping strategies, and self-reflective tools to prevent burnout and maintain integrity.

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Ever had a patient swear their bite feels “off” – even though the articulating paper marks look perfect and you’ve adjusted everything twice over? Or maybe you’ve placed a beautiful quadrant of onlays, only to have them return saying, “these three teeth still feel proud.” If that sounds familiar, you’re not alone.

In this episode, I’m joined (in my car, no less!) by Dr. Robert Kerstein, who was back in the UK to teach about digital occlusion and the power of the T-Scan and ‘disclusion time reduction therapy’. We dig into why a patient’s bite can still feel “off” even when everything looks right, how timing is just as important as force, and why splints and Botox don’t always solve TMD.

Robert explains why micro-occlusion is the real game-changer, how scanners could mislead you, and why dentistry still clings to articulating paper.

So if you’ve ever wondered why “perfect” cases still come back with bite complaints, or whether timing data can actually prevent fractures and headaches, this episode will give you plenty to chew on – pun intended.

https://youtu.be/0lCAsjFhsXIWatch PDP247 on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Micro-occlusion, not just “dots and lines,” is the real driver of patient comfort and long-term tooth health.
T-Scan measures both force and timing, which scanners and articulating paper cannot capture.
Many patients show signs of occlusal damage without symptoms.
Disclusion Time Reduction (DTR) treats TMD neurologically without splints, Botox, or TENS.
Relying on occlusograms alone for guiding reduction is risky.
Dentists can reduce post-treatment complaints by balancing micro-occlusion with T-Scan.
Adopting T-Scan requires proper training.
CR can be a convenient reference point, but MIP works well in most cases if micro-occlusion is managed.
Objective, repeatable data builds patient trust and provides medico-legal reassurance.

Highlights of this episode:

00:00 Teaser
01:13 Intro
4:41 Protrusive Dental Pearl – Removing a Temporarily Cemented Crown
06:39 Introduction
08:48 Global Training Footprint
09:32 What Robert Teaches (DTR & T-Scan)
09:55 Occlusion as Neurologic
10:33 Macro vs Micro-Occlusion
11:33 Neural Pathway
15:00 MIP vs CR Framing
16:48 Signs Without Symptoms
19:16 Silent Majority
20:08 Why Treat Asymptomatic Signs
20:50 Disclusion and MIP
22:28 Occlusogram Caveats
24:53 Midroll
28:14 Occlusogram Caveats
28:29 Why Occlusograms Mislead
29:21 Don’t Adjust From Color Alone
31:47 What Pressure/Timing Enable Clinically
33:02 Prosthetic Reality Check
34:46 Patient-Perceived Comfort
35:29 Why Isn’t T-Scan Everywhere?
36:29 Political Resistance
37:42 CR as Utility
38:18 MIP and Vertical Dimension.
39:48 Macro ≠ Micro
41:00 Material Longevity Benefits
41:57 T-Scan Training
42:58 Three Competencies to Master
44:20 Micro-Occlusion Rules
44:46 Outro

If you want to get more clued up on TMD, tune into this episode for the latest insights and guidelines! PDP213 – TMD New Guidelines – however be warned that the guidelines are contradictory to what Dr. Kerstein advises….ah the wonderful world of TMD!

#OcclusionTMDandSplints #OrthoRestorative

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A, C.

AGD Subject Code: 250 – Clinical Dentistry (Occlusion/Restorative)

Aim: to explore the role of micro-occlusion and timing in TMD and restorative success, highlighting how tools like T-Scan provide data that other tools cannot. This episode seeks to give dentists practical insights into diagnosing, preventing, and treating occlusal problems with greater accuracy.

Dentists will be able to:

Describe the role of micro-occlusion and disclusion time in TMD symptoms and tooth wear.
Recognising the limitations of traditional methods of occlusion adjustment.
Understand how objective occlusion data supports comfort, longevity of restorations, and preventive care.

Click below for full episode transcript:Teaser: Pressure is a force over surface area. And when it gives us the red, the blue, yellow, it's not measuring the force, so it cannot tell us the pressure. So tell us about what the nuances of being careful with the occlusogram and where it fails in the face of something more sophisticated, like the T-scan.

The essence of a scanning technology is that all the teeth are scanned with the patient’s teeth apart. No one’s biting. There’s no forces captured. There’s no contacts. There’s no gathering of teeth banging together or rubbing around. So it completely is falsely representing. These colour coded occlusograms have no force information in them at all.

Anyone who’s used articulating paper, which most of us do, and the T-scan, you still mark the teeth with paper, but you choose the contacts to treat based on the data, not based on where the paper marks look. And very often, the most pressure points of contacts are small, scratchy little marks that dentistry says are light force, which you’re completely wrong because again, the load is applied over area. So if you have a very small area, you have the potential for very high pressure.

Jaz’s Introduction:Protruserati, the occlusogram is lying to us. Does that sound familiar? Well, we welcome back again, Dr. Robert Kerstein. If you remember way back in episode 109, we made an episode called, “Articulating Paper Is Lying to Us,” and you guys absolutely loved it because Arctic paper is lying to us.

You should totally listen to that episode if you haven’t already. And if you haven’t, essentially the arctic paper marks you see on teeth are flawed in the sense that you can’t look at a mark and accurately say that, oh yeah, that’s more force, or that’s less force, or that’s hitting first. You don’t get that data.

And not only that, but you also get false positives when it comes to articulating paper. Now, similarly, I’ve got Robert Kerstein back again talking about the occlusogram. Now the occlusogram is that heat map you see when you do a scan, when you do an intraoral scan of a patient, upper arch, lower arch, and then you do the occlusion.

Most modern scanners will give you some sort of a heat map of the occlusion and we call that an occlusogram. And we may all at the beginning make this mistake, this very simple error, that when you see red on the occlusogram that means high force. Well, we will absolutely and emphatically bust that myth today.

You see the heat map or the occlusogram is just a measure of proximity. How close in space is that cusp to that fossa? And if it’s very close, it’s gonna be red. And if it’s maybe a few microns away, it’ll be a colder colour. Absolutely does not tell you how much force or timing or pressure, none of that stuff. Just contact proximity. So we must be careful in how we interpret that data. It would be misinformation to tell a patient that a certain tooth is having more load because of the colour.

Hello Protruserati. I’m Jaz Gulati and welcome back to your favourite dental podcast. Today’s guest is none other than Dr. Robert Kerstein. Rob Kerstein is like the godfather of digital occlusion. When I was in New Mexico a few months ago with Dr. Bobby Supple, he described Dr. Kerstein as the Einstein of occlusion, and it’s an absolute pleasure to chat with him again.

It’s a different format of the podcast. We’re driving, well, I’m driving, he’s my passenger. And so one of the team members, when they were listening to this, they said, it’s like carpool karaoke vibes. And don’t worry, we will not start doing a little singing and dance in the middle of this episode, but something a bit different, a bit fresh. Me and Dr. Kerstein were on the way to some DTR training in the UK.

DTR is Disclusion Time Reduction, essentially, if you listen to that episode that we did with Nick Yiannios. We talked about frictional dental hypersensitivity, and essentially lots of friction between the back teeth could cause your teeth to become sensitive. So this posterior dental friction is also implicated in TMD, thus resurfacing that old debate: is occlusion a causative factor of TMD?

Now, we all know some CAMs and some reviews that suggest that occlusion has no relationship to TMD. Whereas my guest, Dr. Robert Kerstein, says that TMD is a neurological condition and has everything to do with occlusion, and particularly that muscular TMD group would greatly benefit from an occlusal adjustment or something to change about their occlusion, to reduce that sensory input and their noxious muscular spasms.

And I saw all this freehand. I can’t wait to share my experience of what I witnessed when Dr. Robert Kerstein came to my practice and I treated three patients. So I’ll leave you on that teaser if you like, ’cause we have another episode coming with Dr. Jeremy Bliss talking all about occlusion, TMD and Disclusion Time Reduction, aka DTR.

Dental PearlBut for now, let’s enjoy this episode of occlusogram. And just before we join th...

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Is social media killing professionalism in dentistry?

Are young dentists really “clowns” online—or is lightheartedness perfectly fine?

Is social media a disease? Where’s the line between humor, banter, and outright disrespect?

In this episode, Jaz is joined by Joseph Lucido from the States to tackle these tough questions head-on. Sparked by a fiery Facebook rant, they dive into whether social media is harming our profession, how dentists should present themselves online, and if there’s still room for fun without crossing the line.

Whether you love or hate dental content on social media, this conversation will make you rethink how we represent our profession to the world.

Shout-out to two US doctors creating excellent, entertaining content on social media

Dr Brady Smith
Dr. Nicholas J Ciardiello

Check out the 3-Step Modern Dental Marketing Plan from Clear to Launch Dental — designed to help you simplify your marketing and grow your practice without the overwhelm.

https://youtu.be/W7Uh-ML9dZgWatch IC063 on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Takeaways

Social media etiquette is crucial for healthcare professionals.
Avoid controversial topics to maintain professionalism.
A social media presence is essential for modern dental practices.
Patients often check social media to verify a practice’s credibility.
Content should reflect the personality of the dentist and practice.
Highlight satisfied patients to build social proof.
Consistency in posting is key to maintaining engagement.
Separate personal and professional social media accounts.
Batch content creation to save time and effort.
Engaging content can lead to more patient inquiries.

Highlights of this episode:

00:00 Teaser
00:31 Intro
01:47 Introducing Joseph Lucido: Social Media Expert
03:21 Social Media Etiquette for Dentists
06:14 The Importance of Social Media Presence
12:04 Balancing Professionalism and Humor Online
17:39 Authenticity in Social Media
19:51 Balancing Personal and Professional Content
21:51 Effective Social Media Strategies
25:27 Time Management for Social Media
27:26 Do’s and Don’ts of Social Media
29:43 The Power of Social Proof
30:49 Conclusion and Resources
32:47 Outro

Love this episode? Don’t miss Best Practices in Social Media for Dentists – How to Stay Out of Trouble Yet Be Impactful (IC035)

InterferenceCast #Communication #BreadandButterDentistry

Click below for full episode transcript:Teaser: What is the correct etiquette in 2025 and beyond for social media for dentists?

Teaser:The biggest shortcut a lot of social media questions get would be, we tell a lot of docs, this is social media, it’s social in nature, so your job is not to directly sell 24/7. The most extreme version of yourself is gonna get the most attention. So you might get, oh, look, I’m getting a lot of views. But going back to what I said earlier, it’s, well, what are people thinking when they see this?

Jaz’s Introduction: I saw a rant on Facebook. Obviously it was on Facebook. Where else do rants belong, right? It was saying, what has happened to our profession? What has happened to our beloved dentistry? The kind of crap we’re seeing on social media.

This dentist, who’s basically vexing about the way that he thinks young dentists are portraying themselves on social media, this anonymous poster of course, was saying we’re being clowns, we are disrespecting patients, we’re doing all sorts of unsavory things to get views and likes.

So Protruserati, is this the death of professionalism in dentistry? Is social media a disease? Is there a proper way to conduct yourself on social media, or is a bit of humor and banter and a bit of lightheartedness acceptable?

I’m a bit of an idiot on social media sometimes, but I know someone who does know. Today we’ve got our guest, Joseph Lucido from the States, and I asked him all these tough questions. He knows a thing or two about social media. So in this episode, you’ll find out what is the proper way to conduct yourself and whether Joseph thinks there is a space for idiots like me.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is an interference cast. This is a nonclinical arm of the podcast. Hope you enjoy the main interview and I’ll catch you in the outro.

Main Episode:Joseph Lucido, welcome to the Protrusive Dental Podcast. For those who are listening right now, Joseph has sat in this wonderful, you’ve got this wonderful background, that common look of the books behind you, so it makes you look like you’ve got so much authority. And he totally looks badass. But I had to ask him, is this real or is it fake? And actually he reached out, man, this is a very beautiful library behind you. Joseph, welcome to the show, my friend. How are you doing?

[Joseph] I’m doing great. Happy to be here.

[Jaz] Tell us about yourself. You’re not a dentist, but tell me how you are connected to dentistry. What makes you an authority? Talk about social media for dentists today, which I’m really excited to get into.

[Joseph] Sure. Probably starting around eight years old, I wanted to be a dentist. Just being in the dental office, I always loved getting my teeth cleaned. I had a few uncles that were dentists. It was just exciting for me.

And then just through my education, formally marketing degree, and then half of the books behind you are on marketing or psychology. And then it comes down to just different reps over and over and over on different platforms with docs, seeing what works, seeing what doesn’t work. I guess that gives me, I don’t know about the authority, but it gives me a pretty sharp edge on what works and what doesn’t.

[Jaz] Well, I think that does give you authority. The fact that they have skin in the game, the fact that you work with people on this, so you totally have the authority.

Interesting title we’ve opted for, right? Social media clown or healthcare professional. I really like this. When I first read it, I thought, oh crap, he’s onto me. He’s seen my videos. Because sometimes I’m a bit of a clown, and sometimes I’m very professional. I’m really looking for what your thoughts are on this.

So I guess the first place to start is, what is the correct etiquette in 2025 and beyond for social media for dentists? It’s a big topic and we can break it down and go anywhere you like.

[Joseph] Yeah, there’s gonna be a bunch of nuance to it, but the biggest shortcut a lot of social media questions get would be, what is the potential patient, the person viewing this, the followers, what are they gonna think after seeing whatever I post?

That should just be your starting point for everything social media related. Before you post, you want to be intentional in thinking. Now it becomes intuitive after a while to do it the right way, second nature. But from an etiquette standpoint, we wanna be thinking, I don’t wanna post anything that’s too controversial or too polarizing.

Now I’m talking specifically through the lens of a healthcare professional. If you’re trying to get attention some other way, that’s fine. But if we’re talking about being a professional in healthcare, we don’t want to talk about politics or religion. Avoiding these topics can alienate 50% or more of your audience, and it also kind of speaks to your self-awareness. You probably shouldn’t be posting this from a business perspective.

Arguing online, never a good look. Taking a combative stance, anyone who sees that, even if you’re defending yourself, even if you’re 100% in the right, that’s not what you wanna do from an etiquette standpoint.

We tell a lot of docs, this is social media, it’s social in nature, so your job is not to directly sell 24/7. Everyone’s seen the doc that posts and all they’re doing is selling, and you’re not gonna follow them.

[Jaz] So what you mean by that is, “Come in for our new patient Invisalign offer,” and just banging on about it every single day, and that’s it, it’s like repeat.

[Joseph] Even the other post is too much. And what we’d even argue is, the way that we operate it is we have the docs say, you do nothing from an office level organically. You should be fun, entertaining, posting like that, and then we’ll take care of the direct selling, because that’s what our team has experience in.

You don’t have experience in, how do I sell something, specifically the language that needs to be used, the call to actions, where the buttons go. That is so outside of your purview. But what’s inside of you, you’re an expert on you and your off...

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Cracked teeth — the diagnosis we all hate as Dentists!

How do you decide when to monitor and when to intervene?

What is the recommended intervention at different scenarios of cracks?

Should we be chasing cracks and reinforcing with fibers; is there actually enough long-term data to support that approach?

Over the years, we’ve had some epic episodes on this topic — from Kreena Patel’s “I Hate Cracked Teeth” (PDP028) to Dr. Lane Ochi’s Masterclass on Diagnosis and Management (PDP175).

But in this brand-new episode, Jaz is joined by Dr. Masoud Hassanzadeh to bring it all together — not just the diagnosis of cracks, but their management. They explore when to intervene, the role of fibers in preventing propagation, and even the fascinating possibility that cracks in teeth may have some ability to heal, just like bone!

This one’s a deep dive that will change how you talk to patients — and how you approach cracked teeth in your own practice.

https://youtu.be/VHYRBnfJS3IWatch PDP246 on YouTube Protrusive Dental Pearl

Your patient’s history predicts the future!

Ask if past extractions were difficult → clues you into anatomical challenges.
Ask how they lost other teeth → if cracks, be proactive with today’s cracks.

History isn’t just background—it’s a clinical tool.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Cracks in teeth can be diagnosed using magnification and high-quality imaging.
Patient factors such as age and muscle strength play a significant role in crack prognosis.
Symptomatic cracks should be treated to prevent further propagation.
Understanding the anatomy of the tooth is crucial for effective treatment.
The healing mechanism of cracks in teeth is possible but varies between enamel and dentin.
Fibers can be used to strengthen restorations and manage cracks effectively.
Long-term studies are needed to assess the effectiveness of current crack management protocols.
The use of fluorescence filters can help identify bacteria in cracks.
Chasing cracks should be done cautiously to avoid pulp exposure.
A comprehensive understanding of crack mechanics can improve treatment outcomes.

Highlights of this episode:

00:00 Teaser
00:47 Intro
03:08 Protrusive Dental Pearl – The Importance of Dental History
07:18 Interview with Masoud Hassanzadeh
08:22 Diagnosing and Managing Cracks
21:13 When to Intervene on Cracks
25:50 Restoration Techniques and Materials
28:30 Chasing Cracks: Guidelines and Techniques
36:50 Mechanisms of Crack Healing in Teeth
45:11 Exploring the Use of Fibers in Dentistry
52:43 Introducing the Book on Cracked Teeth
54:57 Percussion-Based Diagnostics (QPD)
56:44 Key Takeaways
57:21 Conclusion and Final Thoughts
01:00:07 Outro

As promised, here are the studies mentioned during the discussion:

Why cracks do not propagate as quickly in root dentin: Study 1a & 1b Root dentin has significantly higher fracture toughness compared to coronal dentin—nearly twice as tough, as demonstrated in multiple studies. The key difference lies in their structure and toughness. Root dentin’s unique collagen orientation adds strength, while its fewer lumens and thinner peritubular cuffs make it less brittle. In contrast, coronal dentin has thicker cuffs, which increase brittleness. Unlike coronal dentin, which fractures uniformly, radicular dentin is anisotropic—its fracture behavior varies depending on direction. These structural features give root dentin greater resistance to cracking, making it more durable under stress.
Studies on decreasing crack length due to crack repair in enamel. Study 2
The importance of the modulus of elasticity of the final restoration in arresting crack propagation. Study 3
The role of fiber in restoring cracked teeth and how it can increase fracture strength—even surpassing that of natural teeth. Study 4
Decision Making for Retention of Endodontically Treated Posterior Cracked Teeth – A 5-year Follow-up Study
The Cracked Tooth: Histopathologic and Histobacteriologic Aspects

Historical Studies on Enamel Crack Healing– 1949 (Sognnaes): The Organic Elements of the Enamel: III. The Pattern of the Organic Framework in the Region of the Neonatal and other Incremental Lines of the Enamel

– 1994 (Hayashi): High Resolution Electron Microscopy of a Small Crack at the Superficial Layer of Enamel

– 2009 (S. Myoung): Morphology and fracture of enamel

Don’t miss out — get instant access to all the research papers discussed here at protrusive.co.uk/cracks!

Dr. Masoud Hassanzadeh has written two essential books every dentist should own:

???? Glossary of Biomimetic Restorative Dentistry???? Your quick-reference guide to the language and principles of biomimetics — explained in a way you can actually use chairside.

???? The Cracked Tooth: A Comprehensive Guide to Cracked Teeth???? Everything you need to know about diagnosis, management, and the science behind one of dentistry’s biggest headaches.

????✨ Dubai 2026: Occlusion + Family Fun ✨????This Easter, join Dr. Jaz Gulati and Dr. Mahmoud Ibrahim for something truly special — a tax-efficient holiday that mixes world-class occlusion training with plenty of family time in Dubai.

???? What’s included? ⏰ 20 hours of hands-on occlusion (mornings only: 9 am–1 pm) ????️ Afternoons & evenings free to enjoy Dubai with your family ???? Pre-learning + online content to deepen your understanding ???? A not-for-profit event — just dentists, families, and fun!

???? Learn more & get your quote at: globaldentalevents.co.uk

???? Make memories with your loved ones while making your CPD hours tax-deductible

Want to level up your knowledge on cracked teeth? ???? Don’t miss PDP098: Cracked Teeth Management with the Direct Composite Splint Technique

PDPMainEpisodes #EndoRestorative #BreadandButterDentistry

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and C.

AGD Subject Code: 070 ENDODONTICS

Aim: To provide clinicians with practical, evidence-based guidance for diagnosing, monitoring, and restoring cracked teeth, with emphasis on prognosis, risk factors, and restorative decision-making.

Dentists will be able to –

Differentiate between enamel and dentine cracks, and recognize when prognosis is hopeless.
Apply appropriate diagnostic tools and clinical criteria to decide when to monitor versus intervene.
Select suitable restorative strategies and materials to manage cracked teeth effectively.

Click below for full episode transcript:Teaser: After 48 hours, they started to see that the crack is just decreasing, like it's just healing. Is it really possible? But it is possible. Like how there is a crack healing mechanism in the bone, there is also crack healing mechanism in the tooth. When I started to learn about cracks, actually the studies were not from dentists.

Teaser: They were fracture mechanic engineering that they just studied about the crack, and nowadays there is a new system, it is called quantitative percussion diagnostic, QPD. There is a stress concentration in that point where the crack is started, so we have to distribute the stress in that place, in that plane. That is the important one. If we are just going to remove the crack and put the restoration on it, I’m afraid it’s just going to happen again.

Jaz’s Introduction: Over the years, we’ve had some awesome episodes on cracked teeth. If you go all the way back to PDP028 with Krina Patel, the episode was titled, I Hate Cracked Teeth, and you know what? I still hate cracked teeth. They’re a damn nuisance. They’re everywhere, and it creates major consent and if the tooth goes non-vital, that kind of conversation, which no one likes....

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With the final places remaining for our Occlusion Getaway, we present the official FAQ Podcast!

Dreaming of combining occlusion learning with a luxury getaway?

Want to earn 56 hours of CPD while soaking up the Dubai sunshine?

Looking for a course where you can master PRACTICAL occlusion in Restorative Dentristry and make it a family-friendly, tax-deductible trip?

Easter 2026 is set to be unforgettable. Join Dr. Jaz Gulati and Dr. Mahmoud Ibrahim for an extraordinary Occlusion Excursion in Dubai — a blend of serious CPD and sunshine that redefines what “continuing education” can be.

We’ve always believed in mixing work and pleasure, and this time, we’re taking it to the next level. Think luxury, learning, and laughter — all under the warm Dubai sun.

Watch IC062 on Youtube

???? What Makes This Course Different?

56 hours of CPD/CE credits, including 20 hours hands-on in Dubai
Full online occlusion curriculum and live webinars before you travel
Morning workshops (9 AM–1 PM) and free afternoons to explore Dubai

Bring your family (Easter school holidays!) or come solo — many dentists are already flying in from around the world.

REQUEST A QUOTE – Limited Places Remaining as of November 1st 2025!: https://globaldentalevents.co.uk/

Spaces are limited and flights are rising, so secure your place early.???? Easter 2026 – Occlusion, sunshine, and CPD in Dubai.

???? 28 March – 4 April 2026

???? Dubai, UAE

????‍⚕️ Dr. Jaz Gulati & Dr. Mahmoud Ibrahim, Organised by Global Dental Events

Highlights:

04:06 Meet the Organizers
05:59 Why Dubai?
10:40 Delegate Experiences and Expectations
13:21 Course Pricing and Tax Benefits
19:05 Course Itinerary and Logistics
24:49 Final Thoughts and How to Join

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Do all whitening gels work the same, or is the brand actually important?

Are lights and in-office “power whitening” just marketing hype?

And what’s the deal with the infamous white diet – do your patients really need to give up coffee and red wine?

In this episode, I sit down with Dr. Wyman Chan, the man who literally hung up his drills in 2002 to dedicate his career to whitening alone. With over 20,000 cases under his belt (and a PhD in the science behind it), Wyman shares his three golden rules for whitening success: trays, communication, and conscious bleaching.

We’re also joined by Dr. Niki Shah, who brings his own insights into whitening and patient care, making this a conversation packed with both science and clinical experience.

Wyman introduces his latest invention—Magic 3, a fizzing gel that reveals and removes plaque while calming gums. Plus, Wyman busts some of the biggest whitening myths (sorry, “white diet”) and explains why he no longer bothers with internal bleaching.

If you’ve ever wondered how to make whitening safer, more predictable, and less stressful for you and your patients—this is the episode you’ll want to tune in for.

Protrusive Dental Pearl

Innovation in Hygiene with Magic 3 – What is Magic 3?

A colorless plaque indicator gel developed by Wyman Chan.
Fizzes on contact with plaque.
Cleans teeth, removes superficial stains, and softens soft calculus.

Clinical Application

Alternative to scaling/polishing for routine patients.
Nervous patients who dislike ultrasonic scalers.
Children (6+) – safe as a Class I medical device.
Orthodontic patients – helps prevent white spot lesions.

Learn more at https://protrusive.co.uk/magic3

https://youtu.be/ImpHJP3WxecWatch PDP245 on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Teeth whitening success depends on tray design, formulation, technique, and compliance.
Conscious bleaching helps minimise sensitivity.
Sensitivity is due to peroxide reaching the pulp.
Patients should adjust wear time gradually, starting short and increasing if comfortable.
Communication and treatment planning are crucial to match whitening regimes with lifestyles.
The “white diet” is not scientifically necessary – normal eating and drinking can resume within minutes.
External bleaching alone can be effective, even for single dark teeth.
Tetracycline-stained teeth can respond to whitening with the right protocols.
The brand is less important than protocol consistency and clinician experience.
In-office light-assisted whitening adds risk, cost, and chairside time without proven benefit.
Allergic reactions are more likely caused by gel additives, not peroxide itself.
Emerging products, such as peroxide-based gels for plaque disruption and gingival health, may complement whitening in the future.

Highlights of this episode:

00:00 TEASER
1:00 INTRO
3:13 PROTRUSIVE DENTAL PEARL
07:05 Dr. Wyman Chan Introduction
13:32 Niki’s Journey in Dentistry
17:03 Whitening Products and Techniques
23:09 Three Keys to Whitening Success
30:03 Addressing Sensitivity in Teeth Whitening
37:43 MIDROLL
41:04 Addressing Sensitivity in Teeth Whitening
46:15 Whitening as Treatment Planning
49:10 Myths and Misconceptions
01:00:27 Lights and In-Office Whitening
01:03:13 Introducing Magic3: A Revolutionary Dental Product
01:16:10 OUTRO

Discover Magic3 and Dr. Wyman Chan’s inventions

If this episode piqued your interest, continue the whitening theme by listening to PDP199 “How To Eliminate Sensitivity During Teeth Whitening”. And don’t miss the upcoming visual follow-up to this episode!

PDPMainEpisodes #BreadandButterDentistry

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A, C, and D.

AGD Subject Code: 780 – Esthetics/Cosmetic Dentistry

Aim: To deepen dentists’ understanding of teeth whitening by exploring evidence-based protocols, tray design, and methods to reduce patient sensitivity. It also aims to challenge common myths and introduce innovations that can improve both patient comfort and clinical outcomes.

Dentists will be able to:

Evaluate the importance of tray design, communication, and conscious bleaching as critical factors for safe and effective whitening outcomes
Identify the common causes of whitening sensitivity and apply strategies to minimise or prevent pulpal irritation during treatment
Assess the evidence behind common whitening myths, including the “white diet” and the use of heat/light for activation.

Click below for full episode transcript:Teaser: What is the three most important features in getting a good whitening result? Number one, because- is it true that patients should try a white diet when having treatment?

Teaser:I heard of that when I was started bleaching 30 years ago- because I don’t have the drill anymore. They say I can’t do internal bleaching. It’s just because I give myself restriction. I have no drills at my clinic. If you’ve got a good protocol, it works- like I can show you some cases just two weeks. It’s amazing result. Get from a C4 to B1, just two weeks.

Two weeks for Tetracycline staining.

This is a colorless plaque indicator. Remove plaque at the same time. Also reduces gingival inflammation. They say we have nothing like that.

Is this solution a substitute for mechanical plaque?

It’s substitute for mechanical cleaning. To me, there’s no need to do polishing.

Jaz’s Introduction:Protruserati. We have got THE Wyman Chan and how I pull this off, this is the guy who I’ve been watching the whitening space for so many years, and actually he kind of disappeared. Where did Wyman Chan go? Was on the lips of every UK dentist for so many years. But guess what? He is back. Alright, lemme tell you about Wyman Chan.

This guy hangs up his drills in 2002 to solely focus on teeth whitening. That’s it. Imagine that. Right at a time where teeth whitening wasn’t even like a proper thing. So since then he’s been like whitening the teeth of celebrities and all the famous people will go to a central London clinic, get their teeth whitened by him using his formulas, his patented technology and his knowledge.

Like he’s a PhD and he’s so passionate about teeth whitening. The guy’s done over 20,000 whitening cases. I was actually thinking. I don’t even think I’ve seen 20,000 patients in general in my career so far. So that just tells you the volume of teeth whitening he’s done and he’s like a mega geek. Like what he doesn’t know about whitening is not worth knowing.

So we take advantage of that. I literally ask him all of your questions that you submitted on Protrusive Guidance, the usual stuff like is the light thing, is it a fad or is there some science behind it? Do you need to adopt a white diet two hours after whitening to make sure that you get a good effect from teeth whitening?

Like that’s all standard. We actually talked about it before, but we revisit it in this episode. But of course, every episode we have a game changers and there’s a few game changers. About three, well, there’s more than three, but the three that are top of my mind right now while recording this introduction.

One is that for non vital bleaching, imagine you get that black central incisor. Usually the way I would treat it is make sure that the root canal treatment is good, and then re-access the access cavity of course, and place my gel inside and whiten from inside and also outside. Now, what Wyman Chan discusses is a protocol of not doing the internal part of non vital bleaching, doing it externally only, which is very fascinating.

The other cool thing he teaches in this episode is this concept of conscious bleaching, which I’d never come across before, but it makes so much sense. It is the number one thing that reduces and eliminates sensitivity. And I’m a little bit upset that no one told me before. It just makes so much sense. I can’t wait for you to listen to this episode and learn about what is conscious bleaching.

Dental Pearl:And the final game changer is today’s Protrusive Pearl. Hello, Protruserati. I’m Jaz Gulati. And every PDP episode we give you a Protrusive Dental Pearl, something to reflect on, something to digest, something to apply to your patients right away. We have all sorts on here. And today’s pearl is about innovation.

Wyman Chan is just like this awesome guy in whitening and he has got so many patents I didn’t even know about this. And one new invention he’s come up wit...

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Why should Dentists be talking about screen time with parents?

Are smartphones even safe for children?

What is the right age to give a child their first phone?

Laura Spells and Arabella Skinner join Jaz in this thought-provoking episode to tackle one of today’s biggest parenting challenges: smartphones and social media in young hands. Together they explore the impact of early phone use on children’s health, development, and mental wellbeing—and why healthcare professionals should be paying close attention.

https://youtu.be/7RUJZqtEr18Watch IC061 on YouTube Protrusive Dental Pearl: Live by your values—not your profession, spouse, or children. Don’t sacrifice for them; choose what aligns with you, so love never turns into resentment.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Screen time is a significant public health concern. Mental health issues are rising due to social media exposure.
Early childhood screen time has long-term effects. Parents need clear guidance on screen time limits.
Community support is essential for children’s well-being.
Health professionals must ask about screen time in assessments.
Regulatory changes are needed for safer screen use.
The impact of social media on self-esteem is profound. Misinformation about health trends can lead to dangerous practices among youth.
Dentists play a crucial role in educating patients about safe health practices.
Parents should engage in conversations about social media with their children.
Creating a family digital plan can help manage screen time effectively.
Collaboration among health professionals needs to raise awareness about the dangers of unregulated products.
Empowering parents with knowledge is essential for effective parenting in the digital age.
Role modeling healthy behaviors is important for parents.

Highlights of this episode:

00:00 TEASER
01:18 INTRO
03:13 PROTRUSIVE DENTAL PEARL
04:54 Introducing Our Guests: Arabella and Laura Spells
09:24 Statistics and Scale of the Problem
18:09 Early Years and Screen Time
22:27 Safer Alternatives and Regulation
27:08 MIDROLL
30:29 Safer Alternatives and Regulation
30:53 Ideal Guidelines for Screen Usage
34:01 The Role of Dentists in Addressing Social Media Issues
44:59 Parental Guidance and Digital Plans
53:53 Final Thoughts and Resources
56:06 OUTRO

✅ Action Steps????Seven Habits of Highly Effective People by Stephen Covey for habits that support balanced parenting and leadership.???? Kindred Squared School Readiness Survey on how early screen use impacts child development. ???? Follow Health Professionals for Safer Screens for practical tips to share with families, and on their Instagram for bite-sized advice???? Support the Smartphone-Free Childhood Campaign to delay smartphone use in children.

If this episode gave you new insights, you’ll definitely benefit from Parenthood and Dentistry (Even if You’re Not a Parent!) – IC025

InterferenceCast #BeyondDentistry #Communication

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and B.

AGD Subject Code: 550 PRACTICE MANAGEMENT AND HUMAN RELATIONS

Aim: To provide dental professionals with an understanding of the health risks of early smartphone and social media use in children, and how dentists can play a role in safeguarding and guiding families toward safer digital habits.

Dentists will be able to –

Recognize the health and developmental impacts of early and excessive screen use.
Identify how social media contributes to anxiety, body image concerns, and misinformation (including dental-related fads).
Discuss practical strategies that families can use to create healthier digital habits.

Click below for full episode transcript:Teaser: We have to address the issue in early years because if you've had your child sitting on a screen from day one, by the time they get to eight or nine and they want a smartphone, which is the ubiquity in their pocket, it's really hard to explain to them why they can't have it.

Teaser:What is the right age for a smartphone?

Yeah. We would say that smartphones with full internet connectivity and everything involved and social media, it’s-

This smartphone usage has become almost the norm for every teenager across the country. And of course what a smartphone does is allow people 24 hours to access to the internet, to social media, to all the unfettered things that we need to, they can see. If you think about whole child health, and that’s how we should be approaching health for our children.

Obesity’s gone up. There’s huge linkages between the seditary behavior of being on screens, but not just the seditary behavior. Because actually if you are sitting on social media or you’re sitting on gaming, you are targeted by fast food manufacturers in a way, way more than you would be on TV. You could have a big argument about the quality of what children are doing on screens when they’re 15, 16.

Or they learning to make music. Are they revising and doing things, but for a two, three, 4-year-old, there are no benefits of being exposed.

Jaz’s Introduction:What a time to be alive as a parent. Back when I was a kid, I would go and play football for hours. My parents, they kind of knew where I was, but there was no way to reach me. And the other thing I remember is that when I was a kid, I wanna go to cinema. And then so you agree with your friends that, look, I’m gonna see you at 11:00 AM, at the cinema on Saturday. And there was none of this like texting and WhatsApp and Snapchat and that kind of stuff, and you would just show up at 11:00 AM on Saturday, and that’s a simple life that we lived.

But now with smart phones and social media, I really worry for our children, which is why I brought some experts on to discuss phone use in children and best practices for screen time and smartphones. And so you are thinking Jaz, what has this got to do with dentistry? Well, we have an active role to play as healthcare professionals.

Early smartphone usage and social media is absolutely detrimental to the health of our children. And as healthcare professionals, we have a duty to know about this and to spread the good word. And many of you, like me, are parents, and we need to hear this stuff. We need training.

We need guidance, and that’s exactly what we bring you today. You’re gonna love our guest, Arabella and Laura. But I wanna say thank you to Protrusive community member, Lydia, Dr. Lydia Roulston. It’s been so nice to chat to you on the app, give each other book recommendations, and you are part of this very organization that’s helping schools and communities to realize the dangers of having smartphones in young hands.

Dental Pearl:I’m so grateful that you’re part of our nice and geeky community. Now, this is an Interference Cast, which is like the nonclinical arm of the podcast, and I usually reserve my Protrusive Pearls for the actual PDP episodes. And as many of you know, I actually struggle when it comes time. I freeze up when it comes time to give a pearl, ’cause I’ve given like 300 in the past.

I’m kind of running out of nuggets. Like obviously there’s an endless amount of dental nuggets and gems out there, but to suddenly pull one out can be a bit tricky. But you know what? I’ve got one from the heart. So even though it’s an icy, I still want to give a pearl. And it’s like from the heart as a parent. In the book, I think it was Seven Habits of Highly Effective People by Stephen Covey.

It talks about being value centered and not being like a profession centered, like your entire world shouldn’t be about being a dentist. Your number plate shouldn’t be dentist. You shouldn’t introduce yourself to, hey, I’m Jaz, I’m a dentist. Like, your identity should not be your profession. The world also shouldn’t revolve around your spouse, nor should your world revolve around your children.

Your world should revolve around your values. And how I’m linking it even more to this theme of parenthood is that, I have a 6-year-old and we go through all the tantrums and behavior issues that all parents do. It’s very normal. And I love talking about being a parent to my patients. I learn a lot from my patients.

I do have an elderly patient base, and so I do get to benefit from their wisdom. And one thing I’ve come to conclude over time is that if you want to do something for y...

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How can you tell if a root canal treatment is truly successful?

Do you always need cuspal coverage after a root canal?

Are hand files still relevant, or has rotary completely taken over?

And does GP pumping really improve the effectiveness of irrigants like hypochlorite?

Emma returns for another Protrusive Student Series episode as she heads into her final year of dental school. Together, we explore the fundamentals of endodontics – covering restoration choices, success criteria, instrumentation, and irrigation protocols.

This episode breaks down the basics every student and young dentist should understand, while also tackling the common debates and real-world challenges of endo.

https://youtu.be/DK1ZAEPE_E4Watch PS017 on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Understanding the ‘why’ behind dental procedures is crucial for effective practice.
Both hand files and rotary files have their place in endodontics, especially for beginners.
Good irrigation techniques are essential for effective endodontic treatment.
Rubber dam isolation is critical for safe and effective endodontic procedures.
Learning to determine the master apical file size is a key skill in endodontics.
The use of EDTA helps in removing the smear layer during root canal treatment.
Endodontic specialists often use advanced techniques and tools for more efficient treatments.
Success in endodontics is not just about radiographs, it is sometimes defined by patient comfort and healing.
Cuspal coverage is often necessary after root canal treatment.
Patient communication is key to managing expectations.
Consent forms should be tailored to individual cases.
Understanding proprioception is important for tooth preservation.

Highlights of this episode:

00:00 Teaser
00:51 Intro
02:50 Emma’s Final Year Reflections
04:34 Exploring Specialties
07:02 Endodontics: A Student’s Perspective
08:15 Rotary vs Hand Files
11:45 Step-by-Step Notes for Students
14:24 Patency and Recapitulation
14:55 Determining Master Apical File Size
16:58 Irrigation Protocols and Techniques
21:22 Typical Irrigation Protocol
23:51 Rubber Dam Importance
27:25 Rubber Dam Importance
28:21 Role of 17% EDTA
28:59 Success Factors in Endodontics
29:46 Success Factors in Endodontics
30:46 Real-World Endodontic Practices
and Challenges
32:11 Understanding Success and Survival in Root Canal
34:26 Successful Outcomes
36:24 Success vs Survival
38:12 The Debate on Cuspal Coverage and Timing
40:48 Proprioception
41:54 Pre-Endodontic Build-Up
42:29 Direct Cuspal Coverage
44:03 Consent and Communication in Endodontic
47:25 Conclusion and Future Topics
49:02 Outro

Resources mentioned:

Outcome of primary root canal treatment: systematic review of the literature – Part 1
Outcome of primary root canal treatment: systematic review of the literature – Part 2. Influence of clinical factors
Radiographic Assessment of the Quality of Root Canal Fillings

Check out Simple Re-RCT Cases – ‘How To’ Guide – PDP233 for more Endodontic insights

BreadandButterDentistry #EndoRestorative

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcome C.

AGD Subject Code: 070 – Endodontics (Endodontic infections, microbiology, and treatment)

Aim: To provide dental students and early-career dentists with a structured understanding of endodontic fundamentals, including instrumentation, irrigation protocols, success factors, and restorative considerations.

Dentists will be able to:

Differentiate between hand and rotary file systems and identify their advantages and risks.
Evaluate the factors influencing the success and survival of root canal treatment.
Recognize when cuspal coverage or pre-endodontic build-ups are required.

Click below for full episode transcript:Teaser: You go to dental school, you're going to be using hand files. You're gonna get taught with hand files, everything's gonna be hand files, and that's how you're taught in dental school.

Teaser:As long as you understand when you’re doing, you’re trying to like determine tug back and you’re trying to determine the master apical file size, for example, right? Those skills you do with hand files and they’re universal.

The most important thing is more important than the final system – Root canal without rubber dam is like doing heart surgery in the toilet. The thrill of the fill. Okay. You put your GP in and it looks as though it is to length and it doesn’t have any voids in it.

And we think, wow, this is success. Right? But the thing is, when you see a radiograph, the radiograph cannot tell you. Whether rubber dam was used, whether hypochlorite was used, whether the coronal seal was really that good, and what protocols were used in terms of this disinfection.

Jaz’s Introduction:Basics of Endodontics. Welcome back to another Protrusive Student Series. This arm of the podcast is for students, young practitioners, those returning back to practice, or you just love listening to the podcast and you want validation. Welcome new listeners and welcome back to the returning Protruserati. We were joined with our Protrusive Student, Emma.

As she transitions into her final year of dental school, she asked all the right questions. Do you always need cuspal coverage after root canal? What kind of cuspal coverage should we go for? What determines if your root canal has actually been successful? Like we’ve all seen root canal treatments that been there for 30 years and they look questionable on the radiograph.

But there’s no pathology. Does that still count as a success? How about hand files versus rotary? Are hand files obsolete? And lastly, how significant is GP pumping to agitate your arrogance such as hypochlorite? All these questions are much more discussed in this episode.

And as of a few episodes ago, these episodes are also eligible for CPD. So if you want some easy CPD for those who are paying subscribers on the Protrusive Guidance app, don’t forget to answer the quiz. You would’ve done all the hard work of listening. You might as well get the CPD saying so by time December comes, you’re absolutely laughing. Let’s join the main interview and I’ll catch you in the outro.

Main Episode:Emma, welcome back to the podcast, a Protrusive Student. How is your summer going? You know, I mean, I remember specifically this transition from fourth year to fifth year. And it’s really strange because like for you, it is different in a way ’cause you’ve finished your finals, right? You’ve passed.

So congratulations, congratulations once again. But it’s like you’re about to enter the final chapter. It’s a bit emotional the next round when you finish finals and then you have like, you enter the rat race. That’s an even bigger, weirder scenario. But tell us about where your headspace is at the moment.

[Emma]I think for my final year, now that I have my exams over, I’m actually kind of excited. I think a lot of people are finding the same. I find a lot of people at Glasgow say that final year is their favorite year, because you don’t have that stress of exams. You’re more just working as a wee dentist and getting put into different outreach placements and you’re just clinical all day, every day, pretty much. So it’s just purely building on your clinical skills and getting more knowledge. So no more lectures. So I’m actually kind of excited for it.

[Jaz]I think that’s so cool. I’m very envious of you actually, because in most dental schools, the final year is like this crushing one. I mean, I can remember, the sheer emotions that you experienced during fourth year, but then it all culminates and I think it’s great that you managed to get out the way in fourth year, and I could really just focus. Your focus shift towards how can I get myself prepared for the real world, right?

[Emma]Yeah, for sure. But definitely this time last year, very nervous. But this year I’m feeling good. I’m feeling excited for it.

[Jaz]Good. I’m really happy, I think this is the best way because now that your focus is, how can you prepare yourself for the real world of practice? You learn differently. ‘Cause I find like with anything, most of the learning happens right towards the very end. There’s a very valuable amount of learning in any cycle that happens towards the end.

And when you have a traditional model of schooling in dental school, whereby your finals exams are in the final year, you are kind of learning to pass an exam, not learning to serve your patients better, improve your clinical skills to as much as you want to. Yes, that’s always, there is a constant theme in the...

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How should you gain consent for ELECTIVE treatments?

Is selling in dentistry something to avoid, or an essential part of patient care?

How much does emotional intelligence really matter for your success and happiness?

Dr. Colin Campbell joins for a powerful episode that dives into consent, sales, and the balance between profit and ethics in dentistry. He also unpacks the huge role of emotional intelligence—not just in clinical practice, but in life.

Expect real talk, strong opinions, and communication gems that can reshape the way you connect with patients and approach your career.

https://youtu.be/Wtugp1t-IrMWatch PDP244 on YoutubeProtrusive Dental Pearl: Read (or listen to) the book Let Them by Mel Robbins — a powerful reminder to take control of your own life and emotions instead of letting outside events dictate them.

Need to Read it? Check out the Full Episode Transcript below!

Takeaways

Building trust with patients is crucial for effective consent.
Consent should be a relationship management exercise, not just a legal formality.
Understanding the patient’s perspective is key to effective communication.
Elective treatments should be approached with caution and ethical considerations.
Sales in dentistry is not a dirty word; it’s about providing solutions to patients.
Emotional intelligence is a vital skill for dentists to develop.
Good dentistry is about doing what is best for the patient, not just for profit.
Continuous education and self-improvement are essential for success in dentistry.

HIghlights of this episode:

00:00 Teaser
00:44 INTRO
01:44 Protrusive Dental Pearl
02:58 Welcoming Dr. Colin Campbell
04:55 Colin’s Background and Philosophy
05:36 The Importance of General Dentistry
08:40 Finding a Niche vs. Being a Generalist
11:14 Understanding Consent in Dentistry
17:42 Fear of Losing the “Sale”
18:50 Building Trust with Patients
22:09 Consent Process Overview
22:49 Patient Consultation Process – Building the Bridge to Trust
29:00 Developing Emotional Intelligence (EQ)
30:00 Patient Consultation Process – The Mechanics
30:58 Patient Consultation Process – Exploring Options
31:13 Join Protrusive Guidance
34:34 Patient Consultation Process – Exploring Options
34:36 Patient Consultation Process – Follow-Up and Consent Pathway
35:54 Patient Pathways After Consultation
36:48 Treatment Plan Letters & Legal Angle
38:45 Approach to Consent Letters
40:21 Personality Types in Consultations
42:21 Systematizing Your Process
43:37 Ethics in Elective Treatments
53:15 Guidance for New Dentists on Elective Treatments
56:33 Interjection
57:48 Guidance for New Dentists on Elective Treatments
57:56 Sales in Dentistry
01:03:05 Conclusion and Final Thoughts
01:05:20 OUTRO

✨ Transform Your Dentistry ✨

???? Campbell Clinic – world-class private care in Nottingham.

???? Campbell Academy – ethical implant training from beginner to expert.

✍️ Colin Campbell Blog – daily insights to challenge & inspire.

If you liked this episode, check out ‘How to Win at Life and Succeed in Dentistry’ with Richard Porter

PDPMainEpisodes #CareerDevelopment #Communication #BestofProtrusive

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and D

AGD Subject Code: 550 – Practice Management and Human Relations

Aim: To explore the ethical, emotional, and practical aspects of private dentistry, with a focus on gaining valid consent, balancing profit with ethics.

Dentists will be able to –

Explain the importance of trust and rapport in the consent process.
Recognize the ethical challenges of elective treatments.
Outline strategies for building long-term career satisfaction and avoiding burnout.

Click below for full episode transcript:Teaser: When you think about the number they have per hour, less than five is normal, right? Less than five of these breath holds is normal. Between five and 15 is your mild category. 15 to 30 is moderate, and above 30 is severe. You see patients that have what we call an AHI Apnea-Hypopnea Index of 60, and sometimes these breath holds can be 30 seconds.

Teaser:Profit is oxygen for my business. Get that? It’s essential for life, but it’s not the meaning of life. I do not wake up in the morning going, oh, I’m gonna get some oxygen today, but if I don’t breathe, I’m dead. Right? So we need to-

I don’t think that’s the question. I think the question is what would I do if you or my wife, brother, mother, daughter, son? And so I’d say what you want me to do is use the experience that I have to pigeonhole you as a member of my family.

The world consent is a relationship management. You can’t treat your patient as if they were you. You have to treat them as if they are them. I would like to say to the guys is if you want to be really successful in the industry, both in terms of financially and in terms of the respect you get from your peers and in terms of the satisfaction you get from your job, try and-

Jaz’s Introduction:Gaining consent for elective treatments, selling in dentistry, the monumental role of emotional intelligence for your happiness in your life and your career. Hello, Protruserati. I’m Jaz Gulati and thank you for tuning in to what I think will be a Protrusive Hall of Famer. This episode gave me vibes of Richard Porter.

The OGs will remember way back when we did an episode called How to Win at Life and Succeed in Dentistry, and we talked a lot about emotional intelligence in that episode. Brilliant episode Richard Porter. Do go back in the archives and check it out, and this episode builds so nicely on that. Dr. Colin Campbell is absolutely scintillating inspiring.

I’m so excited for you to be able to listen and watch this from wherever you’re tuning into. Thank you so much. There are some real great gems on communication and some absolute real talk, controversial, real talk from Colin, which I absolutely loved. So if you’re doing a lot of composite veneers, you may wish to skip this episode. Colin does not mince his words.

Dental PearlNow this is a PDP episode, so I owe you a Protrusive Dental pearl. And you know what, I might have actually given you this pearl before. Like recently, maybe I perhaps gave it in a recent episode, but it’s in my head and it’s so relevant for this episode, right? This audiobook, I listen to, “Let them.” Now if you are even slightly into audible books or had a look at which books are on sale right now.

This book Let Them is everywhere. And for good reason, I listen to an audiobook and Mel Robbins, honestly, this audiobook is so, so brilliantly done. You literally feel like she’s talking to you. It’s so easy to listen to, so conversational and my friends, I think this book will change your life. I’m desperately pleading my wife to read this book and she won’t because she doesn’t read.

So as per the philosophy of this book. Let her, let her not read, let her not gain from this book, but let me drip feed the lessons to her. Let me induce a degree of osmosis, informational osmosis, and take control of the situation. So you kind of get a flavor of this book already. I’ll put the link in the show notes.

This book is all about taking control of your life and not letting what happens around you to control you and your emotions. It’s about you taking control of your life. So once again, Let Them by Mel Robbins. I put the link in the show notes. And now let’s check out this absolutely cracking episode with Colin Campbell.

Main EpisodeDr. Colin Campbell, welcome to the Protrusive Dental Podcast. How are you, my friend?

[Colin]I’m very well, and I’m very excited to be here. Actually.

[Jaz]You’re the one who’s super excited.

[Colin]No, no, no. I just spent a few minutes, when I was preparing just eyeing Jaz Gulati and who he was. So I always like to do my research just to get the background because I don’t think we’ve ever met. So I’m really pleased I used to be on. Thank you very much for inviting me.

[Jaz]Well, I’ve been on the receiving end, some of your lectures, and I want to start by saying that as a public speaker, honestly, up there with one of the most charismatic, energetic and human, like really the way you speak, when I’m listening to you speak, Colin, it’s like no one else in the room.

You are speaking to me honestly, like you have this gift. I dunno if anyone’s told you this. If not, then you need to hear it then, the way you came my radar is dentinal tubules. Maybe in 2019 or something you might done ...

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Can and should Dentists carry out home sleep testing?

It’s actually super easy and I have been doing it for 18 months!

What happens after you screen them—do you know what to do next? This episode will teach you!

Dr. Jaz Gulati shares his personal journey into incorporating sleep testing in practice—after 1.5 years of doing it, the impact has been nothing short of game-changing.

https://youtu.be/H4rTkIuOHWIWatch PDP243 on YoutubeJoined by clinical sleep scientist Max Thomas in this jam-packed episode, they deep dive into what it really means to go beyond awareness of sleep-disordered breathing. He breaks down the practical steps for dentists who want to do more than just refer—and start making a difference in their patients’ lives.

You’ll learn how to bridge the gap between theory and action, how to screen effectively, and why you play a pivotal role in the patient’s journey to better sleep, more energy, and a healthier life.

Protrusive Dental Pearl: If a patient has been seen gasping, choking, or stopping breathing during sleep — that’s pathognomonic for sleep-disordered breathing.

???? Don’t ignore it — they likely need a sleep study. Ask this in every history!

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Understanding obstructive sleep apnea is crucial for dentists.
Dentists are in a unique position to screen for sleep disorders.
The Malampati score is an easy tool for assessing airway obstruction.
Sleep disorder breathing can significantly affect quality of life.
Patient history is vital in diagnosing sleep apnea.
Quality of sleep is more important than quantity.
Dentists should ask specific questions to identify sleep issues. Sleep position can significantly affect sleep quality.
Screening tools like Stop Bang and Epworth are essential for identifying sleep disorders.
NHS sleep testing can vary greatly in wait times depending on location.
Snoring is often a precursor to more serious sleep disorders.
Dentists can play a crucial role in sleep disorder management.
CPAP is the gold standard for treating sleep apnea.
Understanding the legalities of sleep screening is vital for dental professionals. Remote monitoring became essential during COVID-19, shifting paradigms in sleep medicine..
Remote monitoring helps ensure patients are truthful about their usage of devices.
Mandibular advancement devices may be more effective for certain patient profiles.
Patient compliance is crucial, with many struggling to adapt to CPAP.

Highlights of this episode:

00:00 Teaser
01:15 Intro
04:51 Protrusive Dental Pearl
05:52 Introducing the Expert: Max Thomas
09:39 Importance of Screening and Diagnosis
13:41 “Crowding” at the Back of the Mouth
14:46 Mallampati Score
18:54 Understanding Sleep-Disordered Breathing
25:35 Screening Tools and Techniques
32:09 Screening Questionnaires
37:24 Midroll
40:44 Screening Questionnaires
40:53 Athlete Sleep Screening and Marginal Gains
44: 20 Identifying Patients for Sleep Testing
46:15 Snoring: Risk Factor for OSA
51:44 Mandibular Advancement Devices and Legalities
55:33 Diagnostic and Treatment Options
56:57 CPAP: The Gold Standard for Sleep Apnea
01:08:33 Retesting Before MAD
01:14:41 Dentists Warning about DVLA Implications
01:17:18 Final Thoughts and Recommendations
01:19:19 Outro

Resources for Screening Sleep Apnea

S4S Pre-Screening Questionnaire
Mallampati Score
Epworth Sleepiness Scale
STOP BANG Questionnaire

Screening Tools

The Acupebble Device
WatchPAT as an alternative
Send your sleep test for reporting to Max Thomas – excellent service and affordable
Max Thomas’ LinkedIn

If you loved this episode, don’t miss Sleep Disordered Breathing and Dentistry – PDP139

PDPMainEpisodes

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A, C, and D.

AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Sleep Medicine)

Aim: This episode is aimed at empowering general dentists with the knowledge and practical steps to actively participate in the screening and co-management of sleep-disordered breathing through the integration of home sleep testing in their clinical practice.

Dentists will be able to –

Understand the role of general dentists in identifying signs and symptoms of sleep-disordered breathing, particularly obstructive sleep apnea (OSA).
Identify when and how to refer appropriately to sleep physicians or medical specialists after screening.
Explore collaborative workflows between dentists, sleep scientists, and GPs to ensure effective patient management.

Teaser:You end up looking at these studies and there’s actually more time spent not breathing than there is breathing. In some areas, you are six weeks away from a test because they’re not only on top of their list, but their numbers are lower. In other areas, you’ve got high population density and low service output.

So you know, I have seen sleep departments that have got 60 week wait list just for the initial diagnostic tests. You already got the suspicion that they have obstructive sleep apnea. They’re already telling you that they’re struggling, and then they’re told to-

Sleep apnea is one of those things that a patient may need to report and they may need to report it in the case where they have moderate or severe obstructive sleep apnea with sleepiness.

And it’s really important that with sleepiness part is the main focus of the DVLA guidance. ’cause the sleepiness is the symptom that affects safety on the road. If the patient has sleep apnea, but they don’t wake up frequently from their breath holds, they don’t have the interruption to sleep, they don’t have the reduced cognitive function in the day. That sleepiness is what? This is all contingent on.

Jaz’s Introduction:Protruserati, I think this is one of the most profound episodes we’ve done to date. You see, the problem is that everyone’s telling us that sleep apnea is this huge thing and that as dentists we ought to know about it. And there’s plenty of podcasts now out there. Plenty of content out there, plenty of courses out there that are kind of filling that gap of knowledge.

The issue is we’re still hungry. I’ll tell you what we’re hungry for. We’re hungry for the following. Okay, so now you know what sleep apnea is. Now you’ve asked your patient, you’ve done some screening questions to your patient, but then what?

What happens then? Because if you’re not already actively in this space and you kind of refer and you lose that patient forever, what if you as a dentist want to do the sleep test? That’s what I do. I’ve incorporated sleep testing into my clinic for about 15 months now and it’s amazing the results we come back.

Now, I just wanna start by saying that we as dentists, we cannot diagnose sleep disorder breathing. Okay, let me repeat. We as dentists cannot diagnose sleep disorder breathing, but we can screen and we play a pivotal role in its management. So what this episode will do is we’ll bridge that gap between actually knowing about sleep apnea and actually doing something about it as a dentist.

And that is only achieved by those who are testing in their clinic. And let me tell you, it’s not mega expensive. It can be very convenient for your patients. And hey, even if you don’t start testing yourself, you ought to find someone near you or a center near you that can get your patient tested for sleep disorder breathing, such as obstructive sleep apnea.

And correctly reported so that you can genuinely help your patients, help them live a healthier life with more energy, less dozing off during the day ’cause of sleepiness, better quality of sleep for them and their partners, and adding quality life to their years.

Hello Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. If you’...

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Imagine your patient is choking on a rubber dam clamp…what’s the safest way to manage choking when the patient is lying flat?

Your patient’s hands are shaking and they’re drenched in sweat – is it low blood sugar, anxiety, or a cardiac event?

Do you know exactly what to do if your patient has a seizure in the chair?

This second part of the Medical Emergencies series with Rachel King Harris dives even deeper into real-life scenarios that dental teams may face. From seizures and how (and when) to give buccal midazolam, to managing choking in a dental chair, this episode is packed with practical, clear guidance.

We also explore key steps in treating diabetic hypoglycaemia, understanding glucagon vs glucose, and how to confidently manage patients with angina or previous heart attacks—when to use GTN, when to give aspirin, and when to simply wait for the ambulance.

It’s all about staying calm, being prepared, and delivering safe, effective care when it matters most.

https://youtu.be/fyIIsT0dlIcWatch PDP242 on YoutubeProtrusive Dental Pearl: Assign a clear lead to regularly check the expiry dates and supplies of emergency medications and equipment. This isn’t just about ticking regulatory boxes — it’s about saving lives. Little checks like this can make a big difference in a true emergency.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

00:00 Teaser
00:44 Intro
03:09 Protrusive dental pearl
04:14 Recap from Part 1
06:58 Seizures: Personal Experiences and Practical Tips
13:45 Seizure Emergency Kit: Buccal Midazolam
21:29 Emergency Drug Kit Overview
22:10 Choking: Techniques and Guidelines
29:19 Midroll
32:40 Choking: Techniques and Guidelines
34:05 Handling Infant Choking Emergencies
36:11 Recognizing and Managing Hypoglycemia
41:11 Emergency Protocols for Hypoglycemia
47:35 Managing Cardiac Emergencies in Dental Practice
58:59 Final Thoughts and Training Recommendations
01:00:39 Outro

Stay up to date by reviewing the latest guidelines from the Resuscitation Council UK.

Grab your Anaphylaxis Summary + Medical Emergency Cheatsheets from https://protrusive.co.uk/me.

And make sure you’ve listened to Part 1 of Medical Emergencies so you don’t miss any crucial information.

PDPMainEpisodes #CareerDevelopment #BeyondDentistry

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C and D.

AGD Subject Code: 142 Medical emergency training and CPR

Aim: To equip dental professionals with the knowledge, confidence, and practical skills to recognize and effectively manage common medical emergencies in the dental setting, ensuring patient safety and optimal outcomes.

Dentists will be able to:

Identify signs and symptoms of common medical emergencies in dental practice, including anaphylaxis, asthma attacks, seizures, angina, hypoglycemia, and stroke.
Describe the immediate management protocols for each emergency, including correct drug doses, routes, and timings.
Demonstrate appropriate use of emergency equipment and drugs available in the dental setting.

Click below for full episode transcript:Teaser: And you're saying that you deal with one hole only and it's the mouth and not anywhere else.

Teaser:When you’re becoming a dentist and you have to choose between medical and dental school, you either look up one and you look down the other, and so I said, let me look down, not up. So here we are.

That made me realize, and the advice on that Facebook post was, anyone age five or under choke on grapes. And so you totally agree with that?

I do. I do. I just think it’s not worth it. Sweaty. Sweaty. Very, very clammy. You know, there’s pools of sweat that I mentioned with hypose. You can get exactly the same with an MI.

Yeah. Nausea, vomiting, sweaty, clammy, impending doom. So again, a bit like anaphylaxis, they say they feel like they’re gonna die. Blood pressure drops usually. Not always-

But here’s the thing where this is happening, right? I’m going back to-

Jaz’s Introduction:Welcome back to Part Two of Medical Emergencies to get you that big fat tick for your annual CPD requirement for medical emergencies, and hopefully in a way that you can leverage the time of commuting so it doesn’t feel like something extra you’re doing.

Also in a way that was conversational, something that was easy to listen to, and hopefully the retention will be really good. And to enhance that retention, don’t forget, we have got our premium notes, like a revision summary done for you notes for every episode for our premium subscribers. If you’re not on the already, head to www.protrusive.app.

In the last episode, we covered the most common medical emergencies that we see or could see vasovagal syncope, anaphylaxis, which is worrying and common nowadays, but with serious consequences. And we talk a lot about oxygen, like which medical emergencies should we be giving oxygen for and how do you actually give the oxygen?

The thing is right, we as dentists, we hardly ever administer oxygen. We only are told to do it when there’s a medical emergency, but I want to cover it because when push comes to shove and we need to deliver the auction, I’m hoping you found it useful to hear and to watch for those of you’re watching how to actually activate the damn thing.

And what it all looks like and works like. So that was all covered in part one. In this part two, we’re covering seizures, how to handle a patient that is having a seizure, including how you might actually deliver the buccal midazolam. What does it actually look like and feel like? And interestingly why in many scenarios you may not even need to give it.

Then we moved to choking. And we all know about back slaps and abdominal thrust, but we simulated choking and we discussed choking specifically for your patient that is like laying down the chair the exact steps you should do when your patient’s in your dental chair and why. Therefore, you may need to do a one handed abdominal thrust.

And so you get to hear about that and watch that again, if you’re watching on the app. The last two things we discussed were diabetics and how the whole glucose and glucagon works and how to administer each one, as well as our cardiac risk patients. These ones are very common patients that make me a little bit nervous.

These are patients with a history of angina, history of heart attacks in the past, and so therefore, should we be avoiding using adrenaline containing local anesthetics. And what should be doing if they’re having some sort of an episode in your chair. So once again, we’re joined by Rachel King Harris, or today’s part two, Deep Dive into Medical Emergencies.

Dental PearlHello, Protruserati. I’m Jaz Gulati and welcome back to your favorite Dental Podcast. Every PDP episode I give you a Protrusive Dental Pearl. In the last one it was to download for each condition the kind of like cheat sheet prompts that when you open up your medical emergencies drug box, like it’s so reassuring to see the step by step what you’re looking for, what to do next.

It was like a really helpful thing. I think every single medical emergency is boxing. Every dental practice should have this. So that was last episode’s Protrusive Pearl. This one is a bit more simple, but equally important is that are you checking the expiry date of your meds?

Who has been allocated as someone who takes a lead on this? Not only is this important to satisfy CQC or regulatory requirements to make sure your practice can run and stay in business. But this is life saving stuff. So who’s the person who’s checking monthly or quarterly to make sure that nothing is running out of date and that all the supply is there and it’s working and you haven’t run outta oxygen or your glucagon’s not outta date, and all those things.

So make sure you have a clear lead because that’s how you Protruserati, these little things are the big things. Hope you enjoy the episode. I’ll catch you at the end. I’ll give you more instructions of how to claim the CPD.

Main Episode:Rachel, welcome back again to the Protrusive Dental Podcast for part two.

[Rachel]Thank you for having me again.

[Jaz]So in the last episode, we covered the common things. What I wanna do is make a really tangible piece of content with your help. So we covered the things that most likely common to happen. Okay. So, vasovagal syncope, ie the faint, super common, went deep into that. We went into anaphylaxis and I think we covered it really well.

We also talked about the oxygen, about what is the right dose of oxygen? Can you actually do harm by giving oxygen? And generally the consensus was, no, actually, it’s a good thing to have in practice. And I also took out the drug kit and it was really nicely how it was organized. And that might be inspiration for other practices.

So one thing I...

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HIGHLY RECOMMENDED CPD for all Dental professionals – without getting bored!

Do you know exactly what to do if a patient faints in your chair?

Could you spot the early signs of anaphylaxis—before it’s too late?

How quickly could you find and deliver adrenaline if it really mattered?

https://youtu.be/7b2oG4g12q0Watch PDP241 on YoutubeAfter six years of podcasting and creating CPD, we’re finally tackling medical emergencies the Protrusive way. In this two-part series, Jaz is joined by lead nurse and medical emergencies educator Rachel King Harris, who breaks down the real-life scenarios every dental team needs to prepare for—without the fluff or generic lecture feel.

From vasovagal syncope to adrenaline protocols, you’ll learn how to stay calm, think clearly, and take action when it matters most. By the end of this episode (and the next), you’ll not only tick the box for your GDC-required CPD—you’ll actually feel ready.

Because when emergencies happen in the chair, panic isn’t a plan. Let’s get you prepared.

Protrusive Dental Pearl: Be emergency-ready! Download a free medical emergencies cheat sheet — a quick guide for symptoms, drugs, and actions during a crisis. You can download this ready-made cheat sheet for free at protrusive.co.uk/me. Print it, laminate it, and pop it into your medical kit. Your whole team will thank you!

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Medical emergencies in dentistry are rare but high-stakes — being prepared is essential.
Guidelines change often — regular refreshers are vital.
You don’t need to memorise everything — use validated resources and calm judgment.
Vasovagal Syncope is the most common emergency in dental settings.
If unconsciousness persists → consider other causes: meds, blood sugar, cardiac issues.
Anaphylaxis can occur even without rash — don’t wait for it.
Key signs: stridor, lip/tongue swelling, wheeze, “impending doom,” difficulty breathing.
Keep emergency drug guides visible and updated (e.g., BDA laminated sheets).
Ampules = longer shelf life, more doses than EpiPens, and more cost-effective.
Don’t wait for the rash — airway signs matter most in anaphylaxis.
Always carry two adrenaline auto-injectors — even for mild allergy patients.

Highlights of this episode:

00:00 TEASER
00:53 INTRO
04:50 Protrusive Dental Pearl
06:01 Meet Rachel King Harris: Expert in Medical emergencies
09:42 Practical Tips for Emergencies
12:05 Understanding Vasavagal Syncope
17:01 GTN Spray
20:09 Recognizing and managing Anaphylaxis
30:05 Midroll
33:26 Recognizing and managing Anaphylaxis
34:41 Allergic Reaction to Chlorhexidine Gel
37:27 What’s Inside Emergency Bag?
41:51 Adrenaline Ampules vs Auto-Injectors
52:04 Oxygen Administration In Dental Practices
57:13 Oxygen and Emergency tools
59:05 Oxygen Contraindication
1:06:37 Outro

Stay up to date by reviewing the latest guidelines from the Resuscitation Council UK.

Check out this Anaphylaxis Summary Document

Enjoyed this one? Make sure to check out PDP159 – How to Manage Children in Dental Pain, where we dive into real-life paediatric emergencies in dentistry.

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C and D.

AGD Subject Code: 142 Medical emergency training and CPR

Aim:To improve the preparedness and confidence of dental professionals in recognising and managing common medical emergencies in the dental setting, with an emphasis on vasovagal syncope, anaphylaxis, and appropriate use of emergency medications and equipment.

Dentists will be able to –

Identify early signs and symptoms of vasovagal syncope and anaphylaxis in a dental setting.
Apply appropriate first-aid management protocols, including patient positioning, airway support, and oxygen delivery.
Understand the updated guidelines for prioritising adrenaline over antihistamines or steroids in anaphylaxis management.

PDPMainEpisodes #BreadandButterDentistry

Click below for full episode transcript:Teaser: When you faint, essentially your blood pressure drops. So that quick event that happens, what you need to do is actually try and I know, I don't know whether your dentistry bed's tilt, but tilting is actually the best.

Teaser:So you want their head down, if the bed’s not quick enough getting up or it’s not working or whatever, you actually can just manually lift the legs and hold them up or get their relative, if they’ve got a relative in with them or somebody that’s come in and then just keep them like that until they come round.

When histamine is released into the patient, they get widespread vasodilation and bronchoconstriction. So those two things combined is a bit of a car crash. Even 0.5 because really you’re going to get an ambulance within five minutes.

It’s true, you’re not though. You need to be carrying two at all times and people don’t. And particularly if you’re teenagers, you know you’ve got a handbag that doesn’t fit it. It’s tricky I actually think that in a medical center am feels better-

Jaz’s Introduction:When you are dealing with a medical emergency in your chair. That stuff can get really scary for dentists. It’s not pleasant to have to deal with it, but we need to be sharp, we need to know exactly what to do because our patient’s life actually depends on this.

This is why it’s a legal requirement in the UK and probably around the world to do medical emergencies training every year, and I’m proud that after six years of podcasting and creating CPD, we can finally now cover this topic in the true protrusive way, and now give you core CPD or CE credits.

The GDC recommends 2 hours per year and in a five year cycle, that means 10 hours of medical emergencies training for the dental team, and this is mandatory. Now, most practices arrange some sort of group session where they’re doing simulation and hands-on CPR, which is amazing, but sometimes we’re left to our own devices and we’re watching these little bit slightly boring videos and lectures online. Always scrambling to buddy up with a neighboring practice to actually get this training done on time.

Now, in this episode, I’ve got a Lead nurse, an educator in medical emergencies. Her name is Rachel King Harris, and one of her roles as well as working in acute medicine is to teach dental teams everything they need to know about their medical emergence training every year. So I’m proud to say that after listening to this Part 1 and the next episode, you’ll give a massive tick box for your annual requirement of CPD.

But the key thing is that you do it in a true protrusive way. We’re going to make it tangible. I’m hoping that Rachel and I, and mostly Rachel, we’ll present things in a way that it actually sticks. Sometimes when the patient is feeling unwell in your chair, we start to get a bit of panic and confusion. Is this just a Vasovagal Syncope or could there be something going on with the patient’s heart?

Is this an anaphylaxis? Should I be giving oxygen? All these questions can come at you a million miles an hour, and you have palpitations and you’re sweating, and medical emergencies are just no fun to deal with.

But after today and the next episode, you’re going to smash your annual requirement of CPD and in a way that you’re going to retain this information because every episode we make some premium notes and we just deliver it in a way that’s a bit easier to listen to, it’s not someone lecturing at you.

You are there by osmosis absorbing these things. And I really told Rachel, I told her I want to create a really compelling piece of content for the dental team. Which makes it tangible and relatable and real world.

What I mean by that is the topics we cover in this 2 hour training are actually medical emergencies that you are likely to actually see in your practice and talking about some details that are really important, but no one ever talks about some.

I’m hoping through that, that should you be in that unfortunate scenario that you will face a medical emergency because of this training, you’ll be feeling much more confident, much better prepared, and of course you won’t be panicking in December trying to make sure you’ve done your medical emergencies mandatory CPD, because we got you covered.

Now to listen to this episode is free for all. Okay? The podcast is free for you, but to actually get the certification, you have to answer some questions and do some reflections, and that’s possible on the protrusive guidance app.

You can listen via Spotify through the app, all Apple Podcasts, again through the app, or watch the video on the app, and the benefit of that is you just scroll down and answer the questions and our CPD Queen Mari will look after you.

And once you start doing more CPD with us, we actually send you quarterly certificates and an annual summary of all your certificates, how many hours yo...

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How on earth can a neck injection eliminate teeth sensitivity?

Can a patient’s tooth sensitivity really be linked to their occlusion?

Is occlusal adjustment ever indicated for sensitivity?

And what’s the actual mechanism behind those cases where everything looks fine — no cracks, no significant wear, no exposed dentine — yet the patient still complains their teeth are sensitive?

In this episode, Dr. Nick Yiannios shares the concept of Sympathetic Dental Hypersensitivity (SDH), a groundbreaking way of understanding sensitivity that goes beyond the usual suspects like caries, erosion, or leakage.

We dive into how the sympathetic nervous system in the pulp can drive unexplained pain, why traditional approaches often fail, and how objective tools like T-Scan and EMG can reveal what articulating paper misses.

This could completely change the way you diagnose and manage those “mystery” sensitivity cases that just don’t add up.

https://youtu.be/a2Mg72Y_zkwWatch PDP240 on YoutubeProtrusive Dental Pearl: When fitting a resin-bonded bridge (RBB), if you’re unsure about the fit and cement gap, use light-bodied PVS on the intaglio surface of the wing. After setting and peeling it away, the thickness of the PVS shows you the expected cement layer. Ideally, it should be thin and even; a thicker area highlights where your gap is excessive.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

The T-scan technology revolutionizes occlusal analysis.
Sensitive teeth can be linked to occlusion and bite adjustments.
Frictional dental hypersensitivity (FDH) is a key concept in understanding sensitivity.
Sympathetic responses may contribute to dental hypersensitivity.
Innovative treatments include laser therapy and ozone application.
Addressing root causes is essential for long-term solutions.
Dentists should explore literature for new insights and techniques.
Critical thinking is vital in dental practice.
Advanced technology can enhance patient care and outcomes. Objective data is essential for effective occlusal adjustments.
Understanding joint function is crucial for dental health.
Differentiating between types of dental hypersensitivity is important.
The sympathetic nervous system plays a significant role in dental pain.
Educating patients about their conditions fosters better outcomes.
The beaker of pain concept helps in understanding patient symptoms.
Continuous learning is vital for dental professionals.
Objective metrics are necessary for accurate diagnosis and treatment.

Highlights of this episode:

00:00 Teaser
00:39 Intro
03:51 Protrusive Dental Pearl
05:42: Dr. Nick Yiannios’ Journey and Innovations
07:46 T-Scan and Digital Occlusal Analysis
08:29 FIRST INTERJECTION
13:46 T-Scan and Digital Occlusal Analysis
14:07 Discovery of Occlusion–Sensitivity Link
20:44 Second interjection
24:25 Student Case – Sensitivity from a Bridge
26:04 Dentine Hypersensitivity
28:39 Cervical Dentine Hypersensitivity
30:44 The Role of Lasers and Ozone in Dental Treatment
35:24 Alternatives for Dentists Without Lasers
43:12 Alternatives for Dentists Without Lasers
44:00 Frictional Dental Hypersensitivity Explained
47:15 The Importance of T-Scan in Dentistry
50:57 Neck Blocks and Sympathetic Responses.
58:24 Third interjection
01:00:01 Neck Block Mechanism
01:12:34 The Beaker of Pain Concept
01:14:38 Fourth interjection
01:16:23 The Beaker of Pain Concept
01:16:59 Community and Collaboration
1:20:57 Outro

Curious to dive deeper?You can explore more of Dr. Nick’s work and insights through these resources:

Upcoming course: CNO6 – Sympathetics in Dentistry: The Missing Link in General & Specialty Practice
AES (American Equilibration Society) – check out their upcoming conference for world-class learning in occlusion and TMD.
CNO – Center for Neural Occlusion
Facebook community: Neural Occlusion
YouTube channel: Dr. Nick DDS – packed with case examples, lectures, and protocols.
CNO YouTube playlist

Studies & Resources

Sympathetic Dental Hypersensitivity – An Alternative Etiology for Dental Cold Hypersensitivity
Greater Auricular Nerve Block Reduces Dental Hypersensitivity to Intraoral Cold Water Swish Challenge: A Retrospective Study
Dr. Mark Piper Lecturing at the American Academy of Craniofacial Pain: Sympathetics & CRPS1

If this episode helped you, check out PDP199: How to Eliminate Sensitivity During Teeth Whitening

PDPMainEpisodes #OcclusionTMDandSplints #BreadandButterDentistry

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C.

AGD Subject Code: 180 OCCLUSION

Aim: To provide dentists with an updated understanding of tooth sensitivity, highlighting the role of sympathetic nervous system involvement, occlusion, and modern treatment approaches beyond traditional desensitizers.

Dentists will be able to –

Explain the concept of Sympathetic Dental Hypersensitivity (SDH) and its link to occlusion and cervical nerves.
Identify diagnostic tools (e.g., T-Scan, JVA, imaging) that provide objective data for managing sensitivity.
Evaluate treatment options, including laser-ozone therapy, occlusal adjustments, and neck block techniques.

Click below for full episode transcript:Teaser: I want you to think the sideways incursive movements like speed bumps. The more speed bumps, the more likely the nervous system doesn't like all that extra bump, bump, bump, bump. So you want to kind of smooth out the ride when you're going left and right. Imagine you're in a car, you want it to be a little smoother.

Teaser:Remember misfolded proteins? If you as a human, which is rare die of prion disease, you are a complete biohazard. They don’t even know what to do with your body. Cremation is not enough, but guess what kills prions? Well, they’re not alive. Guess what destroys prions? Their misfolded proteins. Ozone, trigeminal, cervical, and this all ties into sensitive teeth because it’s not just trigeminal. It’s also-

Jaz’s Introduction:Most of us have the same protocol for managing sensitive teeth. We check the patient’s oral hygiene, we check for acid erosion, be it intrinsic or extrinsic. We try and take care of the acid basically. Most of us are heavily recommending some sort of desensitizing toothpaste, like a Sensodine or an Oral B sensor version, or a pro relief from Colgate, whichever it may be.

Some of us are scrubbing desensitizing agent into tooth, perhaps even fluoride. And if the sensitivity is coming from like a Class five region, like abrasion a fraction, we might slap a composite in there hoping that the sensitivity will improve. Unfortunately, have those patients who no matter which brand of toothpaste they try, like it all helps, but they forever have sensitive teeth. I already have some patients in my mind that fall into this category. So what’s going on there? Why are these patients’ teeth sensitive?

Well, hello there, Protruserati, I’m Jaz Gulati, and welcome back to your favorite Dental podcast. For those of us dental geeks who like to spend a lot of time on YouTube, you probably already know today’s guest: It’s Dr. Nick Yiannios. I remember seeing his videos like, 10 years ago, 12 years ago. And I was like, what on earth is going on? This guy is using a computer to inform him about the bite, and he had all these like EMG leads on the patient and you are thinking, what on earth is going on? I’ve never seen anything like this before.

And then you hear about all these patients problems like they’ve got like clicking, popping, muscular pain, headaches, sensitive teeth, and by the end of the video it shows on the computer screen what the new bite is showing. But amazingly, the patience and their response was pretty spectacular.

When I look back in my journey into occlusion, and now how I’m diving deeper into digital occlusion, like using the T scan for ...

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Is it time to say goodbye to your DSLR?

Are mirrorless cameras really the future of dental photography?

If your DSLR is still working perfectly, should you upgrade now or wait for the right time?

Jaz is joined by Dr. Ashish Soneji in this game-changing episode to discuss the death of the DSLR and why the shift to mirrorless cameras is inevitable.

They break down whether you should proactively switch or strategically hold off, plus what this means for your existing lenses.

You’ll also learn the rules of mix and match—can you use your current DSLR lens on a mirrorless body? And most importantly, which mirrorless lenses are worth buying and which ones to avoid (hint: if they don’t have markings, you might be in trouble!).

If you care about consistent, high-quality dental photography, this episode is a must-listen!

https://youtu.be/Y29Mnz26ZIUWatch PDP239 on YoutubeProtrusive Dental Pearl: Jaz introduces the 21-Day Photography Challenge for beginners, featuring 21 short videos to help dentists take clear, well-framed photos. In just three weeks, participants will master essential shots, including tricky occlusal views, at their own pace.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Investing in quality equipment pays off in the long run.
Mirrorless cameras offer significant advantages over DSLRs.
Lighting is crucial for capturing quality images.
Standardized images require barrel markings on lenses.
Second-hand DSLRs can be a cost-effective option for beginners.
The evolution of camera technology impacts photography practices.
Choosing the right lens is essential for dental photography.
Flash consistency is vital for accurate representation in images.
Upgrading to mirrorless is a smart move for future-proofing photography. Upgrading your camera setup should align with your clinical progression.
Mirrorless cameras are lighter and offer better image quality.
Consider the size and transportability of your camera kit.
Timing for upgrades can be linked to job changes or equipment failures.
Image quality is influenced by megapixels, especially for presentations and printing.
Using the right tools, like smaller mirrors and retractors, can improve photography outcomes.
Testing second-hand cameras before purchase is crucial to avoid issues.
Mobile photography is improving, but may not match the quality of dedicated cameras.
Investing in good photographic equipment is essential for quality results.

Highlights of this episode:

00:00 Teaser
00:47 Intro
01:41 Protrusive Dental Pearl
03:30 Ashish’s Journey into Photography
09:06 The Shift from DSLR to Mirrorless Cameras
13:33 Choosing the Right Camera Setup
15:32 Upgrading to Mirrorless Cameras
19:22 Camera Recommendations for Beginners
27:23 Investing in Reliable Flash Equipment
32:20 Investing in Reliable Flash Equipment
33:48 When to Upgrade Your Camera Setup
38:08 Getting HQ Images: Mirrorless vs DSLR
42:03 Avoiding Newer Lenses
43:23 Posterior Quadrant Photography
47:50 Tips for Buying Second-Hand Cameras
49:54 Mobile Dental Photography: Are We There Yet?
53:20 Getting Your First Mirrorless Camera
55:40 Course Information
57:53 Outro

????Catch Dr. Ashish Soneji’s upcoming course The Magic of Dental Photography this November 2025!

???? Friday 14th November 2025 – Exclusively for BUPA dental care professionals at Bupa Head Office in Staines???? Saturday 15th November 2025 – Open to all dental care professionals at the A-dec Showroom in Bracknell

You can head over tohttps://www.magicofdentistry.com/ and add yourself to the waitlist. Further details on how to book will be sent directly to your email.

Course overview:

Understanding an SLR camera it’s features
Understanding a mirrorless camera and its features
Discussing the process of recording an image
Overview of SLR equipment available and custom set-up for dental photographs
Overview of mirrorless equipment available and custom set-up for dental photographs
Understanding how to record a standardised set of clinical photographic views and posterior quadrant photographs
Logistics of effective clinical photography workflow
Introduction into more advanced techniques
Introduction into recording portrait views
Case presentations
Hands-on implementation of the concepts discussed

If you liked this episode, you will also love Basics of Dental Photography [B2B] – PDP087

PDPMainEpisodes #PDPMainEpisodes

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 130 ELECTIVES (138 Dental photography)

Aim: To explore the transition from DSLR to mirrorless cameras in dental photography and highlight the advantages, optimal setups, and key considerations for upgrading.

Dentists will be able to:

Recognize the benefits of mirrorless cameras, including focus peaking, real-time adjustments, image stabilization, and high ISO performance.
Choose appropriate mirrorless cameras, lenses, and flash setups based on their clinical photography needs.
Assess whether transitioning from a DSLR to a mirrorless system is the right choice based on their current equipment and practice requirements.

Click below for full episode transcript:Teaser: Is it RIP DSLR? It actually is because around sort of 2020, Nikon and Canon have pretty much stopped developing the cameras. There's many advantages of that, mainly from the fact that prices are coming down.Teaser:And also from the fact that technologies moving forward, but also from the fact that you’re not getting so much support from the suppliers. If you have problems or if your camera is going to break or issues like that, you’re not going to get so much support.

Yeah posterior shots exactly. The point that I sort of made at the beginning is it’s about the light, right? It’s about getting that powerful exposure of light, which you’re just not going to get with a camera and there’s so much more better quality images. And even the way that you’re holding your DSLR the mechanics of how you’re holding that, you’re going to a better frame shot, you’re going to create better angles. So if I’m on to invest in the good clip–

Jaz’s Introduction:I’m actually a little bit emotional, guys. It’s the death of the DSLR camera. You’ll find out in this episode why? The future, the now is mirrorless cameras. They are perfect for dentistry and they are the future. They’re not going to make any more DSLRs in the future. But the million dollar question is if like me, you already have a decent camera.

It’s a DSLR, the photos are fine, you have no issues with it, should you? Proactively or preemptively upgrade now to a mirrorless? Or is there perhaps a more strategic time to do that? What are the rules of mix and match? Can I use my existing lens on a mirrorless body?

And you’ll also find out which mirrorless lens to buy and which ones to avoid because they don’t have any markings, that they don’t have any markings. How are you going to keep your photographs in consistent reproducible framing? We cover all that with our guest, Dr. Ashish Soneji.

Dental Pearl:Every PDP episode, I give you a Protrusive Dental Pearl, and this one is pretty special. This one’s dedicated to anyone who’s new to dental photography. Like you’ll hear the importance of dental photography and you know why it’s important. That’s why you’re listening to this episode. You just cannot develop as a clinician without a camera.

So dedicated to the absolute new beginner to photography I’ve created. The 21 day photography challenge. Just give me three weeks and I’ll get you taking consistent, beautiful, nicely framed, nicely exposed photographs. It’s like an online challenge if you like, right? 21 videos. Now they are short little videos that you can consume day by day, and like I said, within three weeks you’ll be taking great photos, like you’ll be proud of them as a beginner, including the dreaded occlusal photo.

The 21-day Photography Challenge starts with which kit to buy and then develops into all the different shots and all the different settings and why you do each setting. You can choose to do one video a day, or you can actually binge the whole series in true Netflix fashion. The choice is yours at the time of publishing this episode, it is now available on the Protrusive Guidance app.

You’ll see it listed in the Jaz’s Masterclasses section. And it’s got all the cheat sheets you need as well. So if you’re brand new to gender photography and you love our content, then do check it out. Now do I think you need a hands-on course? Ideally, right? So what my 21 day challenge does, it gets you started, it gets you to pick up the kit and start taking photos and start practicing those dreaded shots, but to go to the next level I would recommend an in-person hands-on course, which really does elevate you.

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Should we be doing more to save questionable teeth?

What if you could buy more time — without compromising patient care?

Dr. Omar Ikram returns for a powerful episode diving into the real-world decision-making between endodontics and implants. Together with Jaz, they explore tough scenarios — like teeth with nasty cracks or minimal remaining structure — and ask the critical question: when is it truly time to extract?

They break down concepts like retained roots, root burial, amputation, and a new term Jaz introduces — palliative endodontics. Because sometimes the best outcome isn’t immediate replacement, but smart, strategic delay.

https://youtu.be/5msP908JvuIWatch PDP238 on YoutubeProtrusive Dental Pearl: When discussing treatment longevity with older patients, tailor your language to be more relatable. Instead of saying, “I plan my dentistry to age 100,” say, “I want this to last well into your eighties or nineties.” This makes the conversation more personal and realistic, helping patients better connect with the concept of long-term outcomes.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Understanding the limitations of implants compared to natural teeth is vital.
Medical history significantly impacts dental treatment decisions.
Managing patient expectations is crucial for satisfaction.
Palliative endodontics can provide temporary relief and management.
Reading and interpreting CBCT scans requires skill and experience. If it’s not that five millimeter defect, it’s up to you.
The second molar is a good one because often second molars can’t be replaced with an implant.
Retaining roots is definitely a good way to go.
You need to risk assess the patient before extraction.
Palliative endo is technically always an option.
Success in endo can be often difficult to achieve.
Asymptomatic and functional is a good criteria.
If endo is on the table, it’s feasible.

Highlights of this episode:

00:00 Teaser
00:35 Introduction
01:48 Protrusive Dental Pearl
04:15 Interview with Dr. Omar Ikram: Philosophy and Growth
10:17 Endodontics vs. Implants: Treatment Planning
16:35 Antidepressants and Dental Implant Failure
19:37 Managing External Cervical Resorption (ECR)
22:30 Patient Communication
24:16 Cracks and Complications in Endodontics
29:12 Endodontic Protocol
30:50 Challenges with CBCT and Cracks
32:07 Second Molars: Retain or Extract?
35:05 Retaining Roots for Future Implants
36:21 Root Burial and Special Cases
40:08 Root Amputation: A Niche Solution
40:57 Key Signs to Rethink Root Canal Treatment
43:17 Cracked Teeth: Poor Prognosis
47:08 Stained Crack Tooth
50:19 Success vs. Survival in Endodontics
56:02 Final Thoughts and Upcoming Events

Want to sharpen your endo game even further? Watch Stop Being Slow at Root Canals! Efficient RCTs with Dr Omar Ikram – PDP163

Check out Specialist Endo Crows Nest — led by Dr. Omar Ikram, offering expert care, hands-on courses, and practical tips for real-world endodontics.

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and C.

AGD Subject Code: 070 ENDODONTICS (Endodontic diagnosis)

Aim: To help clinicians develop a deeper understanding of when to preserve a tooth through endodontic treatment versus when to consider extraction and implant placement.

Dentists will be able to –

Identify key red flags that may contraindicate definitive root canal treatment.
Understand the concept of palliative endodontics and how it can be used to delay or defer implant placement responsibly.
Recognize the value of retained roots in maintaining alveolar bone, particularly in medically compromised or high-risk patients.

PDPMainEpisodes #EndoRestorative #BreadandButterDentistry

Click below for full episode transcript:Teaser: Biggest difference between implants and retaining the tooth through root canal treatment is that implants, that's the big difference. Sometimes when you say to patients, you'll be dealing with an implant failure in your lifetime.Teaser:They look at you like, really? I thought implant would last till I was a hundred. How long anyone’s gonna last on this planet? But in my planning, I plan to age 100. So I see everyone as living to age 100. And so my planning, I don’t think this will make it, therefore–

Your health is within your own control. Also, it might be only 50%, 25%, but some of it’s within your own control. I want the patient to go on holiday and not be sitting there worrying about whether their tooth might be bothering and they have to go to a dentist and take antibiotics–

Jaz’s Introduction:Endodontics versus Implants: is this even a worthy battle? Let’s be honest, right. Any implant dentist worth their salt would agree that for themselves or their family member where an Endo is feasible and you have a good prognosis, that that is the obvious choice first before having an implant, because an implant will still be an option for the future. And that’s pretty much easy and unanimous in dentistry. Unless of course your patient suffers from titanium deficiency disease.

Now where this becomes more pertinent is those dubious scenarios, lack of tooth structure, those nasty cracks we’ve particularly discussed these two scenarios. Whereby perhaps we should be considering implants. But wait, Dr. Omar Ikram may have a few things to say about that and why we should be considering perhaps root filling, retained roots, root burials, amputation, and a term I introduced called Palliative Endodontics. Why that might have a growing role so that we can defer implants because we know implants do not last forever, Endo doesn’t last forever, nothing lasts forever. So important about seeing the bigger picture when it comes to longevity.

Dental PearlHello, Protruserati I’m Jaz Gulati. Welcome back to your favorite Dental podcast. Every PDP episode, I’ll give you a Protrusive Dental Pearl. Now, there is a theme in this podcast where we discuss about the age of the patient. We all know it’s better to have an implant when you are 60 or 70, than when you’re 40. And one thing I always did is when I communicate to patients, I was inspired by a consultant in Restorative Dentistry Dr Chander used a line to a patient.

He said, “Look, I don’t know how long anyone’s going to live for, but I always plan my dentistry to age 100.” And I’ve been using this line to my patients, and yeah, it’s okay it works well, they get to see the bigger picture. But a lot of patients can’t relate to that. A lot of my patients, their 60’s, 70’s, and 80’s they just can’t relate to that.

They immediately start thinking off topic and thinking, oh, I probably won’t make it. So one of the changes I’ve made in communication based on what Omar discussed with me today, and really the pearl I want to pass on to you is instead of saying to age 100 for everyone, look at your patient. Let’s say they’re in their 70’s and then you wanted to say, “Look, I want this to last well into your 80’s maybe into your 90’s.

Now, they may still think, “Oh, I probably won’t make it.” But it’s just a bit more relatable than putting a number age 100, because chances are most people don’t know a 100-year-old, but they might have friends in their 80’s and 90’s. Do you see what I mean? Obviously, it’s a very niche scenario. But me personally, I have a very age population that I look after my patients on average are 60.

And so this change in terminology in the way I communicate to patients in terms of longevity of treatment. I think’s gonna really help me to get the point across well into your 70’s well into your 80’s. And you’ll hear this again in this episode being a big part of today in this episode with specialist ended on Dr. Omar Ikram.

Before we join the main episode, have you downloaded the app yet? The best way to do it, if you haven’t already, is visit the website www.protrusive.app. Once you’re there, make your account. Then once you’ve made your account, you could download the iOS or Android app and log in to find the nicest and geekiest community of dentists in the world.

What I’ve found is that dentists join the app for the content. The premium notes, the transcripts, the Protrusive Vault, our Mini Master Classes and Courses, just a better overall listening and watching experience. But what they stay for is the community. What they find is that they fall in love with dentistry all over again because dentistry can feel so lonely and isolated.

And on some of these social media groups, you get shot down when you ask for opinions. But really, we’ve brewed a culture very hard to brew, a culture of kindness, being considerate and selflessly sharing information. So remember, the website is protrusive.app. The app is ca...

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Is Practice Ownership worth the stress?

What’s the most difficult thing you have to do as a practice owner?

Thinking about starting your own squat practice?

How long does it really take before you see profit, and what sacrifices do you need to make along the way?

In this episode, Jaz is joined by Dr. Shabnam Zai to unpack the real highs and lows of running a dental practice. From the loss of control as an associate, to the resilience needed during COVID, to the challenges of leadership and managing a team—nothing is sugar-coated here.

They also tackle the big money question: when does a squat practice finally become profitable, and is it worth the grind in those first few years?

If you’ve ever wondered whether practice ownership is for you—or why it might not be—this episode will give you the clarity (and reality check) you need.

https://youtu.be/Tf1bgOWMA2AWatch PDP237 on YoutubeProtrusive Dental Pearl: “DO NOT COMPARE YOUR WORK TO WHAT YOU SEE ON SOCIAL MEDIA”

Most cases shown online are the very best results, done under perfect conditions by clinicians with thousands of hours of experience.

Instead of letting that trigger self-doubt or imposter syndrome, use it as inspiration: respect it, aspire toward it, and occasionally achieve it — but remember that real-world dentistry is different.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Engagement in work is crucial for job satisfaction.
Time management is essential for balancing work and family.
Marketing and patient relationships are vital for practice growth.
Quality time with family is more important than quantity.
Coaching can help surface potential and provide accountability. Delegation is essential for effective practice management.
Vulnerability can arise unexpectedly in practice ownership.
Managing people requires empathy and clear communication.
Being an associate can be fulfilling and offers flexibility.
It’s important to have projects outside of dentistry.
Balancing family life with practice ownership is challenging but possible.
Financial planning is crucial before starting a practice.
Understanding your priorities helps in making career decisions.
Documenting staff performance is key to effective management.
Continuous learning and self-improvement are vital for success.

Highlights of this episode:

0000 Teaser
00:25 Intro
06:10: Guest Introduction – Dr. Shabnam Zai
08:38 Journey into Dentistry and Practice Ownership
15:08 Practice Philosophy and Security
16:33 Decision Making and Growth
19:10 Hardest Part of Being a Practice Owner
24:30 Balancing Parenthood and Dentistry
26:10 Coaching and Supporting Others
30:44 Compliance and Personality Types
34:15 Compliance and Personality Types
35:55 Navigating Career Vulnerability During COVID-19
37:06 The Importance of Self-Awareness and Managing People
40:07 The Forever Associate Trend
43:01 Projects vs Goals
48:33 Balancing Parenthood and Professional Growth
50:47 Financial Considerations for Starting a Practice
59:05 Final Thoughts and Mentorship Opportunities
59:42 Outro

Enjoyed this episode? You might also like Treatment Co-Ordinators – Are They Right For Your Practice? – IC043

PDPMainEpisodes #CareerDevelopment #BeyondDentistry

Connect with Dr. Shabnam:Website → shabnamzai.comInstagram → @drshabnamzai

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes:

B: Effective management of self and working with others in the dental team.

AGD Subject Code: 550 PRACTICE MANAGEMENT AND HUMAN RELATIONS

Aim: To provide dentists with an honest, practical insight into practice ownership—particularly squat practices—covering the challenges, rewards, financial realities, and mindset shifts needed for success.

Dentists will be able to –

Explain the main motivations for becoming a practice owner versus remaining an associate.
Describe the key challenges of practice ownership, including compliance, leadership, and financial planning.
Outline the realistic financial commitments involved in setting up a squat practice.

Click below for full episode transcript:Teaser: Sometimes when you take a step back, you can actually take a bigger step forward. When people say, how much does it cost to set up a spot, I laugh because it's completely the wrong question to be asking.Teaser:The reason I say that is, is because how much your practice is gonna cost depends on, but I did it by reducing clinical day, but I cut down from five to four. What was interesting, my income didn’t change. You know, you have to be honest. Sometimes practices don’t work out. You know, and that’s okay, but–

Jaz’s Introduction:Practice ownership, it makes a lot of sense. In fact, in a lot of countries that is the culture. You qualify, you buy a practice, you do your own brand of dentistry. You are never truly fulfilled until you are a practice owner. In fact, in some countries, the associates are rare. Now, here in the UK, US, Australia, there is a big associate culture, if you like. There are many associates out there.

And you know what? As an associate, myself, there are so many good things, but there are also some bad things, the lack of control. What if tomorrow a corporate takes over the practice completely changes the culture? It’s what happened to me. And then you have to jump ship and start your patient base all over again. You lose that security, you lose that control and security control are too major reasons we explore today and why one may consider to become a practice owner.

And particularly we’re talking about a squat practice. A squat practice is when you buy a building and you turn it into a dental practice. So whilst the themes we cover in today’s episode with Dr. Shabnam Zai, it does apply to buying an existing dental practice because we talk about leadership, we talk about being the boss, being the principal.

A lot of our advice, especially when we talk about money towards the end, is about when you are doing a startup or a squat. Hello, Protruserati I’m Jaz Gulati, and welcome back to your favorite Dental Podcast. You’ll find out why I don’t think owning a practice is right for me at this stage of life. And maybe never, maybe you’ll never be right for for me, there are a few really good and really important reasons why I hate the idea of running my own practice. So you’ll get to hear about that later, but then you get to hear about so many benefits and good things and why it might be the best thing that ever happened to you, as explained by Shabnam.

The kind of themes that we cover are: Is it right for you to be a practice owner? What are the sacrifices you have to make? What’s the most difficult thing you have to do as a practice owner? How long would it take for you to make a profit? Does it mean that you may have to give up your clinical dentistry? What’s the most challenging thing about being the boss?

Dental PearlAnd so many other themes explored in this one hour podcast. Now this episode is eligible for CE credits as Protrusive Education is a PACE approved education provider, and so when you answer the quiz at the end on the app, you’ll get your CE and CPD. Talking of the app, the app has inspired today’s Protrusive Dental Pearl.

I’d like to give you a quick win at the start of every PDP episode. So, as you know, we built this community of 4,000 of the nicest and geekiest dentists in the world. It’s absolutely magic. Waking up and seeing all these notifications and all these cases being posted, and all the advice that’s being given and all the, just camaraderie and kindness.

Now, I’m very careful about promoting the app outside of the podcast. We have a very niche audience here of either the most engaged and caring dentists in the world, or dentists who want to be more engaged with what they do, and they’ve all found a home in Protrusive guidance. So if you’re not part of it, check out Protrusive.app that’s the website, www.protrusive.app. Make your account at the time of publishing, it is free to make an account. There are paid plans available if you want amazing value that we offer, but you can just join the community and meet your tribe. You can then download the app on iOS and Android.

But recently Hannah Cooper for a dentist student in Slovakia posted a case and she said deep breath this is my first anterior case, and she felt really beat up by it. Okay. And I thought she’s being very critical of herself bless her. Okay. So she did some good work. And what I love is that Hannah, she made herself vulnerable. She really put it out there as like, guys, can you help me? And the advice that was given, the reflections by the Protruserati, shout out to the usual suspects.

Okay, Mohammad Mozaffari, an absolute legend on the ap...

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Are you living your career by design—or just letting it happen to you?

Do you know what your ideal day as a dentist looks like?

What about your ideal week?

In this episode, Jaz is joined by Dr. Andrea Ogden to explore how you can design a career—and a life—in dentistry that feels purposeful and fulfilling.

They dive into why many of us get stuck on autopilot, chasing goals we’ve never truly chosen, and how to break free by aligning work with your values.

Andrea also shares practical techniques to help you fall back in love with dentistry, so you can build a career that energises you—inside and outside the surgery.

https://youtu.be/XDxlUFeEpbwWatch IC060 on YoutubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

00:00 Teaser
00:21 Introduction
04:49 Guest Introduction – Dr. Andrea Ogden
06:05 Andrea’s Journey in Dentistry
08:51 Pivotal Moments in Dentistry
14:51 Trial and Error in Career Development
15:51 Current Role
16:59 Identifying Strengths vs. Enjoyment in Dentistry
18:18 Challenges for Young Dentists
21:51 The Importance of Career Awareness
24:05 Impact of Social Media
26:57 Understanding the Decline in Dentist Morale
31:51 External Factors Contributing to Stress
35:09 Internal Factors and Cognitive Dissonance
41:17 Practical Steps to Reignite Passion for Dentistry
47:32 Resilience Through Adaptation
48:59 Community and Support Networks
51:46 Enjoying the Journey
56:30 Outro

Key Takeaways:

Dentistry is more than fillings and crown preps—it’s a career you can shape to truly excite you.

Choose Variety & Joy – Build a mix of roles that energise you, not just ones you’re good at.
Ditch the Comparison Game – Your journey is unique; stop measuring it against 15-year veterans on Instagram.
Guard Your Values – Burnout often comes from a mismatch between what you believe in and where you work. Align the two.
Create Space to Reflect – Slow down, think, and use SMART goals to plan your next step.
Find Your Tribe – Mentors, colleagues, and community will keep you inspired and resilient.
Celebrate the Wins – Small or big, they’re proof you’re moving forward.

Loved this conversation? You’ll also enjoy Passion and Values in Dentistry – PDP014

CareerDevelopment #InterferenceCast #BreadandButterDentistry

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes

B: Effective management of self and working with others in the dental team.

C: Maintenance and development of knowledge and skills within your field of practice.

D: Maintenance of skills, behaviours and attitudes which maintain patient confidence in you and the dental profession, and put patients’ interests first.

AGD Subject Code: 770 – Practice Management and Human Relations

Aim: To provide dentists with strategies, insights, and practical steps to rekindle passion for dentistry, align their work with personal values, and develop sustainable career satisfaction.

Dentists will be able to –

Identify personal values and career drivers that contribute to long-term job satisfaction.
Recognise common stressors affecting dental morale and their underlying causes.
Apply structured decision-making frameworks (e.g., SMART goals) to career planning.

Click below for full episode transcript:Teaser: There's a definite difference between doing more of something or because you are good at it and doing more of something because you enjoy it. You know your values are a compass. As to, you know, where you are gonna go in, in, in life. I think if you are listening to this conversation and you are really struggling, is that the first thing you need to do is you-Jaz’s Introduction:Hello Protruserati. I’m Jaz Gulati and welcome back to your favorite Dental podcast. This is the interference cast, like the nonclinical arm, but a very important arm of the podcast.

One of the things that Andrea mentioned, is that when she was studying in dental school, that’s what it was all about. It was just about studying and becoming a dentist and passing your exams, and I resonated with that so much because our date was 6th of June. I knew that on 6th of June 2013, we were gonna get our results.

And I could not imagine life beyond the 6th of June. Like it was all about am I gonna become a dentist? This is what I’ve been building up my last sort of eight to nine years to do. Like I wanted to be a dentist since I was 14, but I couldn’t even think about the future and what it will actually be like to be a real dentist in the real world.

Now, fast forward so many years, I have a lot of real world insight and I’d love to share it with you today along with Andrea. I love people like Andrea because they are all about helping us feel fulfilled in dentistry.

There are plenty of people out there who perhaps dentistry didn’t go the way they planned. They leave and now they want to coach you on your exit plan, which I understand, but what I don’t believe in is making permanent decisions based on temporary feelings and actually attempting to figure out exactly how to make dentistry work for you.

Now, some things I didn’t discuss in the conversation with Andrea, because she was on a roll and I want to give her the space and time to talk about all the wonderful things, including the latter part, the end of the podcast, whereby she actually gives real techniques, is about five techniques she shares to help you feel more fulfilled from dentistry.

But one thing I wanna just talk about while I have this opportunity in the intro is the following. Have you actually put pen to paper to write down what your ideal day actually looks like? Like you are actually allowed to have an ideal day. Have you thought about it?

I didn’t do this until a few years ago, and it made a big difference to my clarity of thinking and where I want to take my career. And the other one, of course is what does your ideal week look like? Once you’ve decided what your ideal day and ideal week looks like, then make that your goal, that’s your aim.

Why wouldn’t you make some decisions right now to make your ideal day and your ideal week become a reality. For example because I think examples really help. I’m someone who if I don’t exercise at least three or four times a week, I don’t feel like I’m living to my truest value. I become grumpy I don’t feel like I’m enjoying my life as much as I could be. And so I know in my ideal week I need that.

Now, I’ve had a few years in my career where that wasn’t happening, especially when we are building OBAB that was such a huge project. I had to wrongly sacrifice some health for that. But now I’m back on track.

And so slotting that into the ideal week for me is really important, and you make it work and you make some key life decisions. And something that you do with your significant other, you decide that you design your perfect life how do you actually want it to look like, where you’re gonna live? What gym membership will I will have to make sure this all happens.

And so it’s about living a life of purpose, allowing you to live to your truest values. And that was just one example of me making sure that I designed my ideal day and my ideal life to make sure I get to go to the gym 3-4 times a week.

Another thing that was important to me is like I’m someone, I’m not good at multitasking. I think most, most of us aren’t, and we shouldn’t be multitasking. It’s better to focus on one thing, and I’m particularly bad and like sometimes I get distracted and I feel like really overwhelmed easily. And so when I’m in clinical mode, I’m in clinical mode. And because I love my clinical dentistry, it’s not a big deal for me to do a 12 hour shift.

I know it’s not for everyone, but I’m more than happy to do an 8:00 AM till 8:00 PM if it means I can work less days. So for me that made perfect sense that I have a really long Monday and now I don’t have to work a Thursday anymore, for example. And this has only just come to fruition. It’s something that we agreed on about a year ago, and then we had to wait for my Thursday patients to diminish, if you’d like.

And now I really consolidated my clinical days. This allows me to be in the zone on Monday. And whilst I don’t get to see my kids much on a Monday, I get to make up for it on the other days. because now three days a week, I get to do either school drop off or a pickup, or both. And the main point of sharing this detail with you, my friend, is that everything I’m trying to do is with great intention, it’s on purpose and it’s by design.

And it doesn’t happen overnight. It actually took a discovery process first, and then you put your action plan, and you relentlessly chase that. And that ideal week may look different for everyone. But if you don’t decide what your ideal day or ideal week looks like, then you’ll never get it. If you don’t know where you’re going, how do you know when you’ll g...

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Is gold really dead or making a comeback 2025?

Are zirconia and biomimetic dentistry sounding the final bell for precious metal restorations?

Is there still a place for gold in modern practice—and when is it actually the best option?

Dr. Lane Ochi joins Jaz for a rare live podcast episode to unpack the current and future role of gold restorations. From skyrocketing costs and lost lab skills, to emerging alternatives like milled cobalt chrome, this episode covers everything you wish dental school taught about gold.

They even dive into clever tricks for temporizing gold and discuss the surprising lab workaround that may save your patient money—without compromising function.

https://youtu.be/QWhY2_Oghd0Watch PDP236 on YoutubeProtrusive Dental Pearl: You can achieve profound anesthesia for lower molars—including cracked, heavily worn ones—using Articaine buccal infiltrations instead of an ID block, even in dense bone cases.

???? Key nuance: Ensure blanching of the attached gingiva and infiltrate through the papillae for better effectiveness.

Watch the detailed technique breakdown (including patient feedback):

https://youtu.be/cCXacw5DE4M?si=gDmYTKiFYxhYvbj3Articaine works—master the nuances!

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Use gold in tight spaces, short preps, or when longevity matters.
Simpler preps = better milling, easier seating.
Burnish when needed—but focus on great impressions.
Talk to your lab. Explain your margins, internal spacing, and cement plans.
Treat the patient, not just the prep: comfort, cost, and communication matter.

Highlights of this episode:

0:00 Introduction
2:06 Protrusive Dental Pearl
06:19 Welcoming Dr. Lane Ochi
09:40 The Resurgence of Gold in Dentistry
14:11 The Importance of Preparation and Cementation
18:17 Cost-Effective Alternatives to Gold
21:39 Burnishing Gold Margins
26:53 Partial Coverage Margin Designs
29:04 Retention vs. Resistance in Tooth Preparation
43:14 Vertical Preps with Gold
45:05 Immediate vs. Delayed Dentin Sealing
47:23 Challenges with Temp Bonding and Solutions
49:13 Recap
50:02 Lab Considerations for Gold Crowns
54:53 Perforated Gold Crowns
57:24 Temp Bond Troubles and Fixes
59:59 Gold vs. Ceramic Longevity
1:06:25 Gold Crowns on Implants
1:08:44 Wrapping Up and Final Thoughts

Unlock webinars like this one by joining the Protrusive App.

Studies Mentioned in the Episode:

Marginal Gap of Milled versus Cast Gold Restorations
Marginal Fit of Gold Inlay Castings
Longevity of the Tooth Restoration Complex : A Review

Catch another episode from Dr. Lane Ochi: Cracked Teeth and Dentistry’s Tough Questions with Dr Lane Ochi – PDP175

PDPMainEpisodes #BreadandButterDentistry #OrthoRestorative

???? Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES).

????️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician” ???? February 18–19, 2026 · Chicago, Illinois Don’t miss Dr. Jaz Gulati and Dr. Mahmoud Ibrahim as featured speakers, presenting on “Occlusion Basics and Beyond”

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 250 OPERATIVE (RESTORATIVE)DENTISTRY – Preparation technology

Aim: To provide clinicians with a comprehensive understanding of the rationale, techniques, and clinical considerations for using gold restorations in modern restorative dentistry, including when and how to use them, cost-effective alternatives, and how to communicate value to patients.

Dentists will be able to –

Justify the use of gold restorations based on their mechanical properties, clinical longevity, and adaptability under occlusal forces.
Compare gold with alternative materials (e.g., zirconia, cobalt chrome) in terms of fit, performance, and cost-effectiveness.
Explain the principles of traditional and modern gold preparation designs, including vertical margins, bevels, and resistance features.

Click below for full episode transcript:Teaser: Zirconia is not turning out to be the product that we wanted it to be. It does break and you know, unfortunately, even three Y, it's not self-healing. Why do we still call it the gold standard? Because it works. Longevity is there.Teaser:Well, Mrs. Smith. What is your desire, longevity, or pretty? The beauty is that when they looked at the occlusal margins, the ones they could finish, the state acceptability was-

Jaz’s Introduction:In this world of lithium disilicate, and zirconia, is there a place for gold? Many years ago, it was agreed that nothing beats gold. Gold is the best because it gives you absolutely brilliant longevity. It’s kind to opposing tooth structure and you can burnish the margins. What does that actually mean? We’re actually going to cover it in this episode. What does it mean? Is there a place for Gold in 2025 and beyond?

I’ll tell you, the last time I did a gold restoration about three years ago, I had to sell my left kidney to pay the technician. Gold is expensive. Are the benefits of gold worth that expense? Or perhaps, just perhaps, there’s a viable alternative to gold, what you’ll find out today.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is a slightly different one. We did this live. This was a rare live podcast with one of my heroes and mentors, Dr. Lane Ochi, one of the geekiest and kindest dentists I know. And to see him communicate with us on Protrusive Guidance, our network.

And every time we all get stuck and we’re like, oh, what do we do with this query? Or something like really obscure and geeky about material science or how things were done back in the day and we’d always tag Lane. Dr. Ochi is an absolute pleasure to have you as part of the community, and thanks for doing this live with us.

So for those who are now listening on Spotify, Apple, or watching on YouTube, just bear in mind that I do lots of shout out when I do a live on Protrusive Guidance. It’s very much responding to the chat, engaging, serving. So you’re gonna hear lots of names being shouted out.

Dental PearlNow, every Protrusive episode we give you a Protrusive Dental Pearl. This one is already spilling the beans. It’s giving the secret away of this podcast. It’s gonna blow your mind, right? Many, many years ago, this is probably the first meeting I ever went to, like maybe 13 years ago, it was the British Society of Restorative Dentistry Meeting. Maybe I’ve told this story before to you guys.

I’ve been speaking to you guys for six years now. I can’t even keep track anymore of what I’ve told you and what I haven’t told you. Anyway, back then, we are moaning about the price of gold. Now I had a check, and actually since that meeting, the price of gold has doubled. So here we are in 2013, moulding about how expensive gold is, and now the price has doubled 12 years later.

So we asked the restorative specialist, what should we be using? And so what this specialist said back then, which always stuck with me, is to consider the use of a milled cobalt chrome. That’s right. A milled cobalt chrome for your indirect restoration such as crowns and onlays. So since then when I’ve got second molars and I’m tight for space, I’ve been doing non precious metal crowns and onlays and I’ve been pretty happy with how they fit and especially with how much they cost.

And did you know that something like cobalt chrome is so kind to enamel. So any opposing enamel, it is so kind to it, but is this like a forbidden cheat code and there’s a good reason why we perhaps shouldn’t be using this? Well, stay tuned my friends, because I asked this question to Dr. Lane Ochi and let’s see later in this episode, what he had to say.

But as far as the Pearl is concerned, that specialist believe in it. I believe in it. In fact, recently if you’re on Protrusive Guidance, you would’ve seen me do a live, I treated a crack tooth case and I walked you through exactly why and how I prepared this for a cobalt chrome restoration. I show you the entire prep, the cementation, and this is available with CPD CE quiz. We are a PACE approved education provider, as you know.

So if you’re curious about metal restorations for compromised second molars, when you’re lacking that space, check it out in the Premium Clinical Video section of the app. And speaking of the app, I just wanna do a shout out to Dr. Jamie Adamson.

Jamie said on the app, thank you, Jaz, for the availability of your VertiPrep course. Fitted my first anterior VertiPrep crown today and just plunked it on loving the soft tissues especially. Appreciate your commitment to helping the Protrusive community. Well, Jamie, to you and everyone who’s started to do Ver...

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Can you apply the Dahl technique to localised POSTERIOR wear?

Spoiler alert: hell yeah!

How can the Dahl Technique help when there is posterior wear and NO space to restore?

How predictable is building up posterior teeth (rather than the usual worn anteriors)?

In this episode, Jaz dives into the ‘Reverse Dahl Technique’, a twist on the classic method typically used for localized anterior wear. Dr. Hans Kristian Ognedal from Norway shares his insights, explaining how building up posterior teeth with composite can lead to occlusion magic!

If you’re curious about this technique and want to see a real-life case study, this episode breaks it all down, with a special visual breakdown for those watching on YouTube or Protrusive Guidance.

https://youtu.be/V8MTFfXmdlwWatch PDP235 on YoutubeProtrusive Dental Pearl: Jaz shares insights from Hold On to Your Kids by Dr. Gordon Neufeld & Dr. Gabor Maté, emphasizing how modern children lose parental attachment too soon, turning to peers for guidance. This shift can lead to anxiety and emotional disconnection.

Takeaway: Kids thrive when their primary attachment remains with parents, not peers. Strengthening this bond is crucial for healthy development.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

The traditional Dahl principle focuses on creating occlusal space for anterior crowns.
The reverse Dahl technique is a direct method for treating worn POSTERIOR teeth.
Diet plays a significant role in tooth wear and dental health.
Taking photographs of patients’ teeth can help track wear over time.
Understanding the etiology of tooth wear is crucial for effective treatment.
Building up dental anatomy is essential for successful restorations.
Occlusion should be viewed as a dynamic system rather than a static one.
Patients can adapt well to this treatment modality
“Patients that wear their teeth, they don’t usually have TMJ problems.”

Highlights of this episode:

02:22 Protrusive Dental Pearl
04:50 Guest Introduction: Dr. Hans Kristian Ognedal
07:06 Understanding the Original Dahl Concept
09:31 Exploring Reverse Dahl Technique
13:30 Etiology and Patterns of Tooth Wear
23:46 Facial Patterns and Occlusal Traits Linked to Wear
24:44 Clinical Approach to Posterior Wear
30:26 Patient Comfort and Staging Treatments
32:11 Cuspal Planes and Guidance
34:21 Review Schedule and Observations
38:44 Longevity of Treatments
44:04 Contraindications and Patient Selection
45:24 Case Studies and Practical Tips
49:30 Night Guard Use
53:06 Final Thoughts and Education Opportunities

If you want to learn more about Dahl Technique, be sure to listen/watch:

Why do some Dentists find Dahl Distasteful? – PDP016
Dahl Part 2 (The Spicy Bit) – PDP017
Dahl Technique and ‘Maryland Bridges’ – GF001

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 180 OCCLUSION (Occlusal functional concepts)

Aim: To explore and understand the Reverse Dahl Technique, focusing on its application for patients with localized posterior tooth wear. This technique provides a solution when posterior teeth are worn, and there is insufficient space for proper restoration.

Dentists will be able to –

Understand the principles behind the Reverse Dahl Technique and how it differs from the traditional Dahl Technique.
Identify the clinical scenarios where the Reverse Dahl Technique can be applied.
Comprehend the role of composite build-up in restoring posterior wear and its impact on occlusal reestablishment.

Click below for full episode transcript:Teaser: I think it's a tooth where it's probably a modern disease of our own course. I think I disagree on that one. I think the patients that wear their teeth, they're able to load their teeth quite hard, much harder than I'm able to do. I have an interior open bite and the Class III, I've never been able to touch my front teeth.Teaser:I don’t wear my back teeth. I think I am not able to generate a type of forces that wears my teeth. But I think most patients who wear their teeth, they’re usually in full occlusion. I think having posterior where it’s more a function of consequence of how they function, how they chew, how they eat, how they swallow, how they process food when they take food into the mouth.

Jaz’s Introduction:So whether you use it or not, I’m sure we’ve all heard about the DAHL technique, right? This is when you have localized anterior tooth wear, and what you’re doing in this case is you are building up the anterior teeth even though you don’t have space. And so because you’re building these teeth up, when the patient bites together, now they’re prematurely hitting their front teeth, the back teeth all open.

There are like bilateral posterior open bites, and what happens over time is intrusion of the anteriors and you know, over eruption or Dento alveolar compensation of the posterior and the occlusion. Like magic reestablishes. So if you wanna go deep dive into that, check out our previous episodes on the DAHL technique.

Like these are some of the ones we did five years ago with Tiff Qureshi, and they are literally like Protrusive Wall of Fame. So do check out those and I’ll link them at the bottom. But today’s episode, my friends is on something quite different. It is same, same but different as they say in Asia, right?

It is the reverse DAHL technique. Now instead of having localized anterior tooth wear, we have localized. Posterior tooth wear. Think of that patient who when they bite together, their posterior teeth are just shot, right? There is exposed dentine, there is lots of erosion, and so you’ve got plenty of localized posterior wear.

And then the premolars, canines and anteriors are maybe a little bit worn, but not that worn. And the problem we have is that yes, the posteriors are worn, but when the patient bites together, the back teeth are all contacting, meaning you don’t have space.

So with the reverse DAHL technique or modified DAHL technique, what you do then is you build up the posteriors in composite, you leave the anteriors out of the bite, and then like magic, the posteriors will intrude and everything else over ups, if you like, and the context will reestablish.

Now, our guest today, Dr. Hans Kristian Ognedal from Norway, does a wonderful job of discussing this technique and his experiences, and at the end, he shares a case. So for those of you who are listening, while you’re jogging on a train, while you’re driving, don’t worry, I describe the caseand the exact scenario.

For those of you who are watching on Protrusive Guidance or on YouTube, you’ll actually get to see the images as well if you listen all the way to the end. I was quite excited to record this episode because it’s a, a new one, right? It’s a, it’s a new thing for me. I haven’t seen much published on the interweb about this technique, so hopefully you’ll learn something new.

Dental PearlTalking of learning something new, every PDP episode I give you a Protrusive Dental Pearl. Now, as you know, I’m a family man, and for those of you on our community Protrusive Guidance, I’m always talking about the books that I’m reading, or actually I’m listening to on Audible. The current one, I just feel compelled to talk about it.

It’s called Hold on to your Kids. Like I’ve got two boys, a 6-year-old and almost 2-year-old, and I think a lot about being a dad and being hopefully a good dad. I actually always wanted to be a parent. I actually love my role as a dad it’s my favorite title in the whole wide world. Quite often I’ll pick like, you know, parenthood books or relationship books because just like I’m interested in dentistry and I read their dental literature.

I’m interested in parenting and being the best parent I can be. So I kind of am attracted to these kind of titles. Now, the book, again is called Hold Onto Your Kid, it’s by Dr. Gordon Neufeld and Dr. Gabor Matè. And it essentially talks about how in modern society, children lose the attachment to their parents too soon.

And so what it talks about is that what children of modern society do is when they lose that attachment to their parent, they then gain the attachment from their peers. And then it’s like, you know, the blind following the blind and there’s a major cause of anxiety and disconnection from family. I’m actually now just getting into the really good parts of the book where it’s actually telling me solutions, right.

You know, the whole several first few hours are talking about the problem, right? The problem of losing attachment to a children and how you cannot serve two masters so they can’t be attached to their peers. And attached to you as their parent. At the same time, they have to pick one. And the way that we have the schooling system, the way that we have social media and phones, that they’re constantly now messaging each other and they’re gaining their attachment from their peers no longer from their parents.

Now we need that parent attachme...

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Do you feel confident managing patients with TMD or oro-facial pain?

Are you clear on when to treat conservatively—and when to escalate?

What’s the best SEQUENCE of care for TMD patients?

Emma returns to Protrusive Students fresh from her finals, joining Jaz for an insightful episode on the basics of TMD management. Together, they explore the foundational steps of TMD care, from proper diagnosis to the logic behind a structured treatment hierarchy.

They break down conservative versus aggressive approaches, share clinical tips for muscle and joint assessment, and highlight common mistakes to avoid—especially during palpation and history taking.

Whether you’re a student, a dentist returning to practice, or just want a refresher on TMD, this episode will help solidify your approach and boost your clinical confidence.

https://youtu.be/p5VJzwSka94Watch PS016 on YoutubeNeed to Read it? Check out the Full Episode Transcript below!

Key Takeaways

TMD is a complex topic with various treatment approaches.
Patient education is crucial in managing TMD effectively.
Physiotherapy can significantly aid in TMD treatment.
Different splints serve different purposes in TMD management.
Bruxism can be a silent issue that affects many patients.
Identifying the source of pain is essential for effective treatment.
Stress can exacerbate TMD symptoms in patient cohorts
Continuous learning and resources are vital for dental professionals.

Highlights of this episode:

02:35 Emma’s Finals Experience and Advice
05:16 Deep Dive into TMD: Clinical Insights
09:59 Common TMD Disorders and Their Presentation
18:31 TMD Treatment Options
28:00 Medications and Appliance Therapy
34:25 Practical Tips for Managing TMD
37:19 Addressing Bruxism and Patient Communication
41:00 Protrusive Pathways and Future Plans
43:46 Protrusive Students S2

???? Protrusive Resources

OPPERA Study
Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†
TMD Therapy Hierarchy of Management
Effects of occlusal splint therapy in addition to physical therapy on pain in patients affected by myogenous temporomandibular disorders: A pilot randomized controlled trial
Splints Decision-Making Flowchart

???? Protrusive Pathways Structured playlists grouped by topic (e.g., TMD, bridges, onlays): TMD Content Playlist

???? Crush Your Exam Student NotesDownloadable summaries by Emma, covering TMJ anatomy and function, are available inside the Protrusive Guidance App (request student access via Mari)

If you loved this episode, be sure to watch TMD New Guidelines! Evidence-Based Care – PDP213

OcclusionTMDandSplints #BreadandButterDentistry #Communication

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes

C – Maintenance and development of knowledge and skill within your field of practice.

AGD Subject Code: 200 – Orofacial Pain / TMD

Aim: To provide a practical, evidence-informed framework for the conservative diagnosis and management of Temporomandibular Disorders (TMD).

Dentists will be able to –

Describe the three major categories of TMD and their clinical features.
Differentiate muscular from joint-related symptoms using simple chairside tests.
Explain the rationale for a conservative, staged approach to TMD management.

Click below for full episode transcript:Teaser: TMD is one of those things, which is like so debated, so hotly contested, so controversial. Right.Teaser:Taking these broader categories, like how do these typically present in practice to during an exam, or does it chop and change for every patient?

I tell ’em, I’m not a guru. I don’t know what’s gonna work. But can we at least try things that are conservative and then we can always escalate to more aggressive things?

Jaz’s Introduction:Welcome back to another Protrusive Student episode. Emma is back after finishing her finals exam. So, in Glasgow where she studies you do the finals exams in your fourth year. And so she’ll be soon heading into her final year, which is fifth year.

So it’s strange that they do their final like academic exams in their penultimate year, but I guess that’s how it works there. And I’m pleased to say she passed. She passed, and she’s back again for this series called Protrusive Students. Now it’s not just for students, it can be provision for someone returning back into dentistry or validation for many clinicians.

Or maybe you are feeling that TMD is not your hot point, and so this is a great basics episode to lift up your foundational understanding. Now, it’s very tough to cover TMD in this short episode, but the main takeaway I can tell you now is the hierarchy of treatment or management is probably a better word than treatment.

We do talk about a few clinical gems and a few pertinent points in someone’s history. Or the common mistakes we make when we’re palpating the joints and the muscles. But if there’s one thing that you’re to take away from this foundational episode on TMD management is the hierarchy of treatment and why it exists.

What are the modalities included in conservative care and what are the modalities that are deemed more aggressive? And why we should have a bit more logic and sequence to how we treat our patient. You’d be able to download my hierarchy underneath the link if you’re on the app. And of course, for the students out there who have exams coming up or want some really good revision notes, Emma regularly updates the Crush Your Exam section.

So in this section on the Protrusive Guidance app, you can access it on your phone or on your browser, anywhere you like, and you can download revision notes. For example, PS006 was indirect restorations, a really good overview for young practitioners and students. And for this episode, you can get everything about TMJ anatomy, which is so important.

How can you understand what pathology is if you don’t understand what normal anatomy is? So to access that, just head over to protrusive app. Make your free account and join the ‘Are you a student?’ section. If you can verify you’re a student, you just need to DM Mari on the app. Her name is Mari Benitez. She’s like our CPD Queen, also student lead.

She’ll just need some proof that you’re a student and she’ll let you access the Protrusive vault, which has got like all our infographics and papers. It’s our way of like supporting and nurturing you students. But like I said, this episode’s also useful for those who have a bit more experience, who are qualified, and you can even get CPD or CE credits for this episode.

We are a PACE approved education provider. For that, you need one of our paid plans, and you scroll down, you answer the quiz. And Mari, our CPD Queen will arrange your certificate. Let’s now join Emma the Protrusive Student and welcome her back for this episode.

Main Episode:Emma, welcome back, the Protrusive Student. Congratulations for passing your finals like in Glasgow. You do it in the fourth year. Tell us how was it?

[Emma]It was intense, but I made it through. I think anyone that’s done final exams before. You’ve just gotta keep your head down for a bit and get through it, really. But I survived. So here I am.

[Jaz]Never in doubt, Emma. Never in doubt. I remember we were chatting before you getting results and it’s sometimes difficult to gauge how you’ve done, like I was convinced, I failed. Like it was that one of the OSCEs went that bad. But actually I did end up doing very well and so it was a bit of a family joke now about how I catastrophize.

That kinda stuff. But yeah, it was all good. And now that you’ve been through it, what’s the number one advice you can pass on someone who’s gonna be maybe doing finals next year, for example, or coming up imminently?

[Emma]I would say don’t underestimate anything ’cause they will just ask you anything question by-

[Jaz]You’re supposed to make it, like you’re supposed to make them calm and reassured that, that’s gonna overwhelm them like to the nth degree. But it is what it’s.

[Emma]I think you can either be one of two people. You’re either gonna be someone that knows a little bit about everything or a lot about certain subjects. So for me, I’m one of those peopl...

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Have you heard of Photobiomodulation (PBM)? Or are you thinking… ‘photo-what?!’

Is red light therapy just voodoo science—or is it already part of mainstream healthcare?

Can PBM really help with wound healing, pain relief, and even reduce the risk of dementia?

In this episode, Professor Praveen Arany joins Jaz Gulati to break down the science and clinical relevance of PBM in dentistry. They explore how this light-based therapy works, its applications in managing oral lesions, and why it’s already standard care for cancer patients undergoing chemotherapy.

They also discuss real-world cases, practical protocols, and how PBM could shape the future of dental care. Whether you’re a skeptic or just curious, this episode will open your eyes to an emerging and evidence-based treatment modality.

https://youtu.be/lQrawr3-YQAWatch PDP234 on YouTubeProtrusive Dental Pearl: SHEEP Scoring as a practical tool to assess the prognosis and restorability of compromised teeth.

???? SHEEP stands for:

S – Structure: Amount of remaining tooth structure
H – History: Patient’s dental and medical history (e.g. caries risk, trauma)
E – Endodontics: Endodontic prognosis (ease/difficulty of root canal treatment)
E – Expertise: Your personal skill and experience with managing such cases
P – Periodontal: Periodontal condition and bone support

Each category is scored out of 10, and the total is doubled to give a percentage-based prognosis. This structured approach supports clinical decision-making, encourages honest reflection on the clinician’s own skills, and enhances patient communication during consent. The method is backed by literature, including a paper co-authored by Martin Kelleher.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Photobiomodulation can significantly improve patient comfort and healing.
The treatment is standard for cancer patients undergoing chemotherapy.
There are no known adverse effects of PBM when used correctly.
PBM can be used effectively in various dental procedures.
The future of PBM includes personalized treatment protocols.
Research is ongoing to optimize PBM applications in dentistry.
PBM is distinct from other laser treatments and has unique benefits.
The technology is becoming more accessible to practitioners.
Awareness of PBM’s benefits is growing in the wellness industry.

???? ResourcesProf. Praveen Arany shares papers on:

Light buckets and laser beams: mechanisms and applications of photobiomodulation (PBM) therapy
Photobiomodulation therapy: Ushering in a new era in personalized supportive cancer care
Photobiomodulation Therapy by Prof. Praveen R. Arany
Photobiomodulation therapy in management of cancer therapy-induced side effects: WALT position paper 2022

For full PDFs, you can check out Protrusive Guidance.

???? You can find more of Prof. Praveen Arany’s scientific papers on Google Scholar

???? Two Upcoming PBM Courses!

ADA PBM Course – A dental-focused program by the American Dental Association.???? Contact: Sherie Tynes – tyness@ada.org

PBM in Supportive Cancer Care – Held at Gustav Roussy Hospital, Paris.???? Contact: Dr. Camelia Billard – camelia.billard@gustaveroussy.fr

If you liked this episode, check out Medication Related Osteonecrosis for GDPs – What You Need to Know (MRONJ) – PDP215

PDPMainEpisodes #OralSurgeryandOralMedicine #BreadandButterDentistry #CareerDevelopment

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B & C.

AGD Subject Code: 135 – Laser Therapy/Electrosurgery

Aim

To introduce dental professionals to the fundamental science, clinical applications, and emerging potential of Photobiomodulation (PBM) therapy in dentistry.

Dentists will be able to –

Define photobiomodulation (PBM) and explain how it differs from surgical laser applications.
Describe three key mechanisms of PBM at the molecular level.
Identify clinical situations where PBM can enhance patient outcomes (e.g., mucositis, ulcers, TMD).

Click below for full episode transcript:Teaser: I did not think that you could use light in a therapeutic manner on people. We are not plants, we don't do photosynthesis. So how can you do light treatments on people?Teaser:People used to use a point and shoot approach. They just switch on the light pointed at the patient and hope that they get better. And hope is not a scientific strategy. So-

In a 30-second soundbite, are you able to just describe the actual molecular mechanism or the physiology of how it actually gets the results it does? So our current understanding of photo biomodulation mechanisms is-

Jaz’s Introduction:Did you know there’s something called PBM, which stands for photo biomodulation and I know what most of you’re thinking. Photo what? Listen, I was as confused as you are and I thought, what is this mumbo-jumbo voodoo science? But then I found out that photo biomodulation or light therapy is already the standard of care when it comes to cancer patients undergoing chemotherapy. And then it reminded me of my physio who uses red light therapy for pain.

And today’s guest, professor Praveen Arany, who does a wonderful job on educating us on this treatment modality explains about the mechanisms in wound healing. So, dear Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. I’m so excited to share this episode with you today for so many reasons.

Number one, a lot of the guests I have on, we talk about restorative dentistry or occlusion, things that I really have an interest in and I know a fair amount about. But then this episode, I came in with nothing. I purposely didn’t do any research ’cause I wanted that magic and the aha moments to be alive.

And I enjoyed this. I enjoyed learning about PBM very much, and I know you will too. Number two is our guest has no financial interest at all. He is a pure academic for the love of it, for the love of research. I even asked him to recommend specific PBM units ’cause trust me, by the end of this episode, you want to know.

And he directed me to like guidelines. And scientific websites, which I absolutely love. So I think you really enjoy this, what I feel is really unbiased and it focused on an emerging technology, which I’m so excited to unpack today with you.

So on Protrusive guidance, our community group. I asked a question a few weeks ago, do you know anything about or actively use photo biomodulation in practice? Okay. And 74% of us were like, what? What is that? We have no idea. 7%, just 7% use PBM. And only 18% have actually heard about PBM and its use in wound healing and in dentistry. And you know, interestingly, one of our members, Lindsay, she said there’s a lot of research being done on PBM at the moment, which you’ll see today.

And then she wrote something fascinating, which is also something that was DMed to me on Instagram when I talked about this on the story, is how it can help you in pain. So for example, with Lindsay’s case, it cured her ruptured vertebral disc symptoms we’re using her laser, and she managed to avoid spinal surgery.

And there’s also some great insight from our resident implant geek Doctor Pav Khaira, like research on PBM to reduce the risk of Alzheimer’s and Dementia. But why I can promise you in today’s episode is that we’re gonna make it very relevant for dentistry. You’ll learn about how PBM works and what indication should it be considered, and what are the protocols and what does the future hold.

Dental Pearl:Now, before we unpack this topic, I’m gonna give you a Protrusive Dental Pearl. If you’re new to the podcast, welcome, it’s a good one to join. And every PDP episode I give you a tip, a pearl, a hack. Something you can use, you use straightaway. A lot of times’ clinical. Sometimes it’s mindset and nonclinical.

Today’s is very clinical. So Dr. Jack, as he likes to be known on Instagram, DM me this pearl. He noticed that sometimes I mentioned on these episodes that, ah, I’m struggling to find a pearl for today. And so he rescued me. He said, listen, SHEEP, he said, SHEEP, remember the acronym SHEEP? When you want to find out the prognosis of a tooth, you can use SHEEP.

And so let’s talk about this for a few minutes. From his DM, I was a little bit confused about its application. Then I saw Googled...

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Should you be re-treating that root canal—or referring it out?

What are the red flags that scream “specialist only”?

How do you confidently remove GP without compromising disinfection?

Dr. Ayman Al-Sibassi joins Jaz in this endo-packed episode to help you navigate the tricky world of root canal re-treatments. From solvent selection and GP removal techniques to assessing case difficulty, they break down everything a GDP needs to know to make smart, confident decisions.

You’ll learn how to spot the cases you should be tackling, which ones to send to your endodontist, and what tools and techniques will make the re-treatment process smoother and safer. Because not all re-treatments are created equal—and some are surprisingly simple once you know what to look for.

https://www.youtube.com/watch?v=apMtcuNTLqIWatch PDP233 on YouTubeProtrusive Dental Pearl: A crack in a bonded ceramic restoration isn’t necessarily a failure!

Just like we accept cracks in natural enamel, we can also accept cracks in ceramics—as long as it’s been properly bonded.

Shoutout to Dr. Pascal Magne for this powerful mindset shift!

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Specialist training in endodontics includes a variety of surgical skills.
The complexity of root canal retreatments varies significantly.
General dentists can perform some retreatments, but should assess complexity carefully.
Patient consent is essential, especially regarding potential unrestorability.
Communication about fees should be clear and upfront with patients.
Red flags for retreatment include poor coronal seal and previous treatment quality.
CBCT imaging is becoming increasingly important in endodontic practice.
Collaboration between general dentists and specialists enhances patient outcomes. Many referrals stem from straightforward cases that are poorly managed.
Using solvents can aid in GP removal but should be approached cautiously.
Single visit treatments are often preferred for patient convenience.
Adequate disinfection is crucial, sometimes necessitating a second visit.
The survival rate of root canal-treated teeth is comparable to implants.
Patient age and overall health should guide treatment decisions.
Understanding the difference between success and survival in endodontics is essential.

Highlights of this episode:

00:00 Introduction
05:02 — Protrusive Dental Pearl: Cracks in enamel vs. dentine
06:34 — Guest Introduction: Dr. Ayman Al-Sibassi and his journey into Endo
11:03 Assessing the complexity of re-treatments and when to refer
15:21 The role of CBCT in diagnosis and treatment planning
17:47 Ethical and financial dilemmas: charging for unrestorable teeth
22:05 Red flags in root canal re-treatments
34:55 Techniques for GP removal and file selection
47:07 Cost vs. predictability: re-treatment vs. implants and long-term outcomes

Take a look at this Endodontic Complexity Assessment Tool to help you evaluate how challenging a root canal case really is.

If you enjoyed this episode, you’ll definitely want to check out: Stop Being Slow at Root Canals! Efficient RCTs with Dr. Omar Ikram – PDP163

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 070 ENDODONTICS (Non-surgical treatment)

#PDPMainEpisodes #EndoRestorative

Aim:

To provide clinicians with a structured approach to diagnosing, planning, and executing simple Re-Root Canal Treatments (Re-RCTs), while recognizing case limitations and improving treatment outcomes.

Dentists will be able to:

Identify clinical situations where Re-RCT is appropriate and distinguish them from cases requiring referral or alternative treatment.
Describe the potential challenges such as canal blockages, separated instruments, or apical complications, and know when to refer.
Communicate effectively with patients regarding prognosis, risks, and treatment expectations, including the need for possible referral.

Click below for full episode transcript:Teaser: So if it's higher up on the attached gingiva, I'm thinking more about a root fracture. If it's lower down in the buccal sulcus, then it's more likely to be coming from the apex. And that is a, I'm not saying it's less, probably less likely to be a fracture, whereas if it's really high up, you're thinking maybe a furcation, sorry.Teaser: Fractures somewhere in the root essentially. If we come back to what I said about why most these more straightforward cases, why they fail a lot of the time. As I said, it’s because the gps already not that well condensed to begin with. So in terms of removing the gp, my first go-to in those kind of cases would always kind of be- so the reason I say that is ’cause they’re handfull, so they’re probably a lot safer than using sort of rotary files. You can control it a bit better as well.

Jaz’s Introduction:I used to think that root canal re-treatments were only for specialists and that GDPs should not touch them. Well. How wrong was I? When I entered my training post in Sheffield, it was a a dental core trainee post. Now the rest of the world is kind like a residency.

It was like one year attachment with the restorative department, and this was in a dental hostel. I remember seeing a case, it was a central incisor and it already had a root filling, so it was up to me to do the root canal re-treatment. Now, I was scared. I was, oh my God, I’ve never done a re-treatment before.

I’ve never had to remove gp. And also I was learning how to use the scope of the first time. So for me, I was nervous. I was thinking, this is very much specialist treatment. Will I be able to carry it out? Now, when the case actually came in front of me and I saw the radiograph, it literally was like a GP cone floating in this big wide canal.

Just that one sultry master cone. Plenty of air and fluid if you like around it. No wonder it failed and I accessed the tooth. I literally, with my tweezers, could see so clearly that GP cone, I picked it out and I carried out the root canal treatment and that was the easiest root canal re-treatment ever.

And it just made me realize that had this limiting belief that not all re-treatments are the same. So I guess the point of this episode and what we’ll learn with my guest Dr. Ayman Al-Sibassi, is how to know which re-treatments GDPs should totally get involved with and how to know where perhaps this is one to refer to our specialist colleagues.

You’ll find out the best ways to remove the gutta percha. Is it gutta percha or is it gutta Perker? Honestly, endo is not my thing so much anymore, so I don’t even know how to say it anymore, but you know what I mean. The GP. Which is the best instrument, which is the best solvent? And interestingly, how much solvent should he actually be using?

Like should you be flooding your canal with solvent or should you be just using tiny drops on your instrument? And related to what I just said earlier, I want you to understand more about risk and predictability of re-treatments. What are the red flags that you should not pass go? We cover all this and so much more in this episode.

Now, if you’re new to the podcast, welcome. My name is Jaz Gulati, and therefore you are called affectionately the Protruserati. We are the community of the nicest and geekiest dentist in the world. So if you wanna join that community, head over to www.protrusive.app. The idea is that we don’t want anyone to feel isolated, that they can’t ask for advice.

If anyone’s feeling nervous or unsure about certain treatments, well check the whole backlog of all the episodes we’ve done. But also having peers, like-minded Protruserati to support you is exactly what you’ve created on our app. Now those of you who are returning viewers and listeners, please do hit that subscribe button.

Dental PearlAnd as you know, every PDP episode, I give you a Protrusive Dental Pearl. Now by the time episodes come out to publish, it’s actually probably been a few months sometimes what I’m kind of doing now is like early spring now, and I’m kind of getting ahead so that I can enjoy my summer with my family.

But you guys all get an episode once a week. That is the dream. And one thing that you guys ask me all the time is Jaz, how do you do it? How do you stay motivated with your podcast? How do you get it done? How do you balance family, children, clinical dentistry, and of course watching cricket, which I love doing.

How do I make it all happen? Well, I’ll tell you something guys. Something just from the heart. I have a big team now and they help me so much. It is a real team effort to get every episode out. Every episode that has CPD or CE especially, has probably been through about four different people and about three of those are dentists before it actually reaches publication.

That’s so that we can actually quality control the CPD questions, the learning outcomes, and produ...

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Are you confident when increasing the vertical dimension?

How do you plan, stage, and sequence a full-mouth case safely?

What’s the right deprogramming method—leaf gauge, Kois appliance, or something else?

Dr. David Bloom joins Jaz in this powerhouse episode to demystify the real-world process of increasing vertical dimension. With decades of experience in comprehensive dentistry, David shares how he approaches diagnosis, bite records, temporization, and final restorations—with predictability and confidence.

https://youtu.be/gAaP0VYP84sWatch PDP232 on YouTubeProtrusive Dental Pearl: Pick one occlusal philosophy and stick with it until you understand it well through real cases. Once you’re confident, stay open to other approaches—hearing different views will make you smarter, more flexible, and a better dentist.

If you are looking to get started with the foundations of Occlusion, check out our comprehensive Online Occlusion Course.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

00:00 Trailer
00:55 Introduction
04:43 Guest Introduction: Dr. David Bloom
10:25 Equilibration Techniques Explained
11:18 Interjection #1
15:50 Opening Vertical Dimension vs. Orthodontics
18:06 Interjection #2
23:05 Whitening and Restorative Solutions
25:27 Guidelines for Raising Vertical Dimension
25:52 Interjection #3
29:28 Midroll
32:49 Guidelines for Raising Vertical Dimension
36:06 Visual Try-In and Adapting Vertical Dimension
40:16 Case Planning and Execution
41:16 Interjection #4
43:42 Case Planning and Execution
50:23 Material Preference for Provisionals
52:00 Bite Registration and Final Adjustments
55:06 Do’s and Don’ts for Clinicians
57:15 Conclusion and Resources
58:59 Outro

Key Takeaways

Vertical Dimension and Adaptation: Opening the vertical dimension in dentistry can be challenging, especially for edentulous patients who lack proprioception. However, with proper planning and understanding of occlusion, the human body can adapt remarkably well.
Occlusal Philosophy: It’s important to learn one occlusal philosophy well, whether it’s Kois, Dawson, or another. Understanding different approaches can make you a more rounded clinician, as different patients may benefit from different methods.
Equilibration and Deprogramming: Equilibration is crucial for idealizing occlusion by eliminating interferences. Deprogramming helps in achieving centric relation, a stable and repeatable position for the condyles, which is essential for successful equilibration.
Orthodontics vs. Vertical Dimension: Deciding between orthodontics and opening the vertical dimension depends on the specific case. For example, pre-aligning patients with orthodontics might be necessary to address a restricted envelope of function.
Testing and Adaptation: Testing the vertical dimension with transitional materials like composite can help patients adapt before moving to definitive restorations. Experienced clinicians may sometimes proceed directly to final restorations based on their judgment and diagnostic steps.

Get CE/CPD for this episode only on the Protrusive Guidance App.

????️ A new website is launching soon by Dr. David Bloom — ppcontinuum.com

Also, Dr. David Bloom’s hands-on courses on veneers and minimally invasive dentistry

If you found this episode valuable, you’ll definitely want to watch PDP197: Vertical Dimension – Don’t Be Scared!, part of Occlusion Month.

PDPMainEpisodes #OcclusionTMDandSplints #BreadandButterDentistry

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 180 OCCLUSION (Occlusal therapy)

Aim:

To provide clinicians with a comprehensive understanding of how to safely and predictably increase the vertical dimension of occlusion (VDO) for restorative cases, using a diagnostic-driven, conservative, and patient-centred approach.

Dentists will be able to:

Describe the indications and contraindications for increasing VDO.
Differentiate between conformative and reorganized approaches to occlusal rehabilitation.
Identify the steps involved in diagnostic planning, including CR bite records, wax-ups, and visual try-ins.

Click below for full episode transcript:Teaser: You mentioned something earlier about dentures and vertical dimension. Ironically, I'm probably a little bit more concerned about opening the vertical in an edentulous patient than I am in a denate patient because it's much more harder for them to adapt because they don't have the proprioception. So composite will obviously be non-invasive.Teaser: We’re probably not gonna be prepping the teeth at all, but patients need to be aware that whilst there’s gonna be less cost, I’d consider it as a long-term provisional. Because-

Transitional, almost.

Transitional. Yeah, absolutely. I mean, ideally, if I’m doing restorative, I’d rather not whiten first, because if we have our super thin restorations and our whitening result, over time will fade. It’s much harder to top that up. If you have a restoration.

The first step in a collaboration is to be able to manipulate someone into centric relation. And 90% of the population have a slide from CR Central relation to CO centric occlusion habit by whatever your terminology and the first step in a equilibration is-

Jaz’s Introduction:So we’ve talked about this big topic before, vertical dimension and restorative dentistry. Me and Mahmoud did an episode basically reassuring you that you can safely raise the vertical dimension and that we shouldn’t be so scared of it. What I do in this episode with Dr. David Bloom is really lean on his decades of experience.

Comprehensive dentistry to delve deeper into the intricacies of opening the vertical dimension, the staging, the phasing, the planning, and a full walkthrough of how Dr. David Bloom does it. And you know what? There’s many different ways to go about it. In fact, for those of you who can see me who are watching this, I’m a bit more formally dressed.

I’m not wearing my hoodie. I was actually at an occlusion symposium today, and you had these great speakers and inclusion like Paul Tipton and Koray Feran, Tif Qureshi. And these guys were talking about the importance of canine guidance. And then you had Ken Harris, also a legend in occlusion. And one, the mentors on Kois.

He did not care for canine guidance. It was irrelevant, it was not important. And if you go back into the Archives of Protrusive podcast, you remember two episodes we did with Dr. Andy Toy. About the posterior guided occlusion where actually we don’t want canine guidance. So it goes to show my friends that in the world of occlusion, there’s many ways to do it.

Learn one way, learn it well, it will serve you well. And then the benefit of learning the other ways is that sometimes you’ll find a patient that really fits into that box a little bit better. For example, for many years I didn’t use a Kois appliance. I had my ways of deprogramming that I was very happy with, and just a couple of years ago, I did my first Kois, and I’ve done a few more since then.

And there are certain patients and characteristics that just are very amenable to that way of doing it. But then for most of my patients, I use a leaf gauge. There’s two types of patients. There’s loosey goose and tighty whitey. The tighty whitey patient, we all know this patient, right? It’s the one where you’re trying to do some manipulation, you’re trying to seat the joints and their mandible is just so stiff.

Whereas you have, they’re much nicer loosey goosey patients where you don’t have to work very hard to deprogram them or get everything nice and relaxed and hinging. And these two patients will need a different type of deprogramming. So I say learn one school, one occlusal religion well, and then start looking at the others.

And I think there’s so much to learn from all the occlusion camps. Just like I said, two polarizing views I was listening to today on canine rises and whether canine guidance is even important at all. And you know what? I subscribe to them both. And you are thinking Jaz. That’s not possible. How can you serve two masters?

Well, you can because our patients are so variable. They’re so unique. That’s what actually makes our dentistry fun. If every patient was the same, it would be boring. But our patients come with these unique challenges, these unique presentations, and we have to sometimes be very creative in how we treat someone, how we arrive at treatment decisions.

And lemme tell you, learning about the different occlusal religions has made me a better, more rounded clinician. But for many of you listening early in your career. Honestly, just pick one religion, whether that’s the ...

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How do you manage patients that have ultra high expectations?

What’s the best way to communicate cosmetic outcomes before the final result?

How do you balance your aesthetic vision with what they see?

Dr. Brandon Mack joins Jaz for a deep dive into the realities of cosmetic dentistry—from subjective perceptions of beauty to practical tips that make or break a case.

They discuss how to navigate aesthetic stress, manage patient expectations, and even go into Brandon’s favorite veneer cement and occlusal philosophy. Plus, Brandon shares key failures that shaped his journey—and how you can avoid the same pitfalls.

https://youtu.be/s7puDNP3d7UWatch PDP231 on YouTubeProtrusive Dental Pearl: When discussing smile design with patients, especially in high-end cosmetic cases, set the right expectations early by using this memorable “Eyebrow Analogy”:

Central incisors = Twins (they should be as symmetrical as possible)
Lateral incisors = Sisters (not identical, but related)
Canines = Cousins (more individual)

This helps patients understand that perfect symmetry isn’t always natural or necessary — especially for lateral incisors!

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Cosmetic dentistry as a lens through which all treatment should be approached—balancing patient autonomy with ethical care.
Managing expectations begins before the patient sits in the chair. It continues through structured checkpoints: from initial consultation to provisional feedback and final delivery.
Temps aren’t just placeholders—they are test drives. They align expectations between the dentist, patient, and lab, reducing surprises and improving satisfaction.
Some dentists may under-diagnose due to fear of rejection—not out of true minimalism. Thoughtful planning can make “more treatment” actually less invasive.
Patients often want teeth that are both ultra-white and natural-looking. Brandon developed the concept of believability—a visual balance that delivers a wow-factor while still appearing real.
Creating a mathematically perfect smile can make natural facial asymmetries more obvious. Dentists must weigh beauty against harmony.
Social media and filters have distorted patient self-perception. Dentists must learn to identify signs of body or tooth dysmorphia and respond ethically—not just clinically.
Building relationships with ceramists over time—expecting 15–20 cases before finding synergy. Each technician has unique strengths and should be matched accordingly.
Composite veneers are accessible and beautiful—but extremely technique-sensitive. You become the ceramist. Brandon admires them but uses them selectively due to long-term maintenance concerns.
Panavia Veneer Cement – Translucent for its predictable handling, strength, and minimal risk to thin ceramic restorations.

Highlights of this episode:

01:35 Protrusive Dental Pearl
03:11 Dr. Brandon Mack’s Journey and Philosophy
09:19 Managing Patient Expectations in Cosmetic Dentistry
14:23 Choosing the Right Technician
21:13 “Undersell and Overdeliver” Philosophy
25:12 Conservatism in Cosmetic Dentistry
26:48 Overcoming Failures
33:15 Body Dysmorphia in Dentistry
37:28 Occlusal Philosophy and Techniques
38:30 Fake It Till You Make It?
40:38 Veneer Cement
42:07 Composite Veneers
44:17 Upcoming London Event and Final Thoughts

???? Coming Soon: Occlusion in Dubai ????A luxury course experience at Atlantis, The Palm — yes, the one with the famous waterpark!

???? Learn practical occlusion during the day????‍????‍????‍???? Bring your family for a fun, relaxing getaway???? World-class location, world-class content

????️ Coming Soon: Brandon in London (February 6th and 7th, 2026) – Soho HotelTwo-day immersive aesthetic experience aka ReturnofTheMack

Rewire how you think about cosmetics with Dr Brandon Mack

Participants will learn how to create personalized smile transformations that harmonize with each patient’s unique facial features, moving beyond generic smile designs to achieve truly customized results that enhance overall facial aesthetics.

Bigger picture and smaller details in 2 days: transition zones, light interaction, surface modulation
For new grads and seasoned dentists alike→ “It’s like re-reading a great book. The content didn’t change — but you did.”
Discount Code: PROTRUSIVE for £100 off (case sensitive)

If you enjoyed this episode, don’t miss PDP129: 4 Rules of Planning Aesthetic Dentistry (Ortho-Resto)

PDPMainEpisodes #AdhesiveDentistry #CareerDevelopment

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A, B, C, and D

AGD Subject Code: 780 ESTHETICS/COSMETIC DENTISTRY (Tooth colored restorations)

Aim:

To enhance the clinician’s ability to manage patient expectations, communicate effectively with labs, and deliver predictable, high-level aesthetic outcomes in cosmetic dentistry through philosophy-driven protocols and reflective case-based learning.

Dentists will be able to –

Understand the importance of managing patient expectations in elective cosmetic procedures.
Recognize the role of provisional restorations as communication tools between dentist, patient, and lab.
Reflect on how personal failures can lead to clinical growth and stronger aesthetic outcomes.

Click below for full episode transcript:Teaser: What is cosmetic dentistry? It's not really a specialty. The way that I look at cosmetic dentistry is essentially a philosophical approach to dentistry, and that's it. Like a lens that we look at everything, how can we be comprehensive? And at the center of that lens, there's two things that need to be balanced.Teaser:Number one, why people don’t want to take more creative risk. It boils down to fear. And this idea as dentists we’re so type A that we feel like everything is a Super Bowl. We have to get it right on the first attempt. When you are in the process of doing this, you have to understand the level of anxiety that comes with it on the patient’s part, because everything that we’re doing is semi-permanent, right? Nothing lasts forever, but this isn’t a hair dyeing or a haircut.

When a patient says, I want really white teeth, but I want it to look natural. That is a horse with stripes. It’s not a zebra. It is a horse with stripes. I think that for the young dentists embracing every failure, no matter how big or how small, and understanding that every one of those lessons are an opportunity to put you in a better position to treat the next person better, it’s going to make the next person’s case better, every single failure.

So there’s always five checkpoints for patient expectation. Patients are demanding certain things, and so how much do we balance patient expectation and autonomy, what a person wants for themselves? I think it all boils down to one thing.

Jaz’s Introduction:Cosmetic dentistry is tough. Think about it when you’re removing caries, is there a way to make that objective? Like some of caries removal is obviously subjective because how much I would remove is different to how much you might remove. But with something like caries detector dye, we know that we can turn this procedure and add a degree of objectivity to it, and we have some guidelines that we all work to.

Now, in the world of cosmetic dentistry, there is the lens that the dentist wears, and then there’s a perception of the patient. And as they say, beauty is in the eye of the beholder. Now, add to that the ultra high expectations that patients can carry today and the very nature of cosmetics and beauty being subjective. This is tough. This is what makes cosmetic dentistry tough. So I’m absolutely honored toast today, Dr. Brandon Mack from Florida.

He is one of the biggest names in cosmetic dentistry and we have a really geeky session today. I asked him how he manages those ultra high expectations patients, so big level stuff. And I also ask him little details like what’s his favorite veneer cement? What is Brandon’s occlusal philosophy? And one thing I really love is I ask him to tell us about his failures. And I always appreciate colleagues that share their failures and what they’ve learned along the way.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. If you’re returning to the podcast, maybe you’re watching this on the Protrusive Guidance app. Thank you so much for coming back.

If you are new to the podcast, you picked a really awesome one to join us. I said on the podcast, I actually really enjoyed Brandon’s flamboyant vocabulary. He’s full of energy, and these are the kind of episodes th...

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We use articulators to help ‘mimic’ our patient’s jaw movements, to ultimately do less adjustments/revisions in the future.

But are digital articulators there yet? Or is analog king?

Or is digital dentistry just flashy tech with no real-world benefits?

Can a virtual articulator truly match the movements of your patient’s jaw?

Is a CBCT really better than a facebow—and WHEN should you use which?

In this cutting-edge episode with Dr. Seth Atkins, we dive into the world of digital articulation—exploring how tools like virtual articulators, CBCT alignment, and 3D-printed provisionals are transforming clinical workflows.

You’ll learn how to combine analog wisdom with digital precision, improve lab communication, and make full-mouth rehabs more predictable and efficient than ever.

From mounting accuracy to motion capture, this episode is your ultimate guide to articulating smarter in the digital age.

https://www.youtube.com/watch?v=fT31Ecf_kDoWatch PDP230 on YouTubeProtrusive Dental Pearl: Always send your lab the color version of your digital scan — the PLY file — not just the STL. STL shows shape, but PLY shows color — like markings and tissue detail. Ask your lab: “Are you seeing color, or do you need the PLY?”

Better scans = better results

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Digital methods can enhance accuracy and patient outcomes → but only when used intentionally.
Understanding both analog and digital techniques is crucial → they complement each other, not compete.
Mentorship plays a significant role in advancing dental education → experience accelerates clinical confidence.
Digital workflows can significantly reduce chair time → and improve patient comfort in the process.
The integration of CBCT with digital workflows enhances diagnostics → giving clearer insight into static and functional relationships.
Digital provisionals offer a cost-effective and efficient solution → saving time, money, and frustration for both dentist and patient.
Axiography is essential for capturing patient motion accurately → because real movement matters more than assumptions.

Highlights of the Episode:

00:00 Introduction
04:00 Protrusive Dental Pearl
05:32 Interview with Dr. Seth Atkins and his Journey into Digital Dentistry
08:06 The Evolution of Digital Articulation
13:38 Digital Workflow and Mentorship
20:01 Accuracy and Efficiency in Digital Dentistry
22:32 Static and Dynamic Relations in Digital Dentistry
31:01 Interjection 1
36:05 Practical Guidelines on Integrating CBCT
37:15 Interjection 2
40:59 Clinical Observations in Dental Rehabilitation
42:29 Interjection 3
45:21 Introduction to Axiography
46:40 Advancements in Digital Dentistry
49:33 3D Printing in Dental Practice
53:31 Motion Tracking on Digital Articulators
57:30 Cost Efficiency of Digital Tools
01:01:10 Alternatives to CBCT
01:05:52 Involvement with AES and Future Plans

Check out the study mentioned: “Comparison of the accuracy of a cone beam computed tomography-based virtual mounting technique with that of the conventional mounting technique using facebow”

???? Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES).

????️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician”

???? February 18–19, 2026 · Chicago, Illinois Don’t miss Dr. Jaz Gulati and Dr. Mahmoud Ibrahim as featured speakers, presenting on “Occlusion Basics and Beyond.”

If you loved this episode, be sure to watch Basics of 3D Printing, Milling and Digital Dentistry – PDP224

PDPMainEpisodes #OcclusionTMDandSplints

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcome C – Maintenance and development of knowledge and skill within clinical practice.

AGD Subject Code: 610 – Fixed Prosthodontics – Emerging techniques and technology

Aim: To provide a comprehensive understanding of how digital articulators can enhance clinical workflows, improve occlusal precision, and minimize restorative complications through accurate static and dynamic articulation.

Dentists will be able to:

Differentiate between analog and digital articulation methods, including their benefits and limitations.
Apply digital workflows to provisional restorations, improving efficiency, patient experience, and predictability.
Recognize cost-saving and diagnostic advantages of digital design in restorative and full-arch treatment planning.

Click below for full episode transcript:Teaser: I got into some of the digital things initially, more for selfish reasons. The key there is not necessarily digital for the sake of digital. It's how well can we do analog?Teaser:Do you think the new grad, the new generation coming through, all they’ll ever know is digital, is that a bad thing or is that a good thing?

Yes, and the reason I say that is I think it’s the correct answer for both. Yes, bad and good.

Are you at any point picking up your analog facebow and then working on analog articulators to wax up, or have you got to a point now whereby the trust and the faith you have in your digital workflow means that you can do it fully digitally?

The biggest thing that a lot of people don’t understand is-

Jaz’s Introduction:Analog versus Digital. Are we there yet? How on earth does a digital articulator work and what’s the point? And are there any real advantages to the digital workflow other than it looking cool and pretty on the screen? Can it help you be more efficient, more accurate, more predictable?

We’re gonna cover all those things with our guest today, Dr. Seth Atkins. I tell you, this guy is a wiz. He’s part of the organizing committee of the AES, that’s American Equilibration Society, and this is part of the AES takeover. We are promoting the AES 2026 conference, which has got some of the biggest names in occlusion, comprehensive dentistry and TMD over two days in Chicago.

The date is 18th and 19th of February, 2026, and it’s called the Evolution of the Oral Physician. The lineup, I tell you, is absolutely phenomenal, and also it’s a privilege to be one of the speakers alongside Mahmoud Ibrahim. We have the 8:00 AM slot on Thursday 19th of February, so it’d be great to see as many of you there as possible.

Hello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Let’s talk about digital articulators. Now, let’s go back to basics for our students and younger colleagues. The whole point of an articulator is that we can mimic the patient on the table because we can’t take the patient home with us and design the restoration in the mouth.

And then fit it the next day. We have always needed a way to mimic the patient, mimic their head, mimic their movements, mimic their bite so that we can work on the benchtop. So the analog way was to use a face bow and then feed that face bow into something like a semi adjustable articulator. Now what you see on the articulator, this analog articulate in front of you, we’re hoping is somewhat representative of your actual real patient, so that when you design the cuspal inclines of the molar, let’s say that you are restoring that when you put it in the mouth.

And the patient then moves left and right, it happens, so in the same way as it did on the articulator. The ultimate benefit of that is less adjustments, more accuracy, and ensuring that the design that you intended actually works in the patient’s mouth. Now, when you talk about comprehensive dentistry and doing more units, doing full mouth cases, you can appreciate how important it is to replicate the patient.

And let me tell you, this episode is all about digital. We are moving away from analog facebow and analog articulators. Now you’ll see how Seth explains why we can never probably be fully a hundred percent digital in these big cases because the final stages still need to be analog because our patient, when we fit the crown in the mouth. That’s an analog process, so we still need some analog knowledge, but how can we harness the power of digital articulators?

It’s a very exciting, very geeky episode, and I put a few interjections in there to help make it as tangible as possible so that our younger colleagues, our students, can also follow along. That’s always the mission of this podcast.

I asked Seth how we are now transferring the patient to the digital articulator. So like I said, in the analog world, we use a face bow and we talk about the role of face bow, but then how do we actually now use a digital face bow, if you like, and then how do we ensure that the movements are as close as possible on the digital articulator?

Dental PearlT...

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Are you considering the airway in your treatment planning?

Could centric relation (CR) be compromising your patient’s breathing?

When you open the vertical dimension, are you making the airway better—or worse?

Welcome to another AES 2026 series episode, this time with LEGEND Dr. Jeff Rouse as he joins Jaz in this eye-opening episode to explore how airway, aesthetics, and function are deeply interconnected—especially in prosthodontics.

They discuss key clinical scenarios like vertical dimension changes, examining how your choices may impact the airway—sometimes in ways you didn’t expect. With practical insights and examples, this episode will help you make smarter, airway-conscious decisions that elevate both your functional and aesthetic outcomes.

https://youtu.be/-Ut-qme7VcgWatch PDP229 on YoutubeProtrusive Dental Pearl: Plan your breaks 12 months in advance to avoid burnout and ensure quality time with your loved ones. Prioritize rest and connection before reaching exhaustion—your body, mind, and heart will thank you.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Airway health is crucial in dentistry, impacting aesthetics and function.
Understanding airway issues can lead to better treatment outcomes for patients.
Breastfeeding plays a significant role in childhood development and airway health.
Interdisciplinary approaches are essential for effective adult treatment.
Aesthetics and function are key factors in airway prosthodontics.
Most patients are unaware of their airway issues until they are addressed.
Early intervention in childhood can prevent future airway problems.
Combining orthodontics and prosthodontics can enhance patient care.
Airway management is crucial for overall patient health.
A great bite is not just about teeth alignment.
Pathway wear can indicate deeper dental issues.
Vertical dimension changes can negatively impact airway.
Understanding joint positions is essential in treatment planning.
Continuous education is vital for modern dental practices.

Highlights of this patient:

02:22 Protrusive Dental Pearl
04:34 Interview with Dr. Jeff Rouse Begins
09:05 Understanding Airway Prosthodontics
15:58 The Role of Cone Beam CT Scans
17:58 Treating Children and Early Interventions
24:50 Addressing Adult Airway Issues
29:43 Multidisciplinary Approach in Dentistry
31:46 Patient Transformations and Airway Focus
34:42 Understanding Pathway Wear
41:32 Impact of Vertical Dimension on Airway
48:55 Exploring Different Occlusion Philosophies
51:34 A Sneak Peek at AES 2026: Dental Wear Patterns Of The Airway Patient
55:25 Upcoming Events and Resources

Explore the world of sleep disordered breathing with Prof. Ama Johal in PDP033: “Airway – Dentistry’s Elephant in the Room.”

???? Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES).

????️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician”???? February 18–19, 2026 · Chicago, IllinoisDon’t miss Dr. Jeff Rouse as featured speaker, presenting on “Dental Wear Patterns Of The Airway Patient”

???? Learn more with Dr. Jeff Rouse on The Spear Education Online

PDPMainEpisodes #CareerDevelopment #BreadandButterDentistry

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A, B and C.

AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Sleep medicine)

Aim: To deepen clinicians’ understanding of airway prosthodontics and empower them to recognize airway-related dental issues across all age groups.

Dentists will be able to –

Differentiate between anatomical airway dysfunction and sleep-disordered breathing, and understand the unique role of dentistry in addressing each.
Explain the principles of Airway Prosthodontics, including the significance of tooth position in facial space and its impact on breathing.
Recognize signs of airway compromise in both pediatric and adult patients, including atypical wear patterns, bruxism, reflux, and chronic fatigue.

Click below for full episode transcript:Teaser: They don't want us playing in that world either. They don't. Their world is completely different than ours. And you as a dentist, you don't want to be in that world. It's an ugly, ugly world and most physicians would love to be dentists nowadays, 'cause we have so much more freedom to change and to act and to care for our patients than they do. Most people don't know what they don't know. They just call it normal.Teaser:A woman I was visiting with earlier today had had orthognathic surgery and she said, I didn’t really realize that I never was able to breathe and I never slept until I had the surgery done. People that are constricted in their bites like this, their maxillas are constricted.

And if their maxillas are constricted and their nasal cavities constricted, they can’t breathe well through their nose. And so if you go from giving a small piece of cheese or beef jerky or a peanut to chew, they can manage their airway, have ’em bite into a sandwich with a bunch of bread and a bunch of stuff in it. They can’t, so their chewing cycle will move forward and they’ll hit their front.

For me, airway is just established the aesthetic position of the teeth first and the functional position of the teeth. If you get those things normalized, then we help the patient normalize what they do, which is close the mouth and breathe through their nose.

That’s dentistry and the success of that treatment is does the patient have a beautiful smile and a great bite? That’s success. Not did I reduce the apnea level? We’re treating 26 month old as the youngest I’ve ever heard, done Invisalign first to expand, start expansion early, but at four you can start to see if you’re leaving them in a constricted pediatric arch that the permanent teeth are gonna erupt outside of the housing of the bone. So the orthodontist never moved the teeth outta the bone. They were never in the bone to begin with.

Jaz’s Introduction:How does the airway relate to aesthetics and function? Interesting concept ’cause we think about aesthetics, we think about function, but are we necessarily thinking about the airway when it comes to our treatment planning?

Related to this is a scenario like, let’s think of complete dentures. When we deliver complete dentures, the joint position that we usually select is centric relation or seated condyle position. Now the question is, is this position adversely affecting their airway? i.e. by moving their condyles in into centric relation, which usually means they’re moving their jaw a little bit further back. Is that necessarily worsening their airway?

Well, we answered that in this episode. And how about when we’re opening someone’s bite? Well, in prosthodontics, when we open someone’s bite, there are some scenarios where you are at risk of making the airway worse and other scenarios where you’re probably not gonna make the airway worse.

And you’ll learn this episode exactly what those two distinctions are. I’m joined today by the Dr. Jeff Rouse absolute giant in our profession. What a lovely guy he is. Author of one of the best dentistry textbooks there are Global Diagnosis. He’s also a very prominent educator with spear education and the impact this man has made in airway and dentistry and prosthodontics is just absolutely amazing.

So it’s real privilege to host him today as part of our AES takeover. See, Jeff Rouse is one of the speakers at the AES Conference, 2026 in February, and that will be held in Chicago. And we’re trying to shine a light on this conference because it’s based on occlusion, right? It’s related to occlusion, but it’s so much more than occlusion.

In fact, the theme of the AES conference next year is the Evolution of the Oral Physician. Let me say that again. The Evolution of the Oral Physician. So it really looks more than just the occlusion. When I attended a few years back, they really are a comprehensive, holistic group that brings together all the occlusion camps and me and Mahmoud Ibrahim, have the privilege of being able to speak there.

But we are a small piece of it. You know, some of these giants, like Dania Tamimi that we had on previously, Lukasz Lassman, Jeff Rouse, who you’ll hear from today, is gonna make a really great conference. We’re shining a light, so check out aes-tmj.org, that’s aes-tmj.org to learn more about this conference in Feb 2026.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl, and quite often the pearl I give depends on my mood and my context and what I’ve been doing that day or the ...

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Have you actually looked back at your long-term cases to see how layering compares to injection moulding?

Is traditional freehand layering still your go-to for anterior composite aesthetics?

Are you using it because it gives the best result — or just because that’s how you were trained?

In this episode, Dr. Marco Maiolino joins Jaz Gulati for a meaty discussion about injection moulding—a technique that’s changing the game in anterior composites (and posterior!)

This isn’t about trends. It’s about clinical outcomes.

We’ve all admired the beauty of layered composites—translucency, halo, the “natural” look. But after 5, 7, or even 10 years… do they hold up?

Dr. Maiolino brings over a decade of follow-up data—and the results might surprise you.

https://youtu.be/wHs8QQkgPhUWatch PDP228 on YoutubeProtrusive Dental Pearl* When in doubt between two shades (e.g., A1 vs. A2), always choose the lighter shade. Higher-value shades blend better and result in higher patient satisfaction. * Techniques: Use the composite button method and black-and-white photography to objectively evaluate shade blending. * Outcome: Lighter shades minimize the risk of patient dissatisfaction and rework.

???? Download the full Premium Notes for this episode—including clinical comparison of injection moulding and layering technique, long-term before/after documentation, and Marco’s complete injection moulding protocol: ???? protrusive.co.uk/im

Need to Read it? Check out the Full Episode Transcript below!

Key Clinical Takeaways* Injected composites often outperform layered ones in long-term follow-up. * Color stability is as much about technique as it is about material selection. * Edge bonding requires careful occlusal planning and respect for functional dynamics. * The biologic cost of veneers is frequently underestimated—additive approaches can be more conservative. * Composite thickness and occlusal harmony are critical for restoration longevity. * Rigorous documentation and honest case review matter more than dramatic presentations. * Failures are not setbacks—they are opportunities for professional growth and better patient care.

Episode Highlights:

0:00 Introduction
02:45 Protrusive Dental Pearl: Practical shade selection hacks
08:54 Dr. Marco’s journey into injection moulding
15:44 Why Marco transitioned away from layering
18:00 Edge Bonding and Occlusion Considerations
25:20 Layering vs. Injection Moulding
29:15 Variations of Injection Moulding Techniques
32:32 Injection Moulding for Edge Bonding
39:29 Edge Bonding Protocol and Materials
49:18 Understanding Failures and Diagnostics
53:23 Managing Tooth Wear with Injection Moulding
55:47 DAHL Approach Complexity and Cost
56:41 Swallowing Patterns Affecting Treatment Success
01:00:07 Importance of Case Selection
01:01:08 Rubber Dam Use
01:03:17 Flexible Use of Techniques
01:17:24 Outro

????Upcoming Talks & Courses

Dr. Marco Maiolino will be one of the notable speakers at the Injectable Restorations European Summit 2025, taking place on November 7–8, 2025. This highly anticipated event gathers leading experts in the field and will be held in Europe. For more information and registration details, visit the official website: injectionsummit.eu.

If you loved this episode, be sure to watch Stop Being a Perfectionist – it’s OK to Fail – PDP184

PDPMainEpisodes #OrthoRestorative

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes C and D

AGD Subject Code: 250 Operative (Restorative) Dentistry (Direct restorations)

As clinicians, we’re constantly challenged to balance esthetics, function, and longevity in our restorative work. In this episode, Dr. Marco Maiolino joins Jaz Gulati for a candid, evidence-driven exploration of injection moulding—a technique that’s rapidly shifting the paradigm in anterior composite restorations. This isn’t about chasing trends; it’s about critically evaluating what truly works for our patients over the long haul.

Dentists will be able to:1. Understand the indications, benefits, and limitations of edge bonding and injection moulding.

Recognize how minimally invasive dentistry can provide reversible, conservative treatment options. 3. Appreciate the importance of proper planning and case selection when using techniques like injection moulding.

Click below for full episode transcript:Teaser: More layers you do, in my experience, more aging, you will get on that restoration. So if you see in my office, I have just three comp, I have a A1, A2, A3. So injection moulding is a way to apply composite that for me is the best.Teaser:I’m glad you mentioned it, that you are so convinced and dedicated to the injection moulding way to deliver a restoration that you’ve pretty much now found ways. As long as you can make your scaffold.

On the mesial distal, you have some composite with just one shade. Now this brown area is much more evident than before. So the patient completed the appointment. Saying, I am very happy. I have no more black triangles. I am very happy. But when you’re doing a study patient with the worn dentition because of occlusal problem, if you are going to do, for example, an important canine guidance, an important incisal guidance, they’re going to break everything after a while.

But honestly, when I see with air drying the restorations with magnification, and I see the interproximal surfaces in comparison to the surface that I have with injection moulding with matrices. This surface-

Is there a composite that you found to have superior longevity in terms of color stability, polishability? Is it a 3M Filtek? Is it Estelite? I dunno, what are you preferring nowadays?

Okay. What I use every single day in my life is I use-

Jaz’s Introduction:Protruserati, there’s been a big shift over the years towards injection molding. Now, some of this has been driven by the industry, of course, right? So we always have to be careful about biases.

Biases are everywhere. Now, use this technique, use that technique because there’s a lot of money involved for these companies. But what I look for is clinicians that change, that pivot from a technique that’s perhaps established and we know of, and they pivot and change to a different technique. And if they can justify why they’ve made that change and share the science or the rationale, I like when something is justified.

There is a clear science behind a decision that’s made by a clinician that’s fantastic. Rather than, oh, this company’s paying me. So I’m talking more about this product. This is why I really respect today’s guest, Dr. Marco Maiolino. We’ve had him on as a guest before on the imperfect dentist. He is such an authentic character.

He talks about his failures very openly, and it’s his failures in layering over time, right? He shares the long-term data of seeing his composites and he is a very good practitioner. High quality isolation, high quality materials microscope, everything. But what he noticed at the eight, 10 year mark is that his layered composites were not looking very aesthetic despite using the best materials and best techniques.

They certainly did not look as lovely as they did at day one. So many years ago. He moved, I believe he said 2014, he moved towards injection molding. Now when I say injection molding, you guys probably think, oh, exaclear or memosil stent, and then you inject the genial injectable composite or any other composite that may be available.

But actually, injection molding is just the name of the technique, the act of injecting into a space. So this could be bioclear or these transparent matrices. It could be just a humble mylar strip behind a tooth, and then you inject the composite into that space once you’ve made your scaffolding.

So really, this episode is about the process of injecting that material and why the injection of composite is superior according to Marco than layering bit by bit and some of the issues that you can face with that, and why in the long run, whilst your layered composite may look a little bit more beautiful, a little bit nicer on day one compared to your injected composite, when you look at them at eight, 10 years, the injected composite looks more consistent, more stable, both types of color. Luster, shape, all those things. So there is a science behind it. And to discuss that science we have Dr. Marco.

Dental PearlHello Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode I give you a Protrusive Dental pearl. Today’s pearl is something I shared a few weeks ago on our community Protrusive Guidance, the home of the nicest and geekiest dentist in the world.

And it’s about my thoughts on shade selection on composite. Now, in previous pearls, I have discussed the button technique. Getting a small button of composite, curing it, and then having a look. Hmm, does it match the adjacent tooth? Is this gonna be the right shade to use for my patient? And in another episode we did with Dr. Jason Smithson, he ...

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Should we really restore primary molars without local anaesthetic or injections?

When should we start taking radiographs for child patients?

Is it time to say goodbye to traditional anterior strip crowns and embrace preformed zirconia crowns?

And seriously – how do you get a wiggly, fidgety child to sit still long enough for a solid restoration?! The secret lies in choosing a technique that’s both quick and effective!

In this episode, Dr. Tim Keys unpacks the real challenges of restoring primary teeth, breaking down the pros and cons of popular approaches like the Hall Crown technique, Pediatric Zirconia crowns, and conventional stainless steel crowns (SSCs).

Tune in for practical insights to make pediatric crown work less stressful and more successful – helping you find the best fit for your little patients.

https://youtu.be/VJm4TFKLXEADr. Keys is also involved in dental education and offers courses through his platform, Kids Dental Tips. One of his upcoming courses is titled “Restorative Paediatric Dentistry,” a two-day event scheduled to be held in Brisbane.

Protrusive Dental Pearl: One of our best ever Protrusive Infographics! This week’s Pearl is a handy downloadable PDF infographic summarising the key points from this episode on Children’s Crowns Techniques. Grab your copy here!

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

The Hall crown technique is a non-invasive approach to treating pediatric teeth.
Radiographs are essential for accurate diagnosis and treatment planning in children.
Case selection is crucial for the success of pediatric dental treatments.
Zirconia crowns have superior aesthetics over stainless steel crowns.
The success rate of intra-coronal fillings in primary molars is lower compared to crowns.
Zirconia crowns rarely fracture compared to strip crowns.
Mild supra-occlusion is acceptable in pediatric dentistry.
Hands-on experience is crucial for mastering crown techniques.

Highlights of this episode:

00:00 Introduction
01:32 The Protrusive Dental Pearl
04:19 Dr. Tim Keys
06:26 Work-life balance & parenting
12:05 Hall crowns Vs Zirconia crowns
13:12 Pediatric crowns and caries management
15:40 Failure rates and clinical implications
17:51 Stainless steel crowns: conventional vs Hall technique
21:03 Case selection and radiographs
25:31 Radiographic criteria
27:04 The Hall Technique
29:59 Technique tips
38:00 Zirconia crowns vs strip crowns
46:55 Education, resources, and further learning
51:02 Outro

Key Article mentioned in this episode: Effectiveness, Costs and Patient Acceptance of a Conventional and a Biological Treatment Approach for Carious Primary Teeth in Children | Caries Research | Karger Publishers

PDPMainEpisodes #BreadandButterDentistry

If you enjoyed this episode, you should check out PDP159 – How to Manage Children in Dental Pain.

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and C.

AGD Subject Code: 430 Pediatric Dentistry.

In this episode, Jaz and Dr. Tim Keys explore practical approaches to restoring pediatric teeth, focusing on the selection, preparation, and placement of direct restorations. They discuss material choices, clinical tips, and how to tailor techniques to improve outcomes and cooperation in young patients.

Dentists will be able to:

Understand the clinical indications and benefits of various crown techniques used in the restoration of pediatric teeth
Recognise the importance of selecting appropriate cementation materials and techniques for different types of direct restorations in children
Appreciate the key clinical considerations involved in the preparation and placement of a range of direct restorative techniques in pediatric dentistry

https://media.blubrry.com/protrusive/content.blubrry.com/protrusive/PDP227.mp3Click below for full episode transcript:Teaser: The success rate at 10 years sits between 97% and 99%.

Teaser:This is the traditional conventional approach. Yeah.

Conventional crowd. Yeah. And I would argue that is more successful than what you would be doing in an adult tooth. A name of restorative material in adult tooth that you know is got a 97% to 99% success rate at 10 years.

It’s incredible. So there’s nothing like this. So if you’ve got a patient who’s got a clinical issue, I would encourage all your listeners, please do not do anything without x-rays. And if you can’t get x-rays on that patient because of compliance issues, you really need to reconsider your ability.

The strongest way to get that crown to sit down as the kid ’cause their jaws a lot stronger than my thumb. And so I put a cotton roll in it. I get the kid to bite down really hard and you get a floss with a knot in it, and then you put it on and then you get your DA to put dental assist to put their thumb over the top of the crown. You floss down and then pull it out and then go to the other side. Floss down, pull it out.

I haven’t done a strip crown on a primary interior tooth in five years. And I’m so bloody happy I don’t do them anymore. Keep in mind, each x-ray is the equivalent of around six bananas. Six bananas got radiation in right? So the radiation test is insignificant, really. And I think I need your listeners to really understand that we don’t treat children differently because they’re children.

You know, we wouldn’t treat an adult and extract a tooth on an adult without an x-ray. You wouldn’t do a filling on an adult without an x-ray. You wouldn’t do a nerve based treatment on an adult without an x-ray. So please stop doing it on children because there is no defense for it. It’s completely wrong.

Jaz’s Introduction:This episode is such a wonderful resource and refresher on the whole crown technique. If you listen to the end of this episode with the wonderful Tim Keys. He’s like the Aussie, you know, Aussie man reviews those hilarious videos with a funny Australian accent comedy like Tim has that voice where he should just do dental videos and a funny commentary.

He’d be like, Aussie man dental reviews. And Tim spoke so well, so passionately and so clearly about this topic so that by the end of this episode, you will know the difference between the conventional stainless steel crown technique versus the more contemporary hall crown technique.

When should you use? Which one and all about this newcomer, the zirconia children’s crowns, and how the technique actually is really different and how to prepare the tooth accordingly for a zirconia crown, which is relevant both for anterior and posterior teeth, from knowing which cements to use and whether or not you should use local anesthetic on a child.

And something that Tim’s very passionate about. Should we be taking radiographs on children and at what age? What are the clinical and radiographic science look for, to make sure that a tooth is suitable for this type of treatment, i.e. the whole crown treatment.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Like I said, Tim, honestly just absolutely smashed this episode, and I’m so excited for you to learn from him. As you know Protrusive, we have guests from all around the world, but I have to say there’s something. I have a soft spot for my Aussie guests. I dunno what it is. They just come on and they put on a show every time. So sending love to all the Aussie Protruserati. You guys have been supporting me for over the years, but we’re gonna win the ashes. I just had to put that in there.

Dental PearlEvery PDP episode I give you a Protrusive Dental Pearl, and today’s pearl is just the most wonderful summary of this entire episode. It is one of our famous Protrusive Infographics. There are two ways to get this for free. One is if you’re viewing this episode on the Protrusive Guidance app, then thank you for being a member of the nicest and geekiest community of dentists in the world. Just scroll down and you’ll see the PDF there, and please comment if you’d like it. Number two is, if you’re not on our community, then head over to protrusive.co.uk/kidsteeth. That’s kids teeth.

And when you enter your first name and your email address, I’ll email it to you personally with the PDF in your inbox. Our infographics are pretty famous, the ones that we have on deep margin elevation to which ceramic to use, which type of zirconia to use. We work really hard, especially the oral medicines one.

Again, that was actually another Aussie guest we had on as well. So once again, hat tip to all the Aussie guests I’ve had on the show. But yeah, you’re gonna love this infographic, so please do download it. And if you’re not on the Protrusive Guidance community, what are you waiting for? Honestly, it’s so, so nice to learn from everyone and to share my special snippets.

And actually, there’s a part of this episode that is gonna be only on Protrusive Guidance, and this might actually sway me in a different direction, but. You know at...

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How can dentists help kids breathe, sleep, and grow better—even if the problem isn’t the teeth?

When should you refer, and what tools can you use right now in your practice?

In this AES special episode, Jaz Gulati is joined by Dr. Liz Turner and Dr. Meggie Graham—general dentists who have evolved their practice with a deep passion for airway and whole-child health.

They walk us through five real patients, including Jaz’s own son, to show what airway dentistry looks like in the real world. From growth appliances and myofunctional therapy to inflammation control and ENT collaboration, this episode connects the dots between breathing and behavior, development, and even dental crowding.

https://youtu.be/Y6EfufPd98EWatch PDP226 on YoutubeProtrusive Dental Pearl: “Don’t stay stagnant—keep learning, keep growing, and reinvent yourself every 5–10 years.” Think of your dental career in seasons—explore new areas, refine your interests, and let go of what no longer brings you joy. This keeps your passion for dentistry alive and evolving.

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways

Airway dentistry is a growing field that emphasizes prevention.
Understanding airway issues can lead to better health outcomes.
Dentists can play a crucial role in optimizing health through airway management.
Health optimization is a key focus in modern dentistry.
Interdisciplinary collaboration is essential for effective patient care.
Functional dentistry addresses the root causes of dental issues.
Children’s airway health can significantly impact their development.
Dentists should feel empowered to make positive changes in their patients’ lives. Facial aesthetics can significantly impact self-esteem and health.
Nasal breathing is crucial for overall health and well-being.
Quality of life can be improved through better patient care.
Breastfeeding plays a vital role in a child’s development.
Addressing sleep issues in children is essential for their growth.
Understanding the connection between breathing and systemic health is vital.

Highlights of this episode:

02:04 Protrusive Dental Pearl
04:08 Interview with Dr. Liz Turner
06:18 Interview with Dr. Meggie Graham
07:43 Personal Journeys into Airway Dentistry
16:26 ENT Referrals
21:55 Understanding Airway Symptoms and Treatment
26:10 Patient Case Studies and Treatment Approaches
36:46 The Importance of Nasal Breathing
45:30 Pediatric Airway Concerns and Solutions
55:09 Educational Resources and Final Thoughts

???? Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES).

???? Learn more about airway and breathing issues with Dr. Liz and Dr. Meggie on The Untethered Airway — and stay tuned for their first course, launching soon! – Waitlist for course and email list

Enjoyed this episode? You will also enjoy exploring the world of OSA with Prof. Ama Johal in PDP033: “Airway – Dentistry’s Elephant in the Room.”

PDPMainEpisodes #CareerDevelopment #BreadandButterDentistry

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A, B and C.

AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Sleep medicine)

Aim: To enhance the general dentist’s ability to recognize, evaluate, and initiate management of patients with airway-related dysfunctions across all age groups.

Dentists will be able to –

Identify common dental signs of airway-related disorders in infants, children, and adults.
Understand the systemic impact of airway dysfunction, including its behavioral, developmental, and physiological consequences.
Describe the role of early intervention, including tongue-tie releases and palatal expansion.

Click below for full episode transcript:Teaser: Have you ever been on an airplane and you hit turbulence and the whole plane goes like, nobody can say no to that. It's the same thing with breathing. We need our breathing to be passive and not turbulent.

Teaser: We as dentists shouldn’t be feeling like we’re putting out fires all the time. We should be patting ourselves on the back for being quarterbacks of not just the oral cavity, but of full body health as well. If you’re looking at things with an airway positive spin.

This is an ENT issue. This is a dental issue, but the body has no idea what you’ve studied. It has no idea what your specialty is. It’s just functioning or dysfunctioning the way it is.

Jaz’s Introduction:In this episode, I’m joined by two dentists, Dr. Liz Turner and Dr. Meggie Graham, who started as general dentists, but then they have later niched or pivoted more into airway and health. They still do dentistry, but they’re very much an airway focused passion. I think passion, is the best word, and let me tell you guys, you’re gonna absolutely love the different themes and facets we explore.

The thing I love the most about this episode, which I know you will too, is how it made airway tangible. For example, when I ask my patients, what do you do? They will say something like, oh, I’m in logistics, or I am a project manager, or I am a business consultant. Honestly, I could not even shut my eyes and imagine what they actually do.

Like I wanna know what people do day in, day out. I dunno if it’s just me, but I genuinely cannot imagine what a typical day in their life looks like and how they actually operate. So similarly, when someone says, oh, I’m a dentist, but I have an airway focused practice. I actually didn’t know what that actually looks like day to day.

So one of the questions I asked them is, okay, what does a typical day look like? What interventions do you use? What different tools do you have in your toolbox to help your patient? And I think they both did a wonderful job to explain that. And you’ll see these five patients discussed like five typical patients that they see that we see day in, day out.

These are five real patients, the fifth one being my second son, Sihaan, that we actually discussed who we can help as dentists. But their primary issue is an airway issue, so I love how we made it tangible. Now, this episode is part of the AES takeover. We are shining a big light on the AES conference in Chicago.

That’s in February 2026. The website will all be below, and this is where the creme de la creme come together in occlusion, TMD and Airway. Me and Mahmoud will be speaking at the conference, but honestly, the lineup is insane. I definitely want every single person to click on that link to AES. I’ve got my show notes and have a look.

Does this tickle your fancy? Have you never been to Chicago before? Lemme tell you. It’s an amazing place, great culture, great food, but just comfort the education alone is gonna be mind blowing.

Dental PearlHello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite Dental Podcast. Every PDP episode I give you a Protrusive Dental Pearl, and this one was inspired by my conversation with Liz and Meggie.

Before we actually hit the record button, I was talking about one of the missions. This podcast has is to help dentists fall in love with dentistry again, and we need to remember that the kind of themes we’re talking about, the discipline of dentistry, which is airway that we talk about is growing and is growing for good reason and reminded me of how not only our life, but our career also comes in seasons.

And we need to appreciate that dentistry is a wonderful profession in the sense that we can redefine ourselves or be reborn like every 10 years. Think of it like that, like every 10 years, there could be like a season of your career. For example, for the first 10 years, you could be focused on general dentistry.

The next 10 years you could be general dentistry and facial aesthetics. And maybe in the 10 years into that, it could be just facial aesthetics, for example, should you wish for that. I’m giving quite extreme examples on purpose. For someone else it might be single tooth dense for the first 10 years, then it could be for the next 10 years, full mouth dentistry.

And for the last 10 years it could be periodontally focused alongside full-mouth dentistry. And of course, you can think of every possible combination. You can bring in implants at 10 years, or you can start doing...

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Are you still using long-term provisionals just to test OVD?

Is an occlusal splint really the best way to assess vertical dimension?

Could raising the OVD actually harm your patient?

Dr. Lukasz Lassmann joins Jaz and Mahmoud Ibrahim this AES special episode to challenge conventional thinking around occlusion, vertical dimension, and full mouth rehab. Lukasz shares his unique perspective as a clinician, educator, and researcher, bringing clarity to a topic that often feels murky and divided.

They explore real-world questions like managing asymptomatic clicks before ortho, why occlusion alone won’t “cure” bruxism, and the number one reason not to raise the vertical without proper understanding.

Plus, Lukasz drops an incredible airway assessment tip at the end of the episode!

Protrusive Dental Pearl: Use a comprehensive TMD history-taking form to effectively triage patients into urgent (red), moderate (amber), or low-risk (green) categories—this allows you to prioritize care appropriately and build rapport by focusing on examination rather than data collection during the appointment.

https://youtu.be/ZhIoUxdMMsgWatch PDP225 on YoutubeDownload the form: protrusive.co.uk/tmdhistory

Download the Patient History Evaluation Form

Need to Read it? Check out the Full Episode Transcript below!

Takeaways

Understanding red flags in TMD patients is essential.
Patient history is vital for effective treatment.
Phonetics can be unpredictable in dental rehabilitation.
Diet and sleep significantly affect TMD management.
Gut health is linked to chronic pain conditions.
Communication with patients is key to successful outcomes. Bruxism may not be solely caused by occlusion issues.
Palpating the lateral pterygoid is often ineffective and painful.
Equilibration and centric relation are controversial topics in dentistry.
Increasing vertical dimension can exacerbate sleep apnea.
Holistic approaches are essential in diagnosing and treating TMD.
Not all patients with TMD have malocclusion or attrition.
Sleep apnea is increasingly common in younger, slimmer patients.
Polygraphy is a useful diagnostic tool for sleep apnea.
DISE (drug-induced sleep endoscopy) is a valuable diagnostic procedure.

Highlights of this episode:

02:48 Protrusive Dental Pearl
04:37 Lukasz Lassman’s Journey and Philosophy
08:11 Debunking Myths About Vertical Dimension
12:10 Patients in the Red Zone
23:15 The Role of Diet and Lifestyle in Facial Pain
31:38 Adapting to New Restorative Methods
34:41 Phonetic Challenges in Dentistry
39:02 The Role of Occlusion in Bruxism
41:18 Palpating Lateral Pterygoid Muscle
43:27 Centric Relation vs. Equilibration Debate
50:07 OVD Red Flag: Airway
01:03:27 Conclusion and Future Events

Studies Mentioned:Gut Bless Your Pain—Roles of the Gut Microbiota, Sleep, and Melatonin in Chronic Orofacial Pain and Depression

Randomised controlled trial on testing an increased vertical dimension of occlusion prior to restorative treatment of tooth wear

???? Upcoming Talks & Courses

AES Annual Meeting 2026: The Evolution of Oral Physician – February 18-19, 2026
Lassmann Education: SummerCamp 2025

If you loved this episode, be sure to watch Myth Busting Occlusion and TMJ – PDP022

PDPMainEpisodes #OcclusionTMDandSplints

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 180 OCCLUSION (Occlusal therapy)

Aim: To enhance clinical understanding of occlusal principles, vertical dimension management, and red flag indicators that impact prosthodontic and TMD treatment, based on current best evidence and insights from Dr. Lukasz Lassmann.

Dentists will be able to –

Identify common myths and misconceptions about vertical dimension increase and temporization.
Recognize red flag patient presentations that are not suitable for prosthodontic treatment.
Understand the airway implications of increasing vertical dimension and how mandibular rotation impacts it.

Click below for full episode transcript:Teaser: This is insane. You know, I was always asking, what do you mean progressively you want to increase first like two millimeters and then you want to check if it's all right. If there is no joint pain or- I never start doing prostho or ortho when my patient has pain. I first want to turn my patient to be asymptomatic and then we go ahead.

Teaser:On the first appointment, you are explaining on the second one you are justifying. We don’t want to tell our patients that this is because of the systemic disorders or some psychiatric disorders because we, ourself, we consider it is like showing the white flag that we just confessed that we don’t know the answer we do. If your patient has a problem with the bladder, you as a dentist, you’re not treating the bladder, but you just refer the patient to the proper doctor. Right?

Jaz’s Introduction:Stop placing your patients on long-term provisionals, or even worse, giving them an occlusal appliance. If the sole reason you’re doing it is to test the OVD.

Hello, Protruserati. I’m Jaz Gulati. Welcome back to your favorite dental podcast with an absolute superstar, Lukasz Lassmann. I remember meeting him in 2019 in Dubai on a course, and he just blew my mind. His cases are spectacular, and honestly, I have no idea how this guy does it. You guys say Jaz, how do you do it?

I look at Lukasz and think, how do you juggle everything, PhD, three kids, everything he’s doing in progressing education and occlusion. Absolutely inspiring guy. And yes, of course, we asked him how does he do it? This episode is one of the AES special episodes to shine a light on the AES 2026 conference where Lukasz Lassmann himself will be doing the closing act.

Me and Mahmoud, we got the paracetamol on day 2, AM but don’t worry, me and Mahmoud will try and keep you awake. But Lukasz is the main act and deservedly so. And this episode will give you an insight into his thinking, the work he does, the kind of patient he sees, including at the very end, he will just blow your mind.

It’s a way of checking your patient’s actual airway while they’re laying down in your dental chair, this video at the end, he shares it’s absolutely golden. For those audio listeners, that part lasts for 10 minutes, is on video only because I didn’t want you guys to feel alienated. But for those video watches you are in for a treat at the end.

So my friends, me and Mahmoud on this episode, we asked Lukasz so many questions. It was quite a broad overview and some were quite basic things and some were quite advanced things. And I’ll kind of like chime in now and again just to make a few things tangible because when we talk about occlusion, things can get a little bit saucy, a little bit too excited sometimes.

So we’ll just bring it back down a few pegs now and again with a little interject, which I hope will be helpful. And if it is, please comment below and let us know if it is we discuss real world things like if your patient has a click, does that mean we need to intervene before they have orthodontics, or is it okay for them to have a asymptomatic click?

You’ll also find out how many patients bruxism, me, Mahmoud, and Lukasz have cured from doing a full mouth rehab or an equillibration. Okay, tell you what. I’ll give you the answer. It’s zero. So find out why we believe that in our experience so far, that perfecting someone’s occlusion will not necessarily stop their bruxing.

And I know some of my dear friends and mentors are, are probably about to throw a brick at the screen here or smash their headphones. Let’s try and stay friends, everyone. I know everyone’s got different mixed views when it comes to occlusion, but everyone just take a breath. woosah-woosah. Take a breath. It’s gonna be okay.

Just hear us out. And of course, we’re gonna give you the number one reason not to raise a patient’s vertical dimension. Why by raising their vertical dimension, you might actually be killing your patient a slow and miserable death. All that, and much more to come in this episode.

Dental PearlNow every PDP ep...

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Should You Invest in Chairside Milling or 3D Printing?

How do milling and printing compare in durability and cost?

Which option provides the best long-term ROI for your workflow?

In this deep dive, Dr. Rustom Moopen shares his experience with CEREC, ExoCAD, and in-house fabrication, breaking down the real benefits and limitations of both technologies.

From restoration strength to efficiency and investment costs, this episode unpacks what every dentist needs to know before taking the leap into milling, printing, and CAD/CAM workflows.

https://youtu.be/fgQnrDfXnqIWatch PDP224 on YoutubeProtrusive Dental Pearl: Achieving the same effect (of the ‘Soft Clamp’ by Kerr) with a metal clamp without requiring a potentially painful palatal injection – Dr. Jo Cape (Protruserati) suggests using a cotton bud to apply topical anesthetic to the gingiva where the clamp will be placed, leaving it for a minute, improving patient comfort!

Need to Read it? Check out the Full Episode Transcript below!

Key TakeAway:

Investing in technology like milling can lead to a measurable ROI.
Time management is crucial in dental procedures for efficiency.
Milling is a subtractive process, while printing is additive.
Mentorship is often more valuable than formal courses.
The dental industry is evolving with new technologies.
Understanding the nuances of dental procedures can enhance practice.
Early adoption of technology can set a practice apart.
Milling and printing serve different purposes in dental work.
Mock-ups can save time and improve patient satisfaction.
Milling offers more reliability than printing for dental applications.
The choice between milling and printing depends on personal preference and practice needs.
Milled composites have a proven track record of durability.
Printed splints may not hold up under heavy use.
Investing in milling technology can enhance practice efficiency.
Design software plays a crucial role in modern dentistry.
Understanding the strengths and weaknesses of each method is essential for success. Investing in dental software can be costly but worthwhile.
Learning design software is crucial for modern dentistry.
Milling is generally superior to printing for final restorations.
Regulatory considerations are important for in-house lab work.
Choosing the right milling equipment depends on practice needs.
Training and mentorship are essential for mastering dental technology.

Highlights of this episode:

03:29 Protrusive Dental Pearl
04:59 Meet Dr. Rustom Moopen: Journey of Learning and Mentorship
09:21 Early Adoption of CAD/CAM Technology
11:54 The Practicalities of Chairside Milling
19:01 Emax Chairside Workflow
23:10 Printing vs. Milling: Understanding the Basics
26:48 Printed Mock-Ups and Workflow Integration
29:43 Comparing Milled and Printed Composites
32:07 The Future of Splints: Milling vs. Printing
35:50 Choices After Scanning a Tooth
37:16 Milling vs. Printing: Pros and Cons
41:11 Design Software and Training
49:28 Practical Applications of 3D Printing
53:42 Investing in Digital Dentistry
55:35 Printed Restorations vs Direct Composite
56:45 Regulatory Concerns
58:31 Investing in Milling Units
01:00:53 Ideal Candidates for Milling
01:03:49 Training and Resources

If you enjoyed this episode, don’t miss PDP137 – Q&A with a Dental Technician!

PDPMainEpisodes #BreadandButterDentistry

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 130 ELECTIVES (Product/technology training)

This episode aimed to provide an in-depth understanding of the fundamentals of 3D printing, milling, and digital dentistry, enabling clinicians to integrate these technologies efficiently into their workflow for improved precision, cost-effectiveness, and patient outcomes.

Dentists will be able to –

Differentiate between 3D printing and milling, understanding their respective strengths, limitations, and applications in dentistry.
Recognize the financial implications, including initial costs, long-term savings, and return on investment when incorporating digital fabrication.
Understand the workflow of chairside milling, including preparation, scanning, design, fabrication, and finishing of restorations.

Click below for full episode transcript:Teaser: It makes you better because you're making your own work. Okay. So your preps get better straight away 'cause you are designing everything, you understand things better and you also gotta think that immeasurably because you are faster at everything, 'cause you're doing things the same way. Then you're getting paid more to do the same thing.

Teaser:You are saving on time. Again, time comes back to time. That’s important, how you want approach it. What’s the best way for you for your personal preference as a dentist? So like, cost doesn’t, so they do a lot of IM sort of stuff. And I’m part of that group and I see people just pumping out like beautiful stuff for me.

For me, I like it, but it is very hard for me as though I just don’t see the benefit for me personally, because I would rather just mill it or print it and it makes my life easier. It’s just that the problem with all these really fast growing industries is that you don’t have long-term studies.

You don’t know for sure how long things are gonna last. You could spend 12 grand than pay like thousand pounds for each bottle of resin and then you’re like, okay, I’m gonna replace all these things in two years. Then what’s the point of that? Like, you’ve lost that money and then you’ve lost more money and you’ve lost time as well.

Jaz’s Introduction:Protruserati, I don’t know about you guys, but I am a noob when it comes to 3D printing, milling, and my limit of digital dentistry at the moment is my scanner. Right? My intraoral scanner is great. I’ve been using it for several years. Absolutely hate taking impressions now, obviously, but when it comes to this whole other world of actually production, right?

Printing stuff, milling stuff, man, I have no idea. And so I am so, so pleased to share this episode with you today. I have Dr. Rustom Moopen, who not only is one of the biggest geeks you’ll ever meet, but he’s a geek in a way that he’s not gonna lose you, right? He’s not gonna talk about like, molecule size of resin and different chips that you need for different printers and processing speeds and that kind of stuff.

In this episode, he will legit tell you why he thinks milling is better than 3D printing. But of course, what is the limit of 3D printing? What can be done with milling and how’s actual software and design part work as part of the workflow. Of course, you’d be wondering how much does this all cost? ‘Cause it doesn’t sound cheap and it isn’t, but it may work out more cost effective for your clinic.

There’s a few things I love about our guest, Rustom and I mentioned it right at the beginning of our chat. You know how I’ve shattered him in the past and saw the CEREC in action, how he really inspired me. I never really then got into the CEREC, but you could see him absolutely flying and he just gets a huge kick of having all these toys.

And importantly, with all these toys and different brands of toys he has, he’s not sleeping with anyone. He’s very unbiased. He’s very real talk and he’s just genuinely helpful. A really good argument Rustom makes in this podcast episode is that when it comes to his sphere of digital dentistry, printing, milling, a lot of people are very secretive about their knowledge.

They put up barriers so that then you have to do these curriculums and courses to be able to gain what he thinks is very basic knowledge. So I’m really hoping that this is the episode that finally brings it all together, and you’ll be amazed with everything that Rustom shares. It just makes so much sense, and he just gives it all away. And that’s just the kind of guy he is. He’s not only a phenomenal clinician, but he’s really, really caring and giving, and that shines through this episode.

Dental PearlOf course, I give you a Protrusive Dental Pearl, and I’m proud today to give you one from our community. Our community is called protrusive Guidance. There’s over 3000 of the nicest and geekiest dentists in the world, and what I like to do is I like to keep it as a little family, right? I don’t try and invite every single dentist I have ever met onto the community.

I actually want you guys to self-select yourselves. If you identify yourself as nice and geeky, and you crave this forum and this chat group in this lovely app that we have on iOS and Android, and of course on the laptop, you go to wwww.protrusive.app, you can access our entire web app, which is very powerful.

Then it’s like a treasure trove of all the content we made over the years. Our special webinars that we have, our paid masterclasses, everything is on there, but the magic of people and t...

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“Jaz, I don’t know which course to take?”

“Should I do Aspire Academy, Kois, Chris Orr or Paul Tipton?” (all great courses and legends by the way!)

Of course its confusing – there are now more ‘Level 7 Diplomas’ than Dentists!

There are also lots of biased testimonials – surely they can’t ALL be the ‘best course I ever did?’, right?

So just HOW do you choose the right postgraduate program to elevate your skills?

What mindset helps new grads thrive, especially when they’re feeling stuck?

This episode shares Lakshmi’s decision making as she opted for the RipeGlobal Fellowship.

Lakshmi’s journey is a perfect example of how the right mindset and a strategic approach to education can transform your dental career. Jaz and Lakshmi discuss her experience of choosing the right course, enrolling in the Ripe Global Restorative Fellowship, and the challenges she faced along the way.

They also talk through the importance of ongoing learning, the impact of mentorship, and how Lakshmi’s mindset shift helped her grow as a dentist. Whether you’re a new grad or seasoned dentist looking to upskill, Lakshmi’s story will inspire you to take control of your career growth and make the most of every opportunity.

https://youtu.be/waC_kQJhcioWatch IC059 on YoutubeBook a free video consultation with the RipeGlobal Team to see if this course is right for you: protrusive.co.uk/RGdiscount

This is an affiliate link that gets you 20% OFF if you enrol – but you first need to discover if it’s the right course for you (it involves treating a manikin in your own clinic!)

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Hands-on experience is crucial for building confidence in clinical skills.
Finding the right practice is important for professional growth.
Investing in continuing education is vital for skill enhancement.
Mentorship plays a vital role in navigating early career challenges.
A supportive team can significantly impact a dentist’s experience.
Understanding one’s learning style is key to effective training.
Practical learning enhances engagement and application in real scenarios.
Balancing time commitments is essential for managing a demanding course load.
Choosing a course that aligns with one’s career goals is vital for success.
Maintaining a passion for one’s work contributes to success.
It’s important to reflect on personal growth and set achievable goals.
The journey in dentistry is not linear; expect ups and downs.

Highlights for this episode:

02:29 Lakshmi’s Journey and Dental School Experience
06:45 First Year as a Dentist
12:01 Finding the Right Practice
19:49 Considering Advanced Courses
25:36 Choosing RIPE Global Fellowship
29:21 Lakshmi’s Hands-On Experience with Ripe Global
37:40 Challenges and Growth in the Fellowship
42:37 Balancing Life and Professional Growth
52:57 Mentorship and Personal Development
54:41 Future Aspirations and Final Reflections

This is a non-clinical episode without CPD. For CPD or CE credits, visit the Protrusive Guidance app—hundreds of hours and mini-courses await!

Stay up-to-date with Dr. Lakshmi’s valuable content and expert advice! Follow her on Instagram!

If you loved this episode, be sure to check out another epic episode – Non-Clinical Growth for the Busy Dentist (Your Health, Relationships, and Business) – IC023

InterferenceCast #CareerDevelopment #BreadandButterDentistry

Click below for full episode transcript:Jaz's Introduction: Hello, Protruserati. I'm Jaz Gulati, and welcome to the introduction of the Introduction, I guess. I think this episode deserved an extra bit right at the beginning to let you know what's in store for you by listening to this episode. Look, the number one question I've been asked for years and years and years is, which course should I do?

Jaz’s Introduction:What’s the best course you went on? What’s the number one course I should be doing right now in my stage of my career and literally daily basis? And it’s a tough one ’cause I need to do some like discovering about you. I cannot answer what’s the best course for you until I learn more about you. So anyway, back to this episode.

A similar interaction happened between me and our guest Lakshmi. And at that time, some years ago, I recommended that she did the Ripe Global fellowship. And so this episode is all about how it went, was my recommendation. Good. And that recommendation was given to her purely based on some of the things that she requested.

Now I’m gonna tell you now that for every single person, that course would look different based on what’s important to you and what kind of learner you are. Some people absolutely smash through online learning, whereas other people really struggle to get the time and to make online learning a priority.

Some people absolutely hate traveling and therefore the online world is well worth it. And believe it or not, there are some colleagues who don’t really need the hands-on so much ’cause their philosophy is, once I understand what I’m doing, once I know what I’m doing, the one or two times you get to do it on hands-on isn’t gonna make a big difference.

‘Cause really practice makes perfect and it’s important I get stuck in with patients and develop that over the next few years, whereas others absolutely need must have loads of hands on. Otherwise they don’t truly grasp the concept of what they’re learning. So everyone’s different and we’re very fortunate that we’ve never had more courses on the planet than today, honestly.

And that number is probably going up and up and up. There are courses everywhere, which actually makes it a bit of a challenge. It confuses us even more about which one to do. Now, I dunno exactly about those in Australia, USA, India or wherever you are in the world, but in the UK we have some brilliant educators.

Like I never did Aspire by Richard Porter and Raheel. I never did Chris Orr’s Continuum, but these are some huge courses that I always hear great things about. Also, Monica Vasan Continuum. So, so much great choice in the UK. Also, shout out to the ACE Academy in London. Look, the list is endless.

There are some great courses out there, but what I want to think about is to decide what’s the best course for you. Figure out what kind of a learner you are. Speak to as many people as you can who’ve done the course. See if it works out with your family life and your logistics and your geography. Try and find out how many people are at the course and what’s like the ratio between educators and learners.

For me, when it gets to more than 12 learners per educator, on some course I’ve been on, like in hotels where there’s been like, 30, 35 delegates and one educator, I haven’t been the biggest fan of that. I also wanna know what is the educator doing? Like how much do they care about your success?

It’s a difference between you being on a course and every opportunity, the educators like somewhere else. Their minds elsewhere, they’re on their phone versus the educator being in your face and really wanting you to grasp every single concept and what are the values and what’s the person like, what is that educator like?

Are they your cup of tea? Can you relate to them? Do they inspire you? Some of the best courses and where I learned the most is when I actually really admired the person. This person inspired me in their personal life and their philosophy and their values, and I often gain more because of that. So please don’t think that just ’cause we’re talking about the Ripe Global Fellowship, that this may be the right one for you.

I want you to do your own research and find out what kind of learner you are. You should know that I have been an educator in Ripe Global before. I’m a shareholder of Ripe Global and I bloody love Lincoln Harris, Michael Frazis, Michael Melker, all these guys behind Ripe Global. And I think it’s an important duty for me to tell you that before we dive into the episode.

And one last thing, just yesterday, I was at my wife’s graduation, right? She got awarded her masters in pediatric dentistry at the Eastman Dental Institute. Very, very proud of my wife. It was no easy feat. It was very tough, with two kids. She was exclusively breastfeeding my second born during her final year, and she came out with a distinction.

So ever so proud of her. And for her, the MSC was a great choice. She liked having that contact time. She was able to do her like online lessons when there wasn’t any contact time. But was there much hands-on? No, it was a lot of reading and research and that kind of stuff. You have to relook at these programs.

Do you actually get to treat patients or not? So there are really pros and cons, but now some of the opportunities she’s getting ...

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Which imaging techniques should you prioritize for TMD patients? Does a panoramic radiograph hold any value?

When should you consider taking a CBCT of the joints instead? How about an MRI scan for the TMJ?

Dr. Dania Tamimi joins Jaz for the first AES 2026 Takeover episode, diving deep into the complexities of TMD diagnosis and TMJ Imaging. They break down the key imaging techniques, how to use them effectively, and the importance of accurate reports in patient care.

They also discuss key strategies for making sense of MRIs and CBCTs, highlighting how the quality of reports can significantly impact patient care and diagnosis. Understanding these concepts early can make all the difference in effectively managing TMD cases.

https://youtu.be/NBCdqhs5oNYWatch PDP223 on YoutubeProtrusive Dental Pearl: Don’t lose touch with the magic of in-person learning — balance online education with attending live conferences to connect with peers, meet mentors, and experience the true essence of dentistry!

Join us in Chicago AES 2026 where Jaz and Mahmoud will also be speaking among superstars such as Jeff Rouse and Lukasz Lassmann!

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Imaging should follow clinical diagnosis → not replace it.
Every imaging modality answers different questions; choose wisely.
TMJ disorders affect more than the jaw → they influence face, airway, growth, posture.
Think beyond replacing teeth → treatment should serve function, not just fill space.
Avoid “satisfaction of search error” → finding one problem shouldn’t stop broader evaluation.

Highlights of this episode:

02:52 Protrusive Dental Pearl
06:01 Meet Dr. Dania Tamimi
09:04 Understanding TMJ Imaging
16:00 TMJ Soft Tissue Anatomy
21:04 The Miracle Joint: TMJ Self-Repair
24:26 The Role of Imaging in TMJ Diagnosis
28:15 Acquiring Panoramic Images
39:35 Guidelines for Using Different Imaging Techniques
41:26 Case Study: Misdiagnosis and Its Consequences
45:46 Balancing Clinical Diagnosis and Imaging
50:17 Role of Imaging in Orthodontics
53:18 The Importance of Accurate MRI Reporting
58:27 Final Thoughts on Imaging and Diagnosis
01:00:54 Upcoming Events and Learning Opportunities

???? Upcoming Talks & Courses by Dr. Tamimi???? AES 2026 Conference (Chicago):

Topic: “Telling the Story of Your Patient Through Imaging”
Focus: Understanding patterns in imaging and how they reveal the patient’s full clinical picture

???? “How to Read a Cone Beam CT” Virtual Course (Concord Seminars)

If you enjoyed this episode, don’t miss out on [Spear Education] Piper Classification and TMJ Imaging with Dr. McKee – PDP080.

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A, B, and C.

AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Imaging techniques)

Aim: To enhance clinicians’ understanding of TMJ imaging modalities, improve diagnostic reasoning, and empower dental professionals to make evidence-based imaging decisions for temporomandibular joint disorders.

Dentists will be able to –

Differentiate between panoramic radiography, cone beam CT (CBCT), and MRI for TMJ evaluation.
Identify the appropriate imaging modality based on specific TMJ diagnoses (e.g., soft tissue vs. hard tissue pathology).
Recognize the risks of under- and over-imaging and apply a diagnostic question-driven approach to imaging selection.

PDPMainEpisodes #OcclusionTMDandSplints #OralSurgeryandOralMedicine

Click below for full episode transcript:Teaser: We do need to make sure that our teeth are in an orthopedically stable situation. And you should never trust what you see in the mouth 'cause the teeth may fit beautifully. But if the condyles aren't seated properly in the fossa, then it's like basically having a house built on quicksand. And this is a big thing that I see a lot in orthodontic treatment and others, they're just thinking about, alright, let's fix these.

Teaser:And they’re not paying attention to the foundation of the house. The teeth are the window dressing. You are not a carpenter, even a carpenter diagnosis. You need to diagnose your patient prior to doing anything to them, to figure out what really is going on.

Medicine, including dentistry is seven parts, diagnosis, two parts treatment planning, and one part execution. So if you get all that, those first nine parts wrong, you’re not treating the patient. You may be treating a symptom, putting a bandaid on something, but you’re not getting the full picture. But we’re really storytellers, we’re detectives and we are looking at the imaging to try to find the stories and the history that the patient can’t verbalize themselves.

Jaz’s Introduction:In our day-to-day dentistry, we take bite wings, we take periapical, and if you’re lucky enough to have a panoramic or a CBCT machine, we may take some of those. But what do we do when we have that TMD patient, TMD, obviously being an umbrella term. Listen to a lot of the other episodes on this podcast.

Learn more about TMD and how we can help as general dentists. But the question we’re really going to explore in today’s episode with an absolute sensational guest, the author of this book right here for the audio listeners is Temporomandibular Joint and Sleep Disorder Breathing by Dr. Dania Tamimi. And let me tell you guys, you are in for an absolute treat in today’s episode.

Some of the analogies she uses and the ways to explain certain elements of TMD, like for example, the clicking joint or the posh way of saying it is disc displacement with reduction. And so many colleagues get confused with that part with reduction. They still have no idea what it means. I’ve spoken to board certified prosthodontists on the phone and even they have been confused about what this actually means.

And so what Dr. Tamimi does in this episode is gives you one word to substitute in a way that suddenly all of this makes so much more sense. All her analogies are brilliant and we will explore, does a panoramic radiograph have value? When should we be considering taking a CBCT of the joints instead?

And are there any special instructions when doing so? And when do we need to take an MRI scan for the TMJ? And a little bit of the spoiler alert. My experiences with the MRIs have been just crazy in the sense that the person who reports it, will make a huge difference to the diagnosis. Let me say that again.

If you send your patient for MRI of the TMJs, well done. You might have helped it. And for the certain patient, we may be getting closer to the truth or to diagnosis, but the report can be so shockingly poor in my experience that, that MRI report ends up being a waste of money. I’ve seen this a few times down in my short career so far, and we discussed that.

I confronted the radiologist, Dr. Tamimi, on why this is happening and she had a really good answer actually. So get those onions ready, Protruserati, lots of chopping to do as you listen to these gems.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is the first AES takeover every year the AES put on a show in Chicago around about the second, third week of Feb, and Dr. Tamimi is one of the guests. And so what we’re doing basically is we’re getting on these absolute superstars in the world of occlusion comprehensive dentistry to create these awesome and engaging podcasts, but also shine a light on the good work done by the AES. Our guest today, Dr. Dania Tamimi, is one of the speakers, and guess what?

Yours truly me and Mahmoud will also be speaking at the AES 2026 in February. Our topic is Occlusion Basics and Beyond. Basically, we wanna put something together for the younger colleagues and cover the foundations of occlusion that you can apply on Monday morning. But the AES has a reputation of actually being leading and at the cutting edge of comprehensive dentistry.

Let me just talk you through the lineup, right? So this is the Protrusive Dental Pearl, by the way, get yourself to AES 2026. Okay, well, I’m kind of kidding, but I’m kind of not. Okay. The real Protrusive Pearl behind this is don’t lose touch with the magic of in-person learning and the magic of conferences where you get to meet your peers. Online is great.

I’ve been a fan of online since I graduated, but I also mixed it with in-person events. Obviously, minus covid. If all you’re doing is going to in-person events, then you’re missing out a lot online. And if all you’re doing is sat in front of a laptop watching videos and webinars, you are really missing the true essence of dentistry, which is the people around you, the new and old friends that you get to see, and the connect...

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Why do some patients struggle with anesthesia, requiring multiple cartridges just to get numb?

Could your TMD patients have an underlying systemic condition that’s been missed?

Are you overlooking the signs of a connective tissue disorder?

https://youtu.be/gaoJKPTV_Z0Watch PDP222 on Youtube”When you can’t connect the issue, think connective tissue!”

Dr. Audrey Kershaw joins Jaz for a fascinating deep dive into the world of connective tissue disorders and their hidden impact on dentistry. Together, they explore how hypermobility, unexplained joint issues, and even a history of spontaneous injuries could be key indicators of an underlying disorder.

They also break down why dentists play a crucial role in screening and identifying these conditions, ensuring better patient outcomes and a more holistic approach to care. Because sometimes, when things don’t seem connected… they actually are.

Protrusive Dental Pearl: Don’t just take a “relevant” medical history—take a comprehensive one! Encourage patients to share all health issues, even those they don’t think relate to dentistry. You might uncover important clues about conditions like connective tissue disorders or sleep-disordered breathing, leading to better care and stronger patient trust.

Need to Read it? Check out the Full Episode Transcript below!

Key Take-aways

Ehlers-Danlos Syndrome is often misunderstood and underdiagnosed.
Patients with connective tissue disorders often face skepticism from healthcare providers.
POTS is a common condition associated with EDS that affects blood pressure regulation.
Many TMD patients may have undiagnosed connective tissue disorders.
Awareness and education about EDS are crucial for better patient outcomes.
The healthcare system can be challenging for patients seeking diagnoses.
Research on local anesthetic effectiveness in EDS patients is lacking.
Personal experiences can help in understanding and diagnosing connective tissue disorders.
Collaboration between healthcare professionals is essential for patient care. Genetic testing is crucial for diagnosing rare types of Ehlers-Danlos.
Dental professionals should be aware of the signs of connective tissue disorders.
Diagnosis can empower patients to understand their health better.
Holistic care is vital in managing symptoms associated with EDS and TMD.
Medical histories should be seen as relevant in dental practice.

Highlights of this episode:

02:17 Protrusive Dental Pearl
04:21 Dr. Audrey Kershaw’s Journey and Insights
09:45 Personal Experiences and Professional Observations
11:55 Diagnosis and Management of Connective Tissue Disorders
13:31 POTS (Postural Orthostatic Tachycardia Syndrome)
15:30 Understanding Ehlers-Danlos Syndrome (EDS)
24:55 Hypermobile EDS and the Need for Awareness
27:53 International Consortium of EDS GP Checklist
28:34 Genetic Testing and Red Flags
31:44 The Role of Dentists in Identifying EDS
40:32 Journey to Diagnosis
43:47 The Value of a Diagnosis
48:43 Dental Implications of EDS
55:00 Final Thoughts and Resources

“If you know one case of EDS, you only know one. Every case is different. Many are severely debilitated, unable to work or carry out daily tasks, often denying their struggles after years of being dismissed.” – Dr. Audrey Kershaw

Promised Resources

Podcast Recommendation:

Linda Blustein’s Podcast (about POTS and connective tissue disorders)

Specialists & Research:

Dr. Alan Hakim – A specialist in Ehlers-Danlos Syndrome (EDS) research based in London.
Norris Lab (U.S.) – Researching genetic markers for hEDS
Local Anesthesia Information

Resources for Screening & Diagnosis:

Diagnostic Criteria for Hypermobile Ehlers-Danlos SyndromeDownload5-part-questionnaire-for-hypermobilityDownloadSymptomatic Joint-Hypermobility GuideDownloadRed Flag PatientsDownloadEducational Conferences & Talks:

Scottish Dental Show – Audrey is involved in raising awareness at this event.
Podcast with Periodontist Reena – Discussing HbA1c meters for diabetes screening in dental practice.
“If you can’t connect the issues, think connective tissues”. An EDS talk for professionals.

Advocacy & Support:

Learn more about EDS and Dr. Audrey Kershaw
Ehlers-Danlos Support UK Scotland – Audrey collaborates with them for better patient care pathways.
EDS PATIENT EMAIL Template April 2025
GMP EDS EMAIL TEMPLATE April 2025
Connect with specialists like Dr. Audrey Kershaw

Pack to aid identification of possible HCTD/EDS cases in the dental setting

Watch YouTube video made for Prof Tara Renton, by Drs Kershaw and Bluestein
Read this – https://gptoolkit.ehlers-danlos.org/
Fill out Oral Surgery Scotland Advanced Medical History Form
Fill out this – International Consortium of EDS GP Checklist

OR use this link – https://apps.apple.com/app/id6642710534

If appropriate, give patient EDS information email EDS PATIENT EMAIL Template April 2025
Send email to GMP GMP EDS EMAIL TEMPLATE April 2025
For any issues, or feedback, please contact Dr. Audrey Kershaw

If you loved this episode, make sure to watch Periodontal and Systemic Link – Correlation or Causation?

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 150 Health medicine and nutrition

Aim: To enhance dentists’ awareness and understanding of connective tissue disorders (CTDs), particularly Ehlers-Danlos Syndrome (EDS), and their impact on dental treatment, local anesthesia effectiveness, TMD, and overall patient care.

Dentists will be able to –

Identify key dental manifestations of EDS, including local anesthesia failure, TMD, and periodontal considerations.
Apply a multidisciplinary approach to managing complex TMD cases with suspected connective tissue involvement.
Appreciate the dentist’s role in identifying and supporting patients with suspected connective tissue disorders.

PDPMainEpisodes #BestofProtrusive #BreadandButterDentistry

Click below for full episode transcript:

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Can composite really outperform ceramic in the right case?

Do you know when to choose an inlay over an onlay?

What makes occlusal veneers so effective — even at just 0.6 mm thickness?

After years of anticipation, Dr. Pascal Magne finally joins Jaz Gulati on the podcast for an episode packed with adhesive dentistry gold. They dive deep into occlusal veneers, material selection, and why indirect composite may be the best-kept secret for worn, root-filled molars.

They also unpack the full bonding protocol step-by-step—from air abrasion and IDS to silane application and cementation with preheated composite. Whether you’re doing full rehabs or composite repairs, this episode is your go-to guide for smarter biomimetic dentistry.

https://youtu.be/WTsF1mD-nToWatch PDP221 on YoutubeProtrusive Dental Pearl: After applying silane, don’t just let it evaporate—let it react for 30 seconds, then air dry, and crucially, use a heat source (like a hairdryer) for 60 seconds to activate it properly and achieve optimal bond strength. This enhances the effectiveness of silane and significantly improves the bond strength of indirect restorations like composite or lithium disilicate.

Key Takeaways:

Occlusal veneers can be as thin as 0.6 mm.
Indirect composite is often a superior choice for restorations.
Proper bonding protocols are crucial for successful restorations.
Focusing on strengths rather than weaknesses is key in dentistry.
Conservative approaches in dentistry can preserve tooth structure.
The vital tooth is always preferable to a non-vital tooth.
Composite resin has wear properties similar to enamel.
Occlusal veneers provide excellent protection for compromised teeth.
Porcelain veneers have long-term durability compared to composites. The evolution of composite materials has led to better options for restorations.
Zirconia is strong but difficult to adjust and bond effectively.
Immediate dentin sealing is crucial for successful bonding and patient comfort.
The Dahl principle allows for minimal preparation in certain cases.
Composites can be as effective as ceramics when used correctly.
Understanding the properties of materials is essential for successful restorations.
Thin occlusal veneers can be successfully bonded with proper techniques.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

0:00 Introduction
02:52 Protrusive Dental Pearl
04:42 Dr. Pascal Magne on His Current Focus
10:16 Understanding Cusp Coverage and Material Choices
15:48 Conservative Approaches in Dentistry
23:16 Unsupported Enamel: Can it Still be Reinforced?
28:05 Occlusal Veneers Indications
37:00 Material Selection: Composite vs Ceramic
01:24:42 Outro

Referenced Studies – all below are available to download on Protrusive Vault in Protrusive Guidance

Effect of immediate dentine sealing on the aging and fracture strength of lithium disilicate inlays and overlays
Short-fiber Reinforced MOD Restorations of Molars with Severely Undermined Cusps
Ultrathin CAD-CAM glass ceramic and composite resin occlusal veneers for the treatment of severe dental erosion
Strains in the marginal ridge during occlusal loading
Antagonist Enamel Wears More Than Ceramic Inlays
Outcomes of resin-bonded attachments for removable dental prostheses
Performance of ceramic laminate veneers with immediate dentine sealing

Keep the learning going with Magne Education

If you enjoyed this episode, don’t miss A Geeky Discussion on Adhesive Onlays – that’s PDP161!

This episode is eligible for 1.25 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 250 OPERATIVE (RESTORATIVE)DENTISTRY (Indirect restorations)

Aim: To provide clinicians with evidence-based guidance on occlusal veneer indications, material selection, and conservative restorative protocols—emphasizing the role of adhesive techniques and biomimetic principles in long-term success.

Dentists will be able to –

Differentiate between inlays, onlays, and occlusal veneers, and select the most conservative option suitable for each clinical scenario
Make informed decisions on material selection based on occlusal anatomy, antagonist material, and long-term clinical performance.
Assess the biomechanical behavior of composite vs ceramic materials, including their effect on stress distribution and enamel wear

Click below for full episode transcript:Teaser: An onlay is always going to make the tooth stronger than an inlay. However, the chances of catastrophic fractures with an onlay are bigger than with an inlay. And I know it's not unanimous, some of my colleagues, they don't like the fact the composite has a lower elastic modulus. But again, you have to understand a non-vital tooth is a handicapped tooth.

Teaser: So the damping affect the damping behavior of this occlusal volume of composite in our studies actually proved to protect the remaining tooth structure at the level of the root. With the occlusal veneer, there’s no need- Element of biomimetic dentistry is to say that the restoration should be allowed to fail in order to protect the tooth. Zirconia is the opposite.

Jaz’s Introduction:It finally happened. Finally got Dr. Pascal Magne on the podcast. If you remember episode 100, I was in Edinburgh at the BACD in the queue to get my book signed by Dr. Magne. And I said to him, please, will you come on the podcast one day? And that day finally came a few years later than I wanted, but we finally made it guys.

And let me tell you guys, you are in for a treat. We’re talking about occlusal veneers. How thin can you go? Like think of a lower molar that is worn and is spawn into dentine possibly because erosion and attrition and you don’t have much space and you don’t really wanna prep so much, we can go as thin as, let’s say 0.6 millimeters.

And what if I told you, you can do it in indirect composite? And that’s probably in many cases, the preferred choice. At the end of the podcast, we discuss the exact protocol of bonding and indirect composite which actually is also gonna help you if ever you’re doing a composite repair, how to bond new composite to old composite.

Now we covered so many geeky adhesive and restorative themes, like why not use zirconia? Why is indirect composite a superior choice, especially for your root filled molars that need cuspal coverage? Which is interesting because I have been doing lithium disilicate for many years thinking that composite was like a cheaper option, was like a second rate option.

Actually, Dr. Pascal Magne says that if it was his tooth, he’d want indirect composite. Well, you are in the right place to find out why he said that, and also why we should not be so aggressive in capping cusps.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your Favorite Dental Podcast. If you’re returning again, thank you so much for being a Protruserati. If you are new to the podcast, you picked a really good one. I’ll tell you what all our podcasts are awesome, thanks to the wonderful guests we have on, so please don’t forget to hit that subscribe button if you like what you hear or see today.

Dental PearlEvery PDP episode, I give you a Protrusive Dental Pearl, and today’s one is of course inspired by Pascal Magne and an adhesive protocol tip. The tip is when it comes to the silane step, that step is so critical in whether you’re bonding an indirect composite or an indirect ceramic such as lithium disilicate. Once you’ve done the correct surface preparation of your indirect restoration, so that’s different for composite, which you’ll hear at the end, and that’s different for ceramic.

And once you get into the silane stage, here’s what you don’t do. You don’t just apply silane and leave it on the side to let it evaporate. No, you want to let it react for 30 seconds, then you want to air dry it. But then you want to use something like a hair dryer. You need to use some hot air to achieve the perfect layer and the perfect chemistry of your silane.

And this surface preparation with silane, such a critical step that it makes a huge difference in the bond strengths you can achieve. So makes your guys that you are air thinning your silane, and then you’re using some sort of a heat source to achieve that optimal layer. And you’ll hear about the the geeky justifications and the steps for this towards the end of this podcast.

Do not go anywhere, guys. You’re gonna enjoy this a lot. And remember, our episodes are eligible for CE. This episode is worth 1.25 CE credits, and we are a PACE approved education provider on our platform, which is called Protrusive Guidance. The website for that is protrusive.App. That’s www.protrusive.App. You’ll have access to over 350 hours of CE.

This includes the podcast episodes, but also our mini courses and on demand webinars, which are thoroughly enjoyed by ou...

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What is the number 1 communication advice for Dentists?

Are you confident in discussing treatment fees with your patients?

Do you struggle with communicating your worth without feeling awkward?

How do you shift your mindset to charge what you’re truly worth without feeling guilty (a money mindset issue)?

https://youtu.be/vapDrnVqHRwIn this enlightening conversation, Jaz opens up about his own struggles with money mindset and how he overcame them to confidently charge for his dental services.

Joined by dental student Naveed Bhatti, they explore the challenges of pricing treatments, offering empathetic solutions to patients, and using the power of visualization to boost confidence in fee discussions.

They also dive into the importance of being transparent with fees, managing discounts, and recognizing your true value as a dental professional. Whether you’re new to the field or have years of experience, these strategies will help you navigate the financial side of dentistry with ease and confidence.

Key Takeaways

Communication is crucial in dentistry, often more than clinical skills.
Active listening is essential; avoid interrupting patients.
Nervous patients may talk excessively; guide the conversation gently.
Patients may withhold information due to fear or anxiety.
It’s important to make treatment recommendations based on patient needs.
Asking open-ended questions can help gather more information.
Experience builds confidence in patient interactions.
Being authentic while adapting to patients is key.
Patients can sense when a dentist is confident or insincere.
Building rapport leads to better patient relationships. Kindness is essential in patient interactions.
Patients often reflect the values of their dentists.
Effective communication can bridge the gap between jargon and patient understanding.
Long-term relationships with patients enhance trust and satisfaction.
Discussing fees requires confidence and transparency.
Visualization techniques can improve communication skills.
Empathy is important, but it should not compromise business integrity.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

01:46 Introducing Naveed Bhatti and His Journey
02:53 The Importance of Communication in Dentistry (Do’s and Don’ts)
08:13 Handling Nervous and Quiet Patients
10:51 Dealing with Patients Who Don’t Tell the Whole Truth
14:35 Making Treatment Recommendations
17:56 Asking the Right Questions
21:36 Balancing Professionalism and Personal Connection
25:49 Handling Difficult Patients
31:38 Effective Communication with Patients
35:05 Discussing Treatment Fees with Confidence
40:25 The Power of Visualization in Dentistry
48:56 Concluding Thoughts and Future Plans

Support Nav’s YouTube channel, The StuDent

If you enjoyed this episode, don’t miss out on Think Comprehensive – Communication Gems with Zak Kara – PDP010!

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcome B.

AGD Subject Code: 550 PRACTICE MANAGEMENT AND HUMAN RELATIONS

Aim:

To enhance dental professionals’ communication skills by exploring effective strategies for patient interaction, treatment planning, and fee discussions—ultimately building trust, improving patient outcomes, and boosting confidence in everyday clinical practice.

Dentists will be able to –

Recognize the importance of active listening and body language in patient communication.
Explain treatment options using patient-centered language and analogies that promote understanding and buy-in.
Discuss treatment fees with clarity and conviction, addressing money mindset barriers and building perceived value.

Click below for full episode transcript:Teaser: If you ask seven dentists, you'll get 12 opinions. You see what I mean? Right. So firstly, okay, you must appreciate that there are so many opinions out there. Every dentist will give a different opinion, which is absolutely mad to just remember. But then remember that when a patient comes to you, they're coming to you, they're seeking your opinion.

Teaser: They’ve selected you either by a geographical convenience or recommendation or whatever. They now ended up in your chair, right? So, all you are ever giving them is an opinion. That’s it. Okay. Here’s the stupid thing, Nav, right? You say to a patient 120, and they’re still gonna be like, oh, 120. That’s too much, right?

And they didn’t even know that was one 50. You just counted it. The worst you could do is you give a discount, but the patient ever knows that you got a discount. That’s the worst thing, that’s the stupidest thing ever.

[Nav]Well, I’m with you.

Jaz’s Introduction:Patient communication is one of those things that you just don’t get taught at dental school, like a few other things. Again, not their fault. We always talk about it never being the fault of dental school. They just need to make you a safe beginner. But the kind of things we worry about once we qualify is how do we actually make a connection with the patient? How can we communicate fees with the patient? And just how do you communicate the patient’s options without coercing them into a particular treatment or trying to be salesy to a patient.

These are all things I cover with Nav Bhatti. Now, Emma is doing her finals at the moment, so we wish her all the best. You got this, Emma. But I tell you this episode really packs a punch. We talk about body language, we talk about building rapport. We talk about patients that you just won’t get along with and how you should manage those, and how over time your patients become a reflection of you. And interestingly, we also discuss your money mindset. It’s actually important when you’re communicating with key paying patients.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is the student arm, but I tell you, these episodes are not just for students, especially this one. Anyone who’s struggling with communicating fees to patients or anything around being a more effective communicator, I really think you’ll gain a lot from this episode. So make sure you listen all the way to the end.

This one is eligible for CPD or CE credits. There’s only one place you can get that, and that’s on Protrusive Guidance. Please do download the app on. iOS or Android store, but to actually make an account, the best way to do that is on the website. That’s protrusive.app. You can try one of our paid plans, and I’m convinced you’ll love being part of the nicest and geekiest community of dentists in the world. Let’s now join Nav, who’s a dental student in Slovakia. As he asks some truly wonderful questions around patient communication, catch you in the outro.

Main Episode:Nav Bhatti. Today’s filling in for Protrusive Student. Emma is doing her finals as we speak right now. We’re excited to grow this with you as well, my friend. Just remind everyone about yourself, my friend.

[Nav]No worries. I’m trying to fill in for Emma for now, which is huge boots to fill by myself and a fourth year dental student in Slovakia of all places, which is a six year course. So I’m not quite at my penultimate year. But, we are almost there, so, it is going quite well.

[Jaz]And if anyone hasn’t listened yet, we know we talked about your journey right, in a previous episode, and that was really cool. You inspired a lot of people, so please do listen to his backstory, how you went from country to country. And finally, you are still a little bit, few years away still, but your enthusiasm, your passion, your drive is amazing.

[Nav]Thank you. A lot of it I must thank sort of Protrusive as a whole community. Your podcast. It kind of keeps myself and my colleagues sort of kicking, inspires us on a daily basis. I’m not just saying that for the sake of it, it genuinely does to see so many people out there supporting us on our journey is just amazing.

[Jaz]And it’s been nice to also see your contributions on the Protrusive app. Like you took out some teeth recently, you saw some surgery recently, and you’re posting about that. So it’s great to have your student viewpoint. And of course today, probably in the title, this may not even be a Protrusive student episode because communication is communication.

This is like the biggest thing in dentistry is far more important than your clinical skills. I’ll just say that right off the bat. Far more important than your clinical skills. So I’m excited to record this episode with you today and just any questions that you have in this sphere and to take it. So Nav, take it away, my friend. How can we help?

[Nav]For sure. I think communication obviously is huge, as you quite rightly said, but for some weird reason, it’s just never taught. At university, you get all this theory, you get all this clinical kind of workload and they teach you how to do fillings and extractions and whatnot, but they never really get you to communicate with the patient effectively.

So this whole re...

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Are ergonomic loupes and fancy chairs really worth the investment?

Is back pain an inevitable part of being a dentist—or can it be prevented?

Are you setting yourself up for a long, pain-free career in dentistry?

What’s the number one thing you should be doing right now to protect your body for the long haul?

Dr. Sam Cope is back, and he’s not just any dentist—he started as a physiotherapist before training in dentistry. That means when it comes to musculoskeletal health, posture, and career longevity, Sam knows his stuff. In this episode, Jaz and Sam revisit the crucial topic of back pain in dentistry and dive even deeper into what actually works to keep you practicing pain-free.

So, if you clicked on this because you’re worried about back pain, take this as your sign—your future self will thank you.

https://youtu.be/lUC45aLXZKkWatch PDP220 on YoutubeProtrusive Dental Pearl: Motion is lotion. Staying active prevents back pain and keeps your career strong. If you’re not making time for exercise, it’s time to rethink your habits. Knowing isn’t enough—action is what matters. Prioritize your health now.

Key Take-Away:

Posture and back pain have no direct correlation.
Apprenticeships provide invaluable experience and learning opportunities.
Investing time in learning and shadowing can accelerate career growth.
Ergonomic tools can enhance comfort but should be tailored to individual needs.
Mental health is crucial for dentists, and seeking help is a sign of strength.
The human body can adapt to various postures with training.
Choosing a specialization should align with personal interests and strengths.
Preventative measures in ergonomics can improve career longevity.
Continuous learning and adaptation are essential in the dental field. Choosing the right dental chair is crucial for comfort.
Preventative strategies for back pain include regular exercise.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

02:05 Protrusive Dental Pearl
04:26 Sam’s Journey from Physio to Dentist
10:33 The Value of Apprenticeships and Mentorship
16:24 Niching in Dentistry
22:30 Ergonomics in Dentistry: Loupes and Chairs
27:03 Choosing the Right Chair for Your Comfort
29:54 Top Tips for Dentists to Prevent Back Pain

This episode is eligible for 1 CE credit via the quiz below.

This episode meets GDC Outcomes A and C.

AGD Subject Code: 130 ELECTIVES (149 Multi-disciplinary topics)

Aim:

To highlight the importance of ergonomics and physical well-being in dentistry. To share strategies for preventing occupational strain and burnout.

Dentists will be able to –

Assess the role of ergonomic loupes, chairs, and posture in reducing strain and improving long-term musculoskeletal health.
Understand the significance of muscle conditioning over posture correction.
Incorporate exercise routines to manage physical strain during long procedures.

If you enjoyed this episode, you won’t want to miss Got Your Back – Physios and Dentists – PDP025!

PDPMainEpisodes #BeyondDentistry #CareerDevelopment

Click below for full episode transcript:Jaz's Introduction: Over 270 episodes ago, I had on Dr. Sam Cope when he was a a baby dentist, and he's unique because he's a physio who trained to then become a dentist. Back then, we discussed about back pain and dentistry and how to prevent it, and we talk a bit more about those themes today. Are ergo loops worth it?

Jaz’s Introduction:Are those posh Bambach kind of chairs. Are they worth it? What’s the number one advice to have a career with longevity and good health from a back pain perspective and as a physio come dentist, what does Sam do? What are the things that he practices? Because he’s a bit like when Christiano Ronaldo rejoined Manchester United.

He was like a, he was a big deal, right? He is the goat. He’s the greatest of all time. I’m a Ronaldo fan. Anyway, when he was in the canteen of Manchester United, he was like eating with all other players. Everyone just looked at Ronaldo, what was on his plate. They wanted to model Ronaldo. So why do I mention that?

Because I’m looking at Sam, whatever Sam’s doing with his posture, with his back, et cetera, I wanna be doing that because he has the most knowledge. He’s musculoskeletal with his physio background. He’s a really good dentist. So let’s see what advice Sam has for us today. Now, after this episode, if you wanna go deeper into back pain, chronic back pain.

We’ve got Ben Physio and Sam Physio come dentist, that was PDP 025, like I said, over 280 episodes ago. In fact, it’ll be good for you to revisit some of the old episodes to see my journey and the journey of Protrusive now that we have team members and whole production line to bring you all this content.

And a special thanks for all of you that member listening to that episode on Spotify all those years ago. There is some new information, applicable information, and Sam’s no longer a baby dentist. He’s really accelerated a fast rate. So I made a big deal over at the beginning of this podcast to talk about his journey.

Because his journey really exemplifies the advice I give to every single young dentist. I get the question all the time, how do I structure my career? How do I grow at the fastest rate possible? How can I find the right clinic? How can I be doing the more of the higher end dentistry? Well, Sam’s playbook is there, and he shares it with us in this episode. So you’ll get some career advice as always, plus how to get more longevity from your career.

Dental PearlThe Protrusive Dental Pearl is a nonclinical one, and it’s taken from this episode and it’s just something that you already know, but it’s just important to hear again, and that is motion is lotion. Too many of my dentist friends are talking to me and saying that, oh, I just don’t have time to excise, and oh, I really let myself go.

I’m not prioritizing it, and that is the wrong way to go. Your physical health and mental health is super important, but just focusing a little bit on the physical aspect, spoiler alert, that is the number one way to prevent back pain and to give you a career with longevity. And you’ll hear later in this episode whether deadlifts are recommended or not or what’s the best type of exercise.

But as long as exercise is part of your life, and for many of you, you guys are running or jogging when you’re listening to the episode and you guys are already living and breathing that and more power to you. But so many of you in the car on the train, and maybe the most exercise you get is when you are going upstairs and downstairs of your surgery and you need to really reevaluate life and your life decisions and how you may be neglecting your physical health.

Again, it’s stuff we already know, but one of the first dental pearls I ever shared with you may actually have been number one and number two was to know something and not actually do it is as good as not knowing it in the first place.

So Protruserati, I’m trying to look out for you here. Are you making time for physical exercise? Are you practicing motion is lotion? I hope you are, and if you’re not hoping, this is gonna give you to kick up the backside to make some sort of regime, some sort of promise to change that by yourself. Because the reason you clicked on this episode is ’cause something piqued your interest about back pain and having a career with longevity. And if you’re not even doing that, then losing out on so many benefits. Anyway. Hope you enjoyed the rest of this episode. I’ll catch you in the outro.

Main Episode:Dr. Sam Cope, welcome back again to the Protrusive Dental Podcast. So nice to see you and your growth and your journey and to see you live at the Protrusive events on the app and doing wonderful things on social media, my friend. Welcome. How are you?

[Sam]Thanks very much and thanks for having me back on the podcast as well. It’s a real honor I’ve seen, ’cause it was in the early stages that I was on last time and it’s really grown and kind of kicked off.

[Jaz]You were about 270 episodes ago, mate.

[Sam]Wow. Yeah. Crazy a dinosaur.

[Jaz]Well, honestly, you did so well then. But there’s some unfinished business, right? The unfinished business is a little bit of a stir that we created and we talked about being no correlation between bad posture. Back pain. Okay. So we wanna just talk a little bit about that, little finer points about that, and also just revisit your journey from physio to dentistry.

But now that you’ve been in the game for a bit longer, right? How do you feel? Do you have any regrets and that kind of stuff. And I hope you like the title of this podcast, My Neck, My Back Fix your posture while removing plaque. I just wanted to go into some sort of a funny theme, but Sam, for those who didn’t listen to that episode, looking at back pain, it was two guests I had at the same time. And so for those who haven’t listened to that, please do check it out, but just remind us about your journey and where you practice today?

[Sam]Yeah, so I started off, I did physiotherapy at King’s from 2011 to 2014, and I actually met some, I was on a course this weekend and met somebody that was there at the same time who was doing dentistry at the same time.

And ...

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Are “contact lens veneers” just fake news?

Why is the traditional 0.7mm prep approach outdated?

Are you truly preserving enamel in your veneer preparations?

Should you ever bond veneers to root dentin or cementum after crown lengthening?

Why is the Galip Gürel technique the gold standard for minimal prep veneers?

https://youtu.be/5BEFD1XaZtEWatch PDP219 on YoutubeDr. David Bloom joins Jaz for an insightful episode, sharing his 36 years of experience in cosmetic and restorative dentistry. With over two decades in the same practice, he’s seen what works—and what leads to failure—when it comes to veneers.

We also cover the key steps in mock-ups, planning, and veneer preparation.

Protrusive Dental Pearl: Always Wax Up for 10: When planning veneers, start with a 10-unit wax-up (even if the patient initially wants 4 or 6). This allows them to visualize their full smile with a mock-up, compare different options, and make an informed decision. It’s not about upselling – most patients will appreciate the fuller look.

Key Take-aways:

Health and diagnosis are foundational in cosmetic dentistry.
Visual try-ins are crucial for patient engagement and satisfaction.
Minimally invasive techniques are preferred for cosmetic procedures.
Communication with patients about their options is essential.
Bonding to enamel is more reliable than bonding to dentin.
Permission statements help in guiding patient expectations.
The transition from veneers to crowns should be carefully considered.
Staining is not the primary concern when bonding to dentin.
A change in surface texture is key in modern dental preparations. Visual aids are crucial in helping patients understand their treatment options.
The Gurel technique emphasizes minimal preparation for veneers.
Effective communication with patients can enhance their treatment experience.
Understanding occlusion is fundamental in aesthetic dentistry.
Veneer thickness should be as minimal as possible for aesthetic results.
Patient involvement in the design process is essential.
Cementation techniques can vary based on gingival health.
Maintaining a facial path of insertion is important for aesthetic outcomes.
Building a good relationship with lab technicians is key to successful restorations.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

02:56 Protrusive Dental Pearl
04:15 Interview with Dr. David Bloom: Journey and Expertise
11:54 The Importance of Enamel in Veneer Longevity
13:46 Prepless Cases and Visual Try-Ins
18:54 Permission Statement
22:24 Visual Try-Ins Protocol
25:13 Decision-Making: Veneers vs. Crowns
28:35 Bonding to Root Dentine and Long-Term Outcomes
33:34 Opening Embrasures: Techniques and Tips
35:19 Visual Try-Ins and Patient Communication
38:50 Wax-up in Occlusion
41:25 The Gurel Technique Explained
47:09 Black Triangles
49:40 Guidelines for First Veneer Case
54:10 Contact Lens Veneers
56:18 Cementation Preferences and Techniques
01:00:15 Final Thoughts and Educational Resources

Need expert guidance on veneers and smile design?

Join Intaglio Mentoring and connect with top mentors for real-time case support and level up your Dentistry. Dr David Bloom is also a mentor on Intaglio.

Watch this space for David’s new educational website coming soon – he teaches Veneers hands-on too.

If you loved this episode, make sure to watch How to Temporise Veneers Step by Step FULL GUIDE – PDP214

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 780 ESTHETICS/COSMETICDENTISTRY (Tooth colored restorations)

PDPMainEpisodes #AdhesiveDentistry

Aim:

To provide an in-depth understanding of minimal preparation veneers, focusing on enamel preservation, diagnostic workflows, patient communication, and clinical techniques to enhance the longevity, function, and esthetics of veneer restorations.

Dentists will be able to –

Identify when a prepless approach is feasible and when minimal preparation is necessary.
Use visual try-ins effectively to enhance patient understanding and involvement in treatment decisions.
Understand long-term maintenance, including managing black triangles, embrasure shaping, and repairs.

Click below for full episode transcript:Teaser: We were used to heavily prepping and it was fine, but what I found was after seven or eight years, these units were popping off. And I mean, I'm a fourth generation bonding guy. I'm OptiBond FL was using the same bond then. I don't think it's about bond strength, it's about the enamel and longevity is enamel.

Teaser:So I found after typically seven or eight years, the units were popping off and I wasn’t sure why. It’s gonna feel artificial, it’s gonna feel strange, but I don’t care what it feels like or I get what it looks like because within five or 10 minutes they’ll have adjusted it. It’s how it looks. I mean, originally when we had Feldspathic, you might say, oh, well just use a completely clear feldspathic portion in there.

And that’s where that it sucks in the color from the underlying tooth. Some people are using Feldspathic and have for many years and it’s a great material. But any veneer is gonna, generally, unless it’s a high opacity, is gonna pick up color as long as it’s thin.

Jaz’s Introduction:It’s another veneers episode. But with someone who’s got so much experience, 36 years and counting, and a wonderful man. Great dentist, a true GDP, who is pivoted into cosmetic and restorative. The key theme of today’s episode when it comes to veneer is not just the full workflow. I’ve done episodes on that before. And yes, we do go deep into the workflow. It’s a lovely perspective to have, but really the main focus is minimal preparation, the importance of preservation of enamel.

But what about those scenarios where, let’s say you have some aesthetic crown lengthening. You have a gum lift. Am I naughty if I’m now partially bonding this veneer on root dentine or cementum? Are those cases more like to stain in the long run? Well, you see from speaking to Dr. David Bloom, he’s been in one practice for 24 years, so he knows what works and what doesn’t.

And he mentions he’s seen some cases that come back as failures. And what was the reason for that failure? We essentially dissect the Galip Gürel technique. This is a really contemporary and essential way of prepping for veneers. Like when I qualified, I was taught that, okay, for veneers you’ve gotta do like, 0.7 millimeter of prep.

And so in my mind, whatever tooth you have in front of you, you put a 0.7 millimeter margin on all these teeth that is totally wrong. And you’ll see for many reasons why that is wrong and why the Gürel technique is really the way to go. It helps us to give the patient the smile they want, but in the most minimal way.

We don’t go too deep into temporization ’cause we did that in a recent episode with Aidan. So to check out that episode, if you haven’t ready, if you wanna go deep into temporaries, but in this one we talk about the mockup, the planning, and the prep itself. Find out in the end why contact lens veneers are fake news and why you should never do a depth groove at the cervical region.

Hello Protruserati, I’m Jaz Gulati and welcome back to Your Favorite Dental podcast. This episode is totally eligible for CPD or CE credits. You’ll just have to answer the quiz at the end.

Dental PearlThe Protrusive Dental Pearl, which I give you in every PDP episode. Gosh, we’ve got hundreds of those. Now I struggle to keep up. Sometimes I get anxiety that I’m repeating a pearl, but it is what it is. And for those of you now listening, I’m examining my hoodie, my Protrusive Hoodie for stains. I went to my mom’s for a curry today. I had some butter chicken, not butter chicken, butter chicken. And I look to have got some on my hoodie.

So, thankfully it’s hidden in the camera, but I can tell you now, the aroma in my office is fantastic. By the way, butter chicken, like is one of my pet peeves. Like Indian people, when they go to Indian restaurants, they always seem to order a butter chicken. It has become, for me, the most like boring vanilla thing that you can get an Indian restaurant.

So my recommendation if you wanna be a bit different like me, is next time you go to a good Indian restaurant. Order the Lamb saag. So this is like a spinach and lamb dish. Much tastier, much richer, much more adventurous, and way less boring than the butter chicken. Anyway, that was a massive digress. I was just coming on to the Protrusive Dental Pearl.

So your patient comes in and they want, let’s say four veneers, upper lateral to lateral, or maybe they want six and there’s a reason why you should never do six, and maybe they want eight, maybe they want 10, you don’t know. But in your wax up, go for 10. Okay? In your wax up, go for 10. Because ac...

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CORE CPD ALERT! ????

How dare I veer away from our beloved clinical topics to talk about… decontamination!?! ????

Have you ever wondered how you should be disinfecting occlusal mirrors without getting them scratched?

Should we be using PTFE inside the pulp chamber if it’s not been autoclaved?

What are the most common decontamination mistakes that we make day in and day out that are so easy to fix?

In this episode, Jaz sits down with Decon Pete, the go-to expert for all things dental decontamination, to drive into the nitty-gritty of keeping your practice squeaky clean (and compliant!). He shares practical tips to make your decontamination process safer, smoother, and stress-free.

Common decon mistakes, PPE slip-ups, distilled vs. RO water, HTM guidelines vs. manufacturer guidelines – this episode will help you feel more confident in decontamination and up your infection control game.

How to reach Decon Pete:

Facebook group: IPC Support by Decon Pete – a private space for dental teams to ask decontamination-related questions.
Website for practice support and consulting: www.deconpete.co.uk

https://youtu.be/013WuXzWE3gWatch PDP218 on YoutubeThe Protrusive Dental Pearl: Pete’s Expert Recommendation on Cleaning your Loupes

Ideally, loupes should be disinfected between every patient, but at the very least, at the end of each clinical session
Avoid submerging loupes in any liquid – instead, use distilled water and a microfiber cloth or cotton buds for frames and nose pads
For lenses, use 70% isopropyl alcohol wipes – no acetone or bleach!
If you’re using a visor with your loupes, you won’t need to clean them as often

Need to Read it? Check out the Full Episode Transcript below!

Key takeaways:

Decontamination is essential for patient safety in dental practices.
Using proper protective equipment is crucial for staff safety.
Transporting instruments safely is a key aspect of decontamination.
Manufacturer guidance should always take precedence over general guidelines.
Policies must be relevant to the specific practice.
Manufacturer’s guidance should always be followed.
Disinfecting instruments is crucial for patient safety.
Water quality impacts the effectiveness of dental procedures.
Distilled water should be used quickly after opening.
Reverse osmosis water is more sustainable for practices.
Proper storage of instruments prevents contamination.

Highlights for this episode:00:00 – Intro03:52 – Protrusive Dental Pearl: Pete’s top tips for cleaning your loupes06:02 – Introducing Decon Pete: Pete’s background in dental decontamination12:40 – Manual cleaning and PPE errors17:51 – Washer Disinfector27:06 – Instrument Transportation30:08 – Guidance vs. Manufacturer Instruction36:05 – PTFE Tape: Sterilization and best practices41:06 – Occlusal Mirror Care48:18 – Distilled vs. RO Water56:37 – Water for Ceramics57:22 – Outro

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC outcomes B and C. This is a GDC Recommended CPD Topic – 5 Hours of Disinfection and Decontamination every 5 year Cycle.

AGD Subject Code: 550 Practice Management and Human Relations.

Dentists will be able to:

Identify common decontamination errors and implement strategies to enhance infection control standards
Appreciate the appropriate methods for cleaning and maintaining dental equipment
Apply best practices for instrument handling, including proper PPE use, safe transportation, and effective sterilisation protocols

If you loved this episode, be sure to check out this one: PDP018 (Don’t Get Sued)

Click below for full episode transcript:Teaser: Manual cleaning instruments just with surgical gloves on. And I see so many practices doing that and it offers them no protection whatsoever. You don't need to use sterile gauze.

Teaser:If you’ve got sterile gauze in, great. But yeah, the cheaper way of doing it, just get non-sterile gauze, or you can use lint-free cloth. The two fundamental waters that we have to use within dentistry for everything is distilled or RO. And the only reasons why we are using those two types of water is because both of them are deemed good quality water. They’ve got no magnesium, nothing like that. And thirdly, they have no endotoxins in them.

Jaz’s Introduction:Protruserati, I’d never thought I’d see the day that I’d be publishing an episode on decontamination. How dare I veer away from those beloved clinical topics to talk about decon? Well, in the UK as you know, it’s a required topic. It’s a recommended topic by the GDC. The problem is a topic like decon is violently boring until now.

I’m so pleased and proud to announce that Protrusive is going to reduce your CPD burden by recording and publishing episodes that are relevant to the recommended fields, but with a twist. Instead of those incredibly boring lectures that are used to in the field of decon, medical emergencies, and radiation protection, I’m actually gonna try my best to make it fun, to make it tangible in true Protrusive nature.

So now you can not only learn something, enjoy the conversation, I hope, but do a massive, big fat tick to the end of year CPD declaration so that by the end of your cycle, you complete your five hours of decon and your recommended hours for medical emergencies and radiation. So, all the good stuff will come soon.

This is core CPD, but not as you know it. It’s gonna be different. It’s gonna be hopefully enjoyable. The reason I think we’ve made it enjoyable is three reasons. Number one, I’m an inquisitive idiot. There are certain fields of dentistry, like implants, like decontamination that I literally know nothing about, and I am learning so much, and I’d love for you to be a fly on the wall and learn, because at the end of the day, sometimes when you are tuning into a conversation, like a podcast type conversation, you soak up and you learn so much more than just being talked at like in a webinar or in a lecture that you may be used to.

Number two, we don’t just cover the usual how many degrees in autoclave we actually cover real world scenarios. For example, how to properly disinfect your mirrors without scratching them, or should we be using PTFE inside the pulp chamber if it’s not been autoclaved. And what are the two most common mistakes that we are making day in, day out that are so easy to fix? Our guest Decon Pete is gonna answer all those questions.

And number three, Decon Pete, our guest today, he’s super knowledgeable, but he’s relatable. He’s a human, he shows us human side, and he’s just so knowledgeable and it was absolutely brilliant to chat with him. I’m so excited for you to listen to this episode and again, put that big fat tick next to CPD.

Now, hundreds of you are used to getting CPD from Protrusive, but understandably, many of you, this will be your first time. I welcome you. I’d love for you to join the Protrusive family. The way to get involved is www.protrusive.app. It’s best to make your account on the web browser so you’re not paying all your money to Apple.

And we Protrusive don’t get anything. I’m just saying the truth. If you wanna actually support Protrusive, you go on the web browser www.protrusive.app, and you choose one of our paid plans, either Podcast CE only, so you get podcast CPD hours and CE credits, or you get access all areas through the Ultimate Education plan.

It is tax deductible, and I think it’s the best value CPD going in the universe. Of course, I’m a little biased. But if you love these episodes, why not answer the quiz at the end of the episode and get your CPD. Also, once you make an account, you can download our native app on Android or iOS and join the nicest and geekiest dentist in the world.

I guarantee you, you’ll sign up for the CPD, but you’ll stay for the people and the friends that you’ll meet on the Protrusive Guidance app. So if you are sick and tired of paying for CPD memberships that you never actually log into. Pick Protrusive ’cause this is the one that you use every single day.

Even one of our dentists, Megan recently said that she checks the app every day as though it’s Instagram. So like I said, if you’re paying for a subscription and not using it, what’s the point? There is so much to learn on the Protrusive community and I’d love for you to join us. If you wanna get the Access All Areas plan, go to protrusive.co.uk/ultimate. That’s protrusive.co.uk/ultimate. And we, the Protruserati, are excited to see you on the app.

Dental PearlThe Protrusive Dental Pearl I have for you is something from the community. You guys asked, what’s the best way to clean your loops? Now, unfortunately, I ran out of time to ask him this question, but I called him up later and I said, Pete, we need to know the answer from you ’cause you are the expert.

And so this is how it goes. Firstly, how often should we be cleaning and disinfecting our loops? Well, technically, if you wanna aim for the highest level, you should be doing it between every single patient. That’s right, every single time you use them. And every time you change a patient before, then you need to disinfect them, because very often there’s aerosol that could be droplets.

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Is Work-Life Balance a Myth?

How do you find the right balance between your professional responsibilities and personal life?

Can you truly have it all…without sacrificing your health or family time?

https://youtu.be/wkAv3noFXNkWatch PS014 on YoutubeIn this episode, Jaz and Emma Hutchison, ‘the Protrusive Student’, dive into the real challenges of balancing parenthood, clinical dentistry, and LIFE! Jaz shares his strategies for managing these demands, revealing that while perfect balance might not exist, navigating life’s seasons with intention can make all the difference.

If you’ve ever struggled with finding your own balance, this episode is packed with key takeaways for dentists at every stage of their careers.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

03:34 Emma’s New Year Reflections and Study Habits
12:20 Balancing Family, Work, and Personal Time
19:50 The Importance of Planning and Support Systems
23:16 Recognizing Opportunities and Setting Boundaries
28:15 Understanding Circle of Concern and Influence
30:24 Eat That Frog: Tackling Difficult Tasks First
31:02 Burnout in Dentistry: Real Experiences
39:51 The Importance of Mentorship
41:07 Just in Time Learning
44:03 Decision Making and Confidence
49:15 Effective Time Management Strategies
51:16 Final Thoughts and Takeaways

Key Takeaways:

Preparation and good mental health are crucial for success during exam periods.
Internalizing knowledge helps in better understanding and retention.
Finding time for hobbies and self-care is essential for well-being.
Planning and prioritizing tasks can lead to more effective study habits.
Support systems play a vital role in managing stress.
You can achieve a lot by focusing on your big priorities.
Eat That Frog: tackle difficult tasks first.
Burnout is a real risk for dentists.
Finding a mentor is extremely beneficial for career growth.
Just-in-time learning is more effective than just-in-case learning.

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Ultimate Education Plan, including Premium clinical workthroughs and Masterclasses.

If you enjoyed this episode, be sure to watch Stress in Dentistry 2024 – Life Changing Decisions – IC048

Click below for full episode transcript:Jaz's Introduction: Guys, there is no such thing as work life balance. It's a myth. 'cause sometimes when I'm with my family and we're on vacation, it's all about my family. Nothing else matters, and that's really the way it should be. But there are other times where things get really busy at work and I'm not able to give my children the quality time that they deserve.

Jaz’s Introduction:And sometimes that happens. Or sometimes you are sacrificing sleep or your health, which really we shouldn’t be doing. But sometimes this happens. ’cause of other events and other priorities at that time. So to find this daily balance and work-life balance that slots into everyone’s magic week, it just doesn’t exist because there’s a season of life for everyone.

And so a lot of what we talk about today with Emma Hutchison, who’s the Protrusive Student. So welcome to this Protrusive Student episode. About 20 or 30% of what we talk about in this episode is related to students, and about 70% is all to do with dentists in the real world. Because Emma asked me, how do I do it? How do I balance everything? How do I balance fatherhood, clinical dentistry, Protrusive? And so a lot of my tactics or the strategies that I use are revealed in this episode.

Hello Protruserati. I’m Jaz Gulati. Welcome back to your favorite Dental Podcast. It’s the student series that we do, but as we’ve seen in the comments on YouTube, mostly dentists tune in because they find it’s nice to reconnect with the basics and with a topic like work-life balance and priorities in life. This is applicable and universal to everyone. So if you like the title and you clicked on, thank you so much and I hope you enjoy this listen.

As part of this Protrusive Student episode, Emma has released her orthodontics for students notes. So in the Crush Your Exam section of the Protrusive Guidance app, there’s a section just for students.

Basically there’s little student forum there. It’s like an up and coming area. So if you’re a dental student, you want free access, please do join the app and email student@protrusive.co.uk proof that you’re a student. And then get, also, get access to the Protrusive Vault. That’s where all our infographics and everything live.

That’s how all community service to students. Emma’s just has done a wonderful job of sharing all her notes, so it’s about, I think 14 or 15 sets of notes on there from dental materials to indirect restoration to now orthodontics for students, and if you’re just a geeky dentist that just wants to download them and read them, then you can totally do that as well. Head over to www.protrusive.app to get started with Protrusive Guidance. Those sections I mentioned are absolutely free.

In this episode, Emma and I discuss so many themes, and what’s striking is that Emma’s time as a locum nurse, so she’d go to different clinics when she was called and she’d nurse for like a new clinic every time, for example, and I asked her, did you ever come across any miserable dentists?

Any dentists that just looked really burnt out or unfulfilled in their profession? Which I think is a really sad thing, right? Everything we do in this podcast is about making dentistry tangible. But also reigniting your passion for dentistry. Reconnecting with that feeling you used to get in your belly when you wanted to get into dental school.

I think it’s really important to just remember that feeling. ‘Cause that sometimes helps us to drive us through a difficult patch. But when I ask Emma about this, and she noticed certain trends, certain qualities about the dentist or the practice that she knew within 10 minutes that, okay, this practitioner is burnt out or this practice lacks a culture, and that’s very relevant to work-life balance and priorities and setting boundaries and all those things. So a big higher level discussion today, and it’s laced with themes like burnout, goal setting and setting. Really importantly, what are your non-negotiables in life? It’s really important to do that, but of course you’ll see that all in the main episode, which will check out now, and I’ll catch you in the outro.

Main Episode:Emma, happy New Year 2025. Welcome back to the show. You are the Protrusive Student, so tell me what student thinks have been up to over this Christmas and New Year period.

[Emma]Over my Christmas and New Year, I’ve been trying to enjoy it, obviously, and I have enjoyed it, but I just know that my big exams are around the corner, so I have been doing work every now and again, just keeping on top of making lecture notes and flashcards and all those sorts of things, but I’ve just not been overwhelming myself. So, that’s what I’ve been.

[Jaz]You need to share these flashcards with the students if you’re comfortable to do something.

[Emma]Yeah, yeah. I use Quizlet for my flashcards. I know a lot of students use Anki as well. I think that’s quite a popular one.

[Jaz]But think these are all digital things, right?

[Emma]Yeah, all digital.

[Jaz]A flashcard on old school still means like in a paper and pen like I used to back in the day.

[Emma]So, no, it’s all there on there. So.

[Jaz]Good. And so it should be so great, if you’re happy to do so, ’cause you’ve been sharing your notes so generously, whenever is the best time for you to share those to the students who will help someone in the world to help pass their dental exams, which would be good. Today we’re talking about a different topic as you requested. Basically the story is, guys, Emma wanted an episode on like the student perspective of orthodontics, and I thought that’s gonna be so difficult to do.

Right? Like, I was extractions, one was a real success and extractions went really well. But you asked me about ortho, like I think, I won’t be able to help you as a student. When you come to your first ClinCheck and your first, it’s all conundrums.

Is this possible with liners or should I refer? I’ll be able to help you then. But actually at the student level, it was always a blur what they wanted and yeah, orthodontics was very, very confusing as a student, I have to admit.

[Emma]That is fine. That’s fine. For this episode anyway, we’ve made like orthodontics student notes for this episode, so. We’ve still got our format.

[Jaz]They can download him in the Crush Your exam section of the Protrusive Guidance app. But the topic chosen by Emma was an interesting one, actually. Work life balance. So what spurred that one?

[Emma]Probably inspired from my Christmas period and my mom’s like, oh, come watch a movie. Come watch a movie. And I’m like, oh, give me an hour. I’m sitting down doing work, blah, blah, blah. And it’s just, I’ve had on my minds that I do have exams coming up. I th...

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When Your Size 10 File is not going to length, what is happening?Your apex locator isn’t giving you a zero reading. Your file is stuck. You’re wondering—have you ledged? Or could something else be at play?

In this must-listen follow-up episode, Dr. Samuel Johnson returns to tackle the biggest endodontic dilemmas left unanswered from part one. If you haven’t checked that out yet, go back and listen—it’s packed with insights on working lengths, apex locators, and even the role of consent in endodontics.

https://youtu.be/1E6pK2iOPjYWatch PDP217 on YoutubeNow, in part two, we go deeper. We’re talking blockages, ledges, portals of exit, and the mysterious phenomenon of file gripping. Plus, Dr. Johnson takes on your burning questions from the Protrusive community—like how he responds to biological dentists claiming root canals should be avoided entirely. (Yep, we’re addressing that controversy head-on!)

Protrusive Dental Pearl: For a more visual learning experience, dive into the Pre-Endo Build-Up on Protrusive Guidance and see Jaz and Samuel’s insights in action.

Sonic Pro Ultrasonic Bath – 10% OFF with coupon code ‘protrusive10’

Improve your Bond Strengths – purchase while stocks last: Sonic Pro Discount

Key Takeaway:

General dentists often overlook the importance of taper.
Removing too much dentin can weaken the tooth.
GP cones can be unstable and affect the procedure.
Reshaping GP cones can often resolve length issues.
Pre-bending GP cones can help navigate tight curves.
Biological dentists have controversial views on root canals.
It’s essential to prioritize the patient’s best interest.
Using endo frost can aid in manipulating GP cones.
Consent should be informed and comprehensive.
Communication between referring dentists and specialists is vital.
Continuous learning is essential for dental professionals.
Ultrasonic activation improves endodontic outcomes.
Pulpotomy and root canal treatments have distinct indications.
Building a supportive community can alleviate feelings of isolation in dentistry.
Dentists should charge for their time and expertise.

Need to Read it? Check out the Full Episode Transcript below!

Highlight of this Episode:

01:03 Protrusive Dental Pearl
01:49 Common Scenarios and Tips for Young Dentists
05:30 File Gripping and Canal Anatomy
08:30 Master Apical File: The Common Dilemma
11:18 GP Cone Issues and Solutions
17:03 Addressing Root Canal Myths
23:35 Cracks in Teeth: Prognosis and Treatment
25:44 Ninja Access Cavities: Pros and Cons
28:21 Common Mistakes in Emergency Endodontic Treatments
33:51 Obturation: Overextended vs Short
34:41 UltraSonic vs Sonic Irrigants
36:15 Pulpotomy and General Dentistry
39:25 Building a Dental Community

As promised, here are the ESE Guidelines on managing cracked teeth.

Watch and learn from Dr. Samuel Johnson on Instagram and YouTube!

Don’t miss the first part of this series: PDP216 – Working Lengths and Troubleshooting Apex Locators

PDPMainEpisodes #EndoRestorative #BreadandButterDentistry

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 070 ENDODONTICS (Emerging concepts, techniques, therapies and technology)

This episode aimed to provide deeper insights into troubleshooting endodontic challenges, particularly when files fail to reach working length. It explores common pitfalls, advanced techniques, and expert strategies to improve clinical outcomes in root canal treatments.

Dentists will be able to –

Recognize common endodontic challenges and strategies to navigate them effectively.
Evaluate the role of master apical files and resolve common dilemmas in achieving optimal shaping.
Identify frequent errors in urgent cases and improve treatment approaches.

Click below for full episode transcript:Teaser: So your size 10 file is stuck. It's not going to length and you're not getting a zero recording on your apex locator. What do you do? Have you ledged? Or could there be another reason for this? This is where we answer that question leftover from part one.

[Jaz]So if you haven’t watched or listened to part one yet, check it out. It was a great introductory episode. We talked all things, working lengths, apex locators, career and consent in Endo. So do check out part one.

In this part two with Dr. Samuel Johnson, gosh, he loves Endo, doesn’t he? And it’s infectious, right? You can totally feel that. We’re going to talk about blockages, ledges, different portals of exit and a phenomenon called file gripping. Then Samuel answers all the questions from you guys, the Protrusive Community.

You guys asked some fantastic questions and it was a great pleasure to ask him all those. One of which what does Samuel think about those biological dentists who are suggesting that root canals are bad and that no one should have a root canal? I know, it’s crazy, but how does Samuel handle those kind of patients? We go deep in all the little facets and details of all things endo. Thanks again for all your questions, guys.

Dental PearlThe Protrusive Dental Pearl for this episode is you need to see, if you haven’t already, you need to watch my pre endo build up video. It’s so relevant to everything that me and Samuel are discussing.

And that video was published just a few weeks ago as part of my POV clinical walkthrough series. You see my full video walkthrough of a couple of cases where I do a pre endo build up and do like a screen recording and interjection and running commentary of everything I’m doing. Very similar to wonderful videos that Samuel makes.

So I’ll put the link to that in the show notes if you haven’t already seen that. If you happen to be listening on Spotify or Apple, then do check out the video on the Protrusive Guidance app or just type in on YouTube, Pre Endo Build Up Protrusive. You will find it. Let’s not delay getting to the main part of the episode. I know you’re going to love this just as much as you loved part one. Let’s go with Samuel Johnson.

Main Episode:Just talk about the common scenario that you want a young dentist to appreciate that when they feel encountered scenario. A great tip there is don’t force it. Slow down, retract because you don’t want to make it worse. And that’s a top tip already.

[Samuel]So I would say, have you reached zero or not? Cause you can get a canal. I’ve had one yesterday. I did distal buccal, which was 17 millimeters and in length. So if you have already reached zero and then at 18, you’re getting this hard stop. You have probably likely ledged it, but don’t panic.

I think we might move on later on to talk about managing ledges, but if you haven’t already reached zero with your apex locator, I think the best thing to do first is just estimate where you are actually within the tooth. So, you can estimate the working length in many ways.

You can use a radiograph, although, sometimes if you can learn how to draw how long it is on your radiographic software. It’s not perfect, but it kind of gets you in that kind. It’s a useful estimate, isn’t it? Another thing as well is, if you’ve got a multi rooted tooth, you say you’ve got a lower six and you’ve got a mesial buccal and you’ve got a mesial lingual.

If the mesial lingual is 19 millimeters or say the mesial lingual is 22 millimeters and you’re getting stuck at 18, you’re probably short. And also take a working length radiograph. I did say I don’t take them, but I do, do take them. Cause sometimes my apex locator is all over the place. And I don’t know why. And sometimes it’s good.

[Jaz]This is the one that you said is not routinely advocated by FGDP, but sometimes when you’re getting erratic measurements and just to verify. That’s when you would take it with and you are doing it with a size 10 because obviously you’re stuck there. Is that right?

[Samuel]Yes. Yeah, absolutely. So say you are near to the end. Okay, this could be a ledge. It could also be complicated anatomy that the x ray is not going to show these many portals of exit. And I would say a really really common sign that it is complicated anatomy, not a ledge is that you get that kind of sticky feeling.

So it’s a hard concept to kind of...

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What makes apex locators reliable—or completely misleading?

How do you determine the true working length of a root canal?

Why is relying solely on radiographs for endo success a risky move?

Dr. Samuel Johnson joins Jaz for a game-changing episode that will make you rethink everything you know about endodontics. In this first part of a two-part special, they dive into the nuances of apex locators, the difference between the radiographic apex and apical constriction, and why our radiographs might be lying to us.

They also explore the power of glide path files, how to improve your endodontics workflow, and an incredible way to consent patients—something that extends beyond just root canals. Because mastering endodontics isn’t just about technique—it’s about communication, precision, and making the right calls for long-term success.

Stay tuned for Part 2, where we go even deeper into endo essentials!

https://youtu.be/M2z8Dl_g4XYWatch PDP216 on YoutubeProtrusive Dental Pearl: Buy a small whiteboard and marker for patient communication. Draw details, highlight the treatment plans, and list pros, cons, and fees. This builds trust, improves consent, and makes treatment clearer. Snap a photo and upload it to the patient’s records.

https://amzn.to/3DzUJfn

Key Takeaway:

Understanding the difference between radiographic and anatomical apex is crucial.
Apex locators are essential tools for accurate working length measurements.
The anatomy of the root canal system is complex and requires careful navigation.
A well-informed patient is more likely to have realistic expectations about treatment.
Glide path files can significantly reduce treatment time.
Avoid forcing files into hard stops to prevent damage.
Complicated anatomy can lead to unexpected challenges during treatment.
Taking radiographs can help clarify uncertain situations.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:

01:40 Protrusive Dental Pearl: Patient Communication
02:39 Welcoming Dr. Samuel Johnson
04:36 Samuel’s Passion for Endodontics
07:07 Reliability of Radiographic Measurements vs. Apex Locators
11:15 Canal Anatomy
14:30 Overextension vs Overfilling
16:23 Combining Apex Locators and Radiographs
20:52 Apex Locators and Hypochlorite: The Perfect Combination?
24:00 Efficiency in NHS Dentistry
26:10 Transitioning from NHS to Private Practice
27:42 Understanding Radiographic vs Anatomical Apex
29:26 The Importance of Consent in Endodontics
33:07 Mastering Apex Locators: Tips and Tricks
37:07 The Role of Glide Path Files in Endodontics
39:19 Troubleshooting Endodontic Challenges

Watch and learn from Dr. Samuel Johnson on Instagram and YouTube!

If you loved this episode, be sure to watch Elective Endodontics? It’s all about Communication – PDP202

PDPMainEpisodes #EndoRestorative #BreadandButterDentistry

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 070 ENDODONTICS (Emerging concepts, techniques, therapies and technology)

This episode aimed to enhance clinicians’ understanding of endodontic diagnostics and workflow, focusing on apex locators, working length determination, and effective patient communication. By refining these skills, practitioners can improve treatment accuracy, efficiency, and patient outcomes.

Dentists will be able to –

Differentiate between the radiographic apex and the apical constriction and understand why radiographs alone can be misleading.
Evaluate the reliability of apex locators and recognize factors that affect their accuracy.
Apply the use of glide path files to improve efficiency and reduce treatment time in root canal procedures.

Want More Clinical Gems?Join the Protrusive Guidance App to get access to masterclasses, premium videos, and exclusive Q&As with experts. Head over to protrusive.co.uk/ultimate to sign up and take your endodontic skills to the next level.

If you found this episode valuable, subscribe to our YouTube channel, leave a review on Spotify or Apple Podcasts, and share it with your colleagues. We appreciate your support!

Click below for full episode transcript:Teaser: This is the best tip I could give you with root canal. If you're new starting out, if you are getting, say you're 18 on a canal and you know it's probably about 20, 22, the best thing for you to do, if you're getting stuck, the best thing to do is not to jam it down there, you're going to pull your hand file out.

Teaser:In fact, you’re going to measure first, how far you’ve got with a rubber stopper. You’re going to take it out, you’re going to measure it, it’s 18. You’re then going to get a higher diameter file. Really what you want to be thinking about is the apex locator is the daddy. They’re the key. You’re going to be trusting that one person.

Essentially you’re just creating that kind of circuit. Do you want to be tickling those periodontal tissues and they said, they’re extremely, extremely reliable. That is the greatest thing about my job in dentistry. You never, ever, ever, ever stop learning.

Jaz’s Introduction:Protruserati, you’re in for an absolute treat. My guest today, Dr. Samuel Johnson, will actually make endodontics fun. Look, I don’t do as many root canals as I used to, and to be fair it’s really not my favorite thing but seeing the wonderful things that Samuel is doing is really making me excited and enthusiastic about Endo, which is why I’m so excited to finally bring him on the show. Not only are you going to enjoy his geekiness and how passionate he is about Endo, he’s also going to charm the pants off you. Just such a lovely guy.

This is part one of a two part special. So in this part one, we look at apex locators and we look at the difference between the radiographic apex and the apical constriction. So basically when you see a radiograph of a root canal and you think, Ooh, that looks short, or, oh yeah, that looks to length quite often, we are wrong. And if you use our radiograph alone as a metric of success, then that might be lying to us. Along with that, we’ll talk about what makes apex locators reliable and what makes them unreliable.

The power of glide path files, which Samuel’s really big fan of. And Samuel will share with you the ultimate way to consent a patient. And this could be used for anything, not just for endo. And I am convinced that this way of consenting patients and then taking a photo of this way of communicating, uploading it to the patient’s notes is just absolutely phenomenal.

So whilst you’re going to level up your endo in this two part episode, you’re also going to be better at consent and communication. And as ever, I always like to dive in about the journey of our guests. And Samuel’s got such a fascinating story about being in the army, an engineer, then the endo MSC, he’s got three kids, it’s all happening and he is just brilliant.

Dental PearlEvery PDP episode I give you a Protrusive Dental Pearl and it’s taken from this episode thanks to Samuel. Look, do yourself a favor, go on Amazon and buy a small whiteboard with a marker pen. Then you’re going to use that whiteboard in all your communication with your patients. Every time they have a crack, you’re going to draw a tooth with a crack.

You’re going to show the patient all the details, draw it for them, highlight it, write the pros and cons, write the fees on this whiteboard. This is a powerful way to communicate and consent. You take a photo of that, then you upload it to the patient’s notes. I know many of the protrusive community have also used this technique before, and those who use the whiteboard in surgery absolutely swear by this technique. I appreciate it’s not for everyone, but some of you will really resonate with this and I truly think it builds a nice connection and high level consent for your patients.

This episode is eligible for CPD or CE credits because we are PACE approved. So once you finish this episode on the Protrusive Guidance app, scroll down, get 80% of the quiz and you’ll...

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Are you confident in managing patients on bisphosphonates or biologics?

Which medications increase the risk of medication-related osteonecrosis of the jaw (MRONJ)?

How do you decide when to extract a tooth and when to refer to a specialist?

In this episode, Jaz is joined by oral surgery consultant Dr. Pippa Cullingham to explore the complexities of MRONJ. They break down the key risk factors, share expert advice on when to proceed with extractions, and discuss the latest guidelines for managing patients at risk.

They also discuss the importance of early assessment – by identifying at-risk teeth early, you can help prevent serious complications and ensure the best outcome for your patients.

https://youtu.be/KnQoI8Z-FhMWatch PDP215 on YoutubeProtrusive Dental Pearl: it is so important to assess patients before they start taking high-risk medications like bisphosphonates or biologics, using radiographs to identify potential issues. Extractions should ideally be done before medication starts to avoid complications, as MRONJ risk increases once treatment begins.

Key Takeaways:

Medication-related osteonecrosis of the jaw concerns medications other than bisphosphonates.
Risk assessment is crucial when considering dental extractions for patients on certain medications.
Guidelines from the Scottish Dental Clinical Effectiveness Partnership are valuable resources for dentists.
Higher-risk patients require careful management and communication with their medical teams.
Denosumab has a different risk profile compared to bisphosphonates.
Patients on long-term bisphosphonates may still have risks even after stopping the medication.
Dentists should feel empowered to manage certain extractions in primary care with proper guidance.
The decision to extract a tooth should weigh the risks and benefits for the patient.
Always assess the patient’s risk before extraction.
Eight weeks is a critical time for assessing healing.
Antibiotics are not recommended for preventing MRONJ in the UK.
Radiotherapy history significantly impacts extraction risk.
Referral to specialists may be necessary for high-risk patients.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

02:15 Protrusive Dental Pearl
03:52 Interview with Dr. Pippa Cullingham: Insights and Experiences
06:40 Medications and Their Risks
10:02 MRONJ: Incidence and Prevalence
13:13 Biologics and other medications
14:19 Guidelines and Best Practices
17:22 Managing High-Risk Patients
25:03 Prophylactic Antibiotics
26:55 Risk Assessment
28:47 Radiotherapy & ORN Risk
31:49 Tips and Key Takeaways
33:32 New Medications & Prevention Strategies

For the best approach to managing MRONJ, check the SDCEP Guidelines and the American White Paper.

This episode is eligible for 0.5 CE credits via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Diagnosis, management and treatment of oral pathologies)

Dentists will be able to –

Be aware of the medications that increase the risk of MRONJ.
Learn how to assess the risk of MRONJ in patients, particularly before starting high-risk medications.
Understand when to proceed with extractions and when to refer patients to specialists for management.

If you liked this episode, check out PDP206 – White Patches

Click below for full episode transcript:Teaser: Patients prescribed a bisphosphonate for cancer were at about a 1% risk of developing an MRONJ following a dental extraction. There's been an update. So it's closer to 5%, we think, but we're not sure if that's because there's increased follow up, increased awareness, more reporting of the condition. So closer to 5 percent on the cancer patients for an osteoporosis. It's bisphosphonate medication, it's around 0. 1, 0. 2, so it's a low risk.

Teaser:A risk in itself is taking the tooth out, so we can’t forget that actually patients on these medications can just get spontaneous MRONJ, it could just happen without taking the tooth out. So the risk is the surgery itself.

When you review at eight weeks, if you notice that there is non healing area, or you suspect it’s an MRONJ, you can yellow card it. So it’s like, you had the BNF and it used to have the actual yellow card in. Now online. So if you just Google yellow card and then you can report the adverse reaction to the medication.

Jaz’s Introduction:If your patient is about to be prescribed something like a bisphosphonate or a biologic, it is so important that before they start these medicines, which puts them at risk of surgical complications, that you have an opportunity to do a complete assessment and decide, are there any teeth of dubious prognosis that need extracting?

Because Protruserati, prevention is better than the cure. Because today’s conversation is all about MRONJ, which is medication related osteonecrosis of the jaw. It can be quite a nasty complication and something that we should be able to just consent our patients. Like the worst thing you could do is your patient is about to start this medicine or is already on this medicine and you didn’t warn them of this relatively low but serious risk.

And we’ll go into all the incidences, prevalences, when you should extract in practice and when you should refer. That’s what this episode is about. I’m joined by an oral surgery consultant, Dr. Pippa Cullingham. And she does a wonderful job of summarizing this and a great guidance that I’m going to put in the links below is the STCEP guidance and also an American white paper for our colleagues in the U. S.

Hello Protruserati, I’m Jas Gulati and welcome back to your favorite dental podcast. No, today is not occlusion. It’s not onlays and restorative and vertical preparations. It’s Oral Surgery, and it’s not even the sexy part of oral surgery, right? It’s not like how to do the sectioning, elevating. This is medicines and their complications, and all important daily decision making.

I’ve got such an aging population that I treat, so this is very real and relatable to me. And all you general dentists around the world, you have patients who are on these medicines. And there’s always a risk calculation that we need to make. And I’m hoping this episode will give you the confidence to know when it’s safe to extract in practice. And the two main reasons that you should be referring to a specialist, perhaps in a hospital setting.

Dental PearlThe Protrusive Dental Pearl, which is like this advice, this tip we give every PDP episode. It’s very relevant to the topic of MRONJ and BRONJ, which is bisphosphonate related osteonecrosis of the jaw. That’s the one that I was taught at dental school. But then of course, we realized that it’s not just bisphosphonates. There’s so many medicines that contribute towards this poor wound healing after extraction due to the alterational bony turnover. And we should be paying attention to this.

And the pearl is that when you have that opportunity to intercept. Like for example, they’ve just been diagnosed with a cancer, unfortunately, or they have osteoporosis and they’re about to start a bisphosphonate or another condition for which they need a biologic, which increases their risk. It is so important to do a very comprehensive assessment, which should include multiple periapicals or an OPG radiograph.

So you can see all the roots, like imagine seeing a crown, which has looked a little bit dubious and you’ve been watching it all these years has never really been symptomatic. But if a patient is about to start one of these high risk medications, it’s so important that you take a periapical radiograph or an OPG.

You need to see if it’s in the patient’s best interest to have this tooth extracted before starting this medication. So you kind of need to change your mindset a bit to let’s see how it goes versus are there any dubious teeth that we should extract before a patient starts any medication. If you can identify any silent infections or dubious prognosis teeth, think of obviously leaking crown margins, which are subgingival caries, but no signs of infection, but really those teeth ought to come out. And that conversation at least needs to be had with the patient before they start such medication.

The best time to extract is before they start the medication because there is zero risk. As soon as they start any of these medications, there will be a risk of MRONJ. And we’ll discuss in today’s episode about what increases your risk and whether there’s anything special we should be doing with our extractions. Hope you enjoy and stick around to the end. There are some CPD questions below if you’re watching this on the Protrusive Guidance app. And I’ll catch you in the outro.

Main Episode:Dr. Pippa Cullingham, welcome to the Protrusive Dental Podcast. It’s so, so good to have you. You messaged me some months ago regarding a post that we did just about common medications. That was actually a credit to Emma, the Protrusive...

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Not quite happy or set with being a GDP? Have you just started as a GDP and want to streamline your learnings for a brighter future? Is an MSc the right plan of action for you? How important are mentors in all of this?

In this episode we discuss Dr Kiran Shakla’s journey from University to Australia to working as a Dentist at a Specialist Practice. She shares with us her top tips on how Dentists can make the most of their weekly schedules and reduce stress while dealing with different cases.

https://youtu.be/IiecXSpsJmcWatch IC057 on YoutubeKey Takeaways:

Hard work and determination are key to success in dentistry.
Work-life balance is crucial for long-term satisfaction in dentistry.
The first ten years post-graduation are vital for career development.
General dentistry can be fulfilling without the need for specialization.
It’s important to recognize when to refer patients to specialists.
Kiran emphasizes the value of personal growth and continuous learning..
Finding joy in everyday practice is essential for a sustainable career. Australia taught me valuable skills in private practice.
Private dentistry focuses more on patient care than money.
Communication is crucial for patient satisfaction.
Finding mentorship can be challenging but essential.
Shadowing experienced professionals enhances learning.
Balancing work and education requires sacrifices.

Need to Read it? Check out the Full Episode Transcript below!

Highlight of this episode:

02:34 Introduction to Dr Kiran Shankla
06:18 Correlation between Uni and the Real World
07:29 Selling a Dream
10:13 Going Hard Early
12:43 Taking Work Home
14:55 General Dentistry
20:48 Kiran’s Journey
24:23 What did the experience teach Kiran?
31:33 Mentoring
34:38 Work Schedule
37:38 Bone to pick with Master’s
43:33 Orthodontic Position
48:53 Working with Nurses
54:33 Networking
56:33 Wrapping Up

Connect with Dr. Kiran on Instagram!

This is a non-clinical episode without CPD. For CPD or CE credits, visit the Protrusive Guidance app—hundreds of hours and mini-courses await!

If you liked this episode, check out: Stress in Dentistry 2024 – Life Changing Decisions – IC048

Click below for full episode transcript:Teaser: They don't have the clinical skill, but they've seen so many people do it, they know what works and what doesn't. And if you get on with them and if they can teach you something, it's like going on a course and someone, I could have paid to go on a course for someone to teach me how to do that. Well, why would I, when my nurse has seen it done a hundred times and she's like, Kiran, this is how it's done. Come on, I'll help you.

Teaser:If anyone stops saying, I don’t know which course to do. This is another course you can create. And you know, often, it’s a secret. It can be free. Often it can be free because there’s so many lovely people out there that are willing to say, you know what, if you want to shadow me 12 times in a year on this, like, once a month, I’m happy.

You don’t have to pay me anything yet. Some people will charge and that’s okay. That’s worth it too. But if it’s free, wow. And if even if it’s charged, it’s still worth it because to be able to shadow you learn so much.

Jaz’s Introduction:Being a general dentist is the toughest gig in dentistry. You have to literally be good and know everything. In this episode I’m joined by Dr Kiran Shakla, a general dentist just like me, and we talk about her journey. I feel there’s so much we can learn when we dissect an individual’s journey. And Kiran’s mindset is really quite special. It’s really going to inspire anyone who’s in the early stages of their career.

Or even if you’re established in your career but you’re not quite happy, you’re not quite settled, you have that itchy foot like Kiran had, then this episode will be really helpful to you. You see, Kiran takes massive action. She moved to Australia all by herself in the middle of nowhere near the outback.

And then when she came back to the UK, she wasn’t quite satisfied. She wanted more, so she did a masters. Now, we discussed in the episode whether a master’s is the right thing to do or not. I have a bone to pick with MSCs. I feel as though there are other ways to gain knowledge or achieve where you want to be in your career without doing an MSC, but it’s great to learn about Kiran’s MSC and how it opened up opportunities and network for her.

We talk about themes of finding the right practice, of mentors, and how lucky she was to have really great mentors. And if you haven’t got great mentors in your life, how to find them. A really simple trick that me and Kiran talk about about halfway in this episode to make sure that you regain control of your life and your career.

How to force some degree of mentorship in your life. We talk about that. And at the end, we have this wonderful exchange where Kiran tells me about her super nurse or super DA that she had and how Kiran was humble enough to learn from the assistant.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. This is an Interference Cast, a nonclinical episode. It’s got so much about communication and mindset and decision making and how you mold your career. Essentially, if there’s one thing you take away from this episode is have a vision, have a goal and bloody go and get it. Hope you enjoy, and I’ll catch you in the outro.

Main Episode:Dr. Kiran Shakla, welcome to the Protrusive Dental Podcast. How are you?

[Kiran]Yeah, I’m really good. Thank you, Jaz, and thank you so much for having me on here. I really hope today we’ll provide some insight to all dentists of all different ages, and hopefully when people look back on their career, or they look at what they do on a day-to-day basis, they can look at it in a more positive light and reflect on it positively.

[Jaz]You have a journey and we’re talking every time I see you at one of the BDA events, and I learned about what you’re up to. And you told me an interesting thing about how about you’re working in an orthodontic practice, and you managed to get a gig where you’re doing all that restorative work. And I said, wow, Kiran, that’s amazing.

How did you even land that? And so, there’s so much to learn about an individual’s journey. Some of the best episodes we’ve had in the podcast interference cast is just learning about an individual’s journey. Not that yours is the only way, but having your way exposed on the table with all the frailties or the good bits, the bad bits, the warts and all, if you don’t mind, it’s really going to help a lot of people.

And I’m sure you get loads of dentists coming up to you asking, okay, well, how did you get to where you are today in terms of the current work mechanics? I guess we have to start at the beginning, Kiran, tell us about yourself.

[Kiran]Yeah, definitely. I mean, it’s strange that you say that because I don’t see myself any different to any other dentist. I just think I’m a normal dentist. Just go to work, live life the way you want. And so, I guess my journey started probably when I was 16 when I got my GCSEs results and never wanted to do dentistry. Didn’t know anything about dentistry. My sister’s a year older than me, so she was going to apply for medicine.

We always knew that. And I’m middle child. So, parents like, okay, this one we’ve got to keep control of. And I got my GCSEs results and it just happened. A family friend who’s a dentist just called to see how I done. She said, oh, Kiran, hey, how have you done? And I said, oh, actually I did a lot better than I was predicted.

I ended up with all A’s and she was like, oh, why don’t you do dentistry? Great for females. You can work part time, you can travel. I thought, okay, great. This is what I’m going to do. And I remember I came home, and I told my parents a few days later, like, okay, I think I’m going to become a dentist.

I had to go to school. I had to change all my A level subjects because I’d applied for all like IT and business studies. It changed all sciences, even to the day Jaz, my dad, I saw him last week and I was talking to him, and he still says, I still can’t believe you’re a dentist because we thought you were going to do dentist IT.

This is like 11 years graduated now. So, and I guess the thing with me is once I want to do something, I will try and do everything I can in my power to make it happen. So I’m not someone who was born smart. I had to study. So, once I decided I wanted to do dentistry, most afternoons, evenings, I was studying, just studying, studying, studying.

And even through dental school, like had five years at Birmingham Dental University was fantastic. I really, really enjoyed it, but I was studying a lot because I know I’m not naturally smart, but I always said to myself, if you work hard and if you’re driven enough, it will happen. What’s there to stop you?

What are the barriers? And I think that goes for dentistry now as a profession, like if you want something enough and if you knock on enough people’s doors and if you do all the right things, ...

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How do we decide whether speciality training is right for us?

Is the best time to specialise straight after Dental School? Or should we gain some experience in practice first?

Dr Beant Thandi joins us today to share his journey into specialising and shares some key experiences that will surely help guide you along the way.

We discuss the different specialities within Dentistry as well as what personality types may suit them. This episode will really help you understand what it takes to specialise and how to get there.

https://youtu.be/f8ZM8EkjSQYWatch IC056 on YoutubeKey Takeaways:– Beant is starting his specialization in periodontics.– His journey began during COVID, leading to a desire to specialize.– Proactive learning and mentorship played a crucial role in hisdevelopment.– Financial planning is essential when considering specialization.– Choosing a specialty should align with personal interests and strengths.– Periodontics offers a breadth of practice that appeals to Beant.– The importance of community support in dental education cannot be overstated.– Reflection and documentation of cases can enhance learning and confidence.– Understanding the financial implications of specialization is vital.– It’s important to stay grounded and not rush into specialization.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:00:00 Teaser02:38 Intro to Dr Beant Thandi04:03 Dental Journey06:10 What Influenced You?12:56 Too Young to Specialise17:50 Judgement by Jaz21:00 Never too Young26:05 Cost of Specialising28:23 Why not the USA?31:30 Roasting Prostho34:45 Roasting Endo37:42 Roasting Ortho39:49 Roasting Oral Surgery45:00 Shoutout to Lucy45:30 Final Thoughts47:28 End Outro

If you liked this episode, check out a classic: Should You Specialise? PDP006

Click below for full episode transcript:Teaser: But one thing I learned from a nurse when I was doing a DCT job was people all progress at different rates. It should be competency based, not necessarily time based things. People learn at different rates. And this was a max fax nurse who's obviously seen regists for decades, where I'm sure like, the junior regists are better than the senior regists. Just because they soak it up more.

[Jaz]The whole pros element, right? Multiple crowns, four rehabs, lots of general dentist do four rehabs, lots of general dentists do all on fours, that kind of stuff. So, nowadays it’s like blurred lines between, okay, what do they actually need a Prosth for? However, prosth, I think they’re very employable. However, lots of people who do an MClinDent Prosth end up being general dentist. We’re just like really good general dentists in practice and still doing checkups and stuff. I have seen that.

[Beant]The fees are 37 and a half thousand pounds a year and they’re subjects-

[Jaz]For a home student.

[Beant]This is for a home student. I’m a home student.

[Jaz]What? How much is it for an international student?

[Beant]60, 000 pounds. Jaz’s Introduction:I think every dentist in the world at one stage of their career has thought about specializing. And most of us never do, right? About 90% in UK anyway are general dentists or at least non specialists. Only 7% actually enter specialist fields of dentistry like perio, prostho, endo, oral surgery, you name it.

How do we decide whether specialty training is for you? There are huge sacrifices one must make both in terms of time and finances. And how can you be sure that you really want to niche and narrow your scope of practice into that one field that you might choose? Is the best time to specialize like straight after dental school? Or is it good to gain a few years experience or many years of experience before you consider specializing?

Hello, Protruserati, I’m Jaz Gulati and welcome back to your favorite on the podcast. I’ve got Dr. Beant Thandi today who’s literally been accepted just now into Perio specialist training. We recorded this a few months ago. So it probably just started his specialist training, but he’s young. He’s a new grad and he’s deciding to specialize early on.

He decided that Perio is his calling and be nice to tap into his mindset. Why is he thinking of specializing in Perio? Why not any other specialty? Why not do some more years in general dentistry? Why not do lots of courses in Perio and be good at Perio, but not necessarily be a specialist. How’s he going to finance this? Nowadays, things are getting so expensive. And that includes the fees for specialist training. Beant is one of our community members on the app. So it’s a great pleasure to host him.

Hope you enjoy this episode. Covers so many themes about specializing. Like we’ve all thought of these questions before. And you know what? I don’t think there’s any right or wrong answers. But I know for a fact, this will help you. If you’re kind of stuck and you’re thinking, is specialist training for me? This is going to help to give you some direction. Catch you in the outro.

Main Episode:Dr. Beant Thandi, you’re about to specialize. Super exciting time. It is so great to have you, to catch you at this stage of someone’s career, because we’ve had specialists on before. We’ve had young specialists on before, experienced specialists.

We’ve had people thinking about specializing, but you’re literally in that kind of limbo period where You’re literally about to start specializing in Perio. So tell us my friend about your journey so far. And when do you actually start your program?

[Beant]Yeah, sure. So, well, thanks for having me on. So we’ve got long story and short story. So to answer the first bit, which people want to know is I’m starting next Monday. I’m going to the Eastman Dental Hospital, do their three year MClinDent course, hopefully come out a specialist, that’s the plan. It will be, yeah. It’ll be a full time course. So I’ve had a bit of a read of the brochure.

It’s going to be like five days a week, pretty intense kind of thing. So pretty much like a job going straight into it. So excited, nervous. I think it’s a happy, nervous, excited. I think I don’t know quite what to expect, but I’m like looking forward.

[Jaz]And so tell us, give us a flavor of what got you to this point. So tell us about your dental school training, like your very early stage in your career. And so people decide to specialize at various times. Like, for example, when I look at someone like, Reena Wadia, a well known perio specialist, who’s been on the podcast before. A bit like you quite early jumped on and she’s doing great things. Equally, I’ve seen clinicians who’ve been in the game for 11, 15 years, then they want to specialize and they’re also equally doing wonderful things. So tell us about your journey so far.

[Beant]Yeah, sure. So my journey all started with cOVID actually. So, when I was an undergrad, it was middle of third year. So we just started seeing patients literally in the January, February started getting going. Treatment plans were done. We’re actually starting to do fillings. It’s getting excited and then bang COVID hits and we’re all sort of shelved. And I remember during that period we all went online with everything and it was all good. We’re still learning. They got us back. So I trained at Birmingham.

They got us back into clinics quite quickly, actually like credit to them. And what happened was it got to a phase where we would go to clinics, go to university, then we’d come home and that was it. Couldn’t do anything else. Couldn’t see anyone. There’s only so many video games and Netflix series you can really watch.

So just got quite bored. It’s a bit odd, but it sounds really weird saying this, but for me, I felt dissatisfied and I couldn’t explain it. I didn’t know what it was because I was telling myself and I know it’s still the truth. I’m going to be a dentist and that’s absolutely amazing. That’s fantastic.

I’m really lucky to be on the course, like what’s going on kind of thing. And then I was quite literally sat in bed at night going to sleep. And I was like, I never thought about specializing, literally a thought in my head. And I go, hmm. It was literally like a moment like that, like went to sleep anyways, carried on.

[Jaz]What year were you in? Was this like fourth year, fifth year?

[Beant]So this is the tail end of third year. So start of fourth year, start of BDS four. And at this point we then, so with this in my mind, it’s like, okay, I’m going to just keep my eye out for things. I wasn’t too like diehard about anything.

I was like, okay, well I’m in a dental hospital. I’m being taught by a load of specialists. Who else better to kind of get that insight from? And so, we were going through a block during, at the time, where we do specialty modules. So we had pros, specialties, perio, endo, oral surgery, oral med, Paeds, Ortho, all sort of the usual blocks.

And I kind of just paid a, I know it sounds silly, a bit more attention to them as could I see myself doing this? Yes...

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Two weeks ago I suffered a spontaneous pneumothorax and it shook me. This episode came at the PERFECT time as such health scares remind us that our health and wellbeing are the highest form of Wealth.

Should Dentists have a therapist to manage stress and anxiety?

Did you know that a BDA survey found 1 in 5 practitioners have seriously considered taking their own lives?

Is it the intense work environment, the pressure from patients, the fear of litigation, or the added burden of business ownership?

More importantly, how can we address this issue and support dental professionals?

Dr. Simon Chard, a cosmetic and implant dentist and co-founder/CEO of Parla (as seen on Dragon’s Den!), joins Jaz to discuss the often-overlooked realities of the dental profession.

https://youtu.be/rH7PtjFTOpkWatch IC055 on YoutubeHere are the two books Jaz recommended during the intro:

The 5 Types of Wealth by Sahil Bloom

Hold on to your Kids by Gabor Mate

Check out The Dental Growth Retreat by Dr Simon Chard

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Simon emphasizes the importance of balancing personal and professional life.
Mental health issues in dentistry are alarmingly high, with many professionals considering leaving the field.
Therapy can be beneficial for everyone, including dentists, to manage stress and emotional challenges.
Building mental resilience is crucial for handling the pressures of dental practice.
Sleep quality and routine significantly impact overall health and productivity.
Mindfulness and meditation can reduce stress and improve mental health.
A structured approach to self-care can enhance resilience in the dental profession.
Exercise is a key component of maintaining mental and physical health.
Creating a supportive community among dental professionals is essential for mental well-being.
Proactive self-care strategies can prevent burnout and improve job satisfaction. You can’t mess up meditation; awareness is key.
Diet significantly impacts mental health and well-being.
Interpersonal relationships are crucial for mental resilience.
Exercise is a powerful tool for physical and mental health.
Purposeful living leads to greater fulfillment.
Hydration and nutrition are foundational to health.
Loneliness can have severe health implications.
Creating time for relationships is essential.
A value-based calendar helps prioritize what matters.
Retreats can provide tools for personal growth and accountability.

Highlights of this Episode:00:00 Intro04:25 Introduction to Dr Simon Chard10:10 Why is Dentistry so Stressful?14:00 Therapy for Dentists19:20 Strategies for Mental Resilience25:20 Mindfulness31:57 Intake40:32 Love45:12 Value Based Calendar48:32 Exercise51:57 Managing Everything54:34 The Retreat

If you enjoyed this episode, check out: Mental Health in Dentistry – PDP185

Click below for full episode transcript:Jaz: The BDA, which is the British Dental Association, it had like something like it was 18% or nearly 1 in 5, right, had thoughts about and we'll just say it taking their own life, right? And I'm sorry to everyone to go in this direction, but it's important that we address it head on.

Teaser:Incredible the number of individuals who are vitamin D deficient in this country. So I vitamin D test all of my surgical patients. We have a finger prick, point of care blood tests that we do ahead of the surgical appointment. I would probably say in my patient cohort, 75% are vitamin D deficient. The digital connection that we have with people is like a junk connection, like junk food and the real interpresonal relationship that we have with people is like whole food and whole connection.

Jaz’s IntroductionI agreed to record this episode with Simon a few weeks ago, right? And so it’s amazing how life works, the funny different ways that life works. Because when we agreed on the topic of health and wellness in dentistry, I did not know that two weeks later, I would have a spontaneous pneumothorax, aka a lung collapse, just a few weeks later. And actually, it has completely shaken my life to the core. I’m okay. I’m a little bit short of breath. I have appointments left, right, and center, CT scans, just trying to figure out, piecing it together, why did this happen?

And sometimes when something like this happens, it really gives you an opportunity to evaluate your life. And oh my goodness, there’s been so much evaluation happening in the last eight days. And this episode just came such a wonderful time for me personally as well speaking to Dr Simon Chard our guest today because he is so into nutrition and health and well being and the advice he has to share with us all is so key so foundational and I encourage you to listen the entire way.

You should not miss it. Some of the gems, especially right at the end, are absolutely beautiful. Even if you just take away one thing from this episode, I think you can implement it and improve your health and well being. So you have a better career, a longer career, better health, better relationships, and of course a more fulfilling life and career.

So these are all things that we talk about in this episode. From sleep hygiene, to our diet, to the importance of interpersonal relationships. This podcast episode is full of book recommendations. Me and Simon really connected on all these different books that we like and so we share them.

So what I’ll do is in the show notes, if you scroll down, especially from the Protrusive Guidance app, I’ll just put all those books that we recommend. The most recent one, so a couple that I’m listening to at the moment and every month on the Protrusive Guidance community, I ask you guys, what are you guys reading at the moment?

I can’t believe how many of you are reading dental textbooks. Come on guys. Okay. It’s important. I get it, but I like to know about what non clinical thing are you reading? It’s really important to just not always read clinical dentistry. I want to see you guys reading and listening to non clinical stuff as well.

So the two that I’m listening to this month is Hold On To Your Kids, right? And this is so important because the book talks about how the children of today, if they don’t feel the attachment and connection with their parents, then you know where they’re going to get that attachment void from? They’re going to get it from their peers.

And nowadays, the way society is built up is that actually, we are sort of driving this culture, whereby kids turn 11, 12, 13 and instead of looking to their parents, they are looking to their peers, and it’s like the blind following the blind. So, Hold On To Your Kids by Gabor Maté and the other author I forgot, but really enjoying listening to that, and oh my goodness, The 5 Types Of Wealth.

I’m just into chapter 2 at the moment, I’m listening to it on my commutes. It has just come at such a wonderful time for me. Because of this whole lung collapse issue, I’ve been really reevaluating my life. And so the five types of wealth talks about, okay, one of those types of wealth is financial wealth.

But if it constantly working and chasing that, you are ignoring the four other types of wealth. So let’s see if I can remember this. Okay. So the other types of wealth, which are the most important, the financial one is fifth, because more money does not equal more happiness. We know that already. It does equal more happiness when you are at poverty, right?

If someone is really struggling financially, right? And you inject more money in their life, that will improve their happiness. But once you get to a certain level, It doesn’t matter. You can triple it, quadruple it, 10x it. It’s not going to make your happiness sustainably better for the long term. So that’s why the financial wealth is the last type of wealth.

The other four types of wealth, which are so important that this book covers so far. And again, I haven’t listened to it all. I’m just listening to it. I just want to share it with you because I’m just in the moment. I’m thinking about my health. I’m thinking about the different types of wealth. It’s just brilliant.

And I’ll put that in the show notes and they are time worth. The other one is social wealth, your relationships, the quality of the relationships in your life. And the next two are physical wealth, of course, and mental wealth. Okay. So yes, you can say physical health or mental health, but actually swapping the word health for wealth is really powerful because it gets you to remember that actually this is a type of wealth.

If you want to live a wealthy life, it’s not about just the finances. That’s just one part of being wealthy. If you are poor in those other four, then my friend, you are not wealthy. So anyway, I’ll put those book recommendations in the show notes and you are...

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A Clinician’s guide to TMD Management

Walkthrough of the latest TMD Guidelines with the authors!

What’s the right approach when a patient presents with both acute and chronic painful jaw symptoms?

How can the latest RCS guidelines simplify your diagnosis and treatment process?

In this episode, Professor Justin Durham and Mrs. Emma Beecroft join Jaz to unpack the latest Royal College of Surgeons TMD guidelines designed specifically to help GDPs navigate these tricky cases. Together, they explore practical strategies for managing TMD, breaking down the step-by-step flowchart that makes handling these cases less intimidating.

From understanding the key principles to applying them in everyday practice, this episode will help you feel more confident in delivering better patient care for TMD.

https://youtu.be/R0NaBJr5g5EWatch PDP213 on YoutubeProtrusive Dental Pearl: Important takeaway: Download the New TMD Guidelines

The folder includes:

A patient version of the guidelines
A dentist version of the guidelines
The full guidelines document
Video of delivering an equilibrated soft bite guard using heat technique

Key Takeaways:

The guidelines for TMD are designed to simplify diagnosis and treatment.
Self-management is crucial for TMD patients and can lead to better outcomes.
Understanding the difference between muscle and joint pain is essential in TMD management.
Early intervention in TMD can lead to significant improvements for patients.
The importance of patient-centered care in managing TMD effectively.
TMD is a common issue that requires a collaborative approach among dental professionals.
The role of pain management in TMD is about improving quality of life, not just curing the condition.
Continuous education and training are vital for dental professionals dealing with TMD. Understanding the pathogenesis of TMD is crucial for effective treatment.
Stabilization splints can provide relief but should be used judiciously.
Effective communication can significantly impact patient pain experiences.
Tailoring treatment to individual patient needs is vital.

Need to Read it? Check out the Full Episode Transcript below!

Highlights for this episode:

00:48 Protrusive Dental Pearl
05:20 Introducing the Guests: Prof. Justin Durham and Mrs. Emma Beecroft
13:05 Stigma and Complexity of TMD in Dentistry
17:01 Challenges of Navigating TMD Treatment Perspectives
22:07 Diagnosing TMD: Tools and Techniques
27:09 Simplified Approach to TMD Examination
30:54 Muscle Palpation Pressure
32:20 Acute Limited Opening: Muscle vs. Joint Origin
40:20 Diazepam for Acute Myogenous TMD
54:58 Debating Soft vs. Stabilization Splints
57:17 Patient-Centered TMD Management
01:09:28 Conclusion and Resources

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 200 OROFACIAL PAIN (Diagnosis and treatment)

Dentists will be able to –

Explore the varied approaches to TMD care and how to align them with evidence-based practices.
Emphasize the importance of self-management strategies and their role in improving patient outcomes.
Advocate for a patient-centered approach, focusing on listening, communication, and individualized care plans.

If you loved this episode, be sure to check out this episode: TMD Full Exam with ‘The TMJ Doc’ Dr Priya Mistry – PDP064

Click below for full episode transcript:Teaser: A standard extroral exam involves, the examination of temporalis and masseter, which are the only two muscles that international recommendations would suggest.

Teaser:So you don’t need to bother with that lateral pterygoid because you’ve got to be, have a bit of a strange finger to reach it, firstly up and around the back of the tuberosity and not evoke kind of vomit on your shoes.

And a medial pterygoid similarly, it’s not a very nice place to have palpated. And actually the vast majority of the diagnoses have been made with pressing on masseter and pressing on temporalis.

When you ask them to open to where they feel comfortable, anything less than 35 millimeters is restriction. For the acute restricted opening, anything 10 millimetres or less. So if they can’t get a finger between their teeth, that’s the ones we’re kind of more worried about from an acute restricted opening. Sometimes overrunning by 10 minutes to allow someone to feel heard, to be really clearly explained to them why they’re getting their problem can be what they need to get over the hurdle.

Not everyone needs to be in RCP and not everyone needs canine guidance group function. If they’ve already got group function, it’s fine. What they need is smooth and easy movement across the occlusal.

Jaz’s Introduction:Finally, some decent guidelines for TMD. Have you checked out the new TMD guidelines? This is exactly what today’s episode is about with Professor Justin Durham and Mrs. Emma Beecroft. They’ve joined me on the show today to discuss the 2024 RCS guidelines for the management of painful temporomandibular disorders, which let’s face it, as GDPs, it can be very confusing for us and very scary for us.

In the episode, I likened it to like trauma. When someone comes in and they’ve evulsed a tooth, we’re like, ah, okay, very time sensitive and it’s something that I haven’t done in a long time. What do I do? I pick up the guidelines. I pick up the trauma guidelines which will be a step by step to guide me on what to do. What’s best for my patients.

We also have some wonderful periodontal guidelines, and now we’ve got a lovely flow chart to follow for TMD. The main mission of today is to get you, and this is the Protrusive Dental Pearl, by the way, this is the most important pearl I can give you, which is to download all the free resources I’m putting below.

Okay. So whether you’re on Spotify and you read the description, YouTube, Protrusive Guidance, wherever you’re watching or listening to this, okay. Please make sure you take some time out today to download the guidelines. In fact, I’ve made it very easy. You don’t have to download individual PDF files. I made a zipped folder with the three main PDFs to talk about today, which is the patient version, the dentist version, and the full guidelines, for a really- want to put yourself to sleep.

You read those ones, but the summary document is actually really fantastic. And the patient one is honestly worth its weight in gold because the main thing is we don’t want to reinvent the wheel. Why are we giving our own practice branded guidelines for TMD? There’s no need to give your patient the document that your practice wrote about all the exercises they should do. Why don’t we show them which exercises to do. So what the guidelines for the patient has is a QR code that takes them to the videos where Emma herself, one of the guests of the podcast today is there showing the patient how to do the exercise.

And these are the latest guidelines. So I would say replace your current and existing documentation on TMD with this one, which is the latest and best advice with the videos. So patient’s not guessing anymore and how to actually do those exercises. In that zip folder, I’ve also added a video of how I deliver a soft bite guard, because that is the most accessible, the cheapest guard, which may help patients in acute pain.

And seeing as so many of us are already prescribing soft bite guards, which I don’t do so much of, but I know that this is the most economical and sometimes the speediest way to get someone care. And when I do these, there’s a specific protocol I follow of heating the splint to get even contact. Think about it.

When you give a soft bite guard, they are not balanced. So I’m going to show you a quick and easy way to get the balance. So that video is in there and any other goodies I can think of at a time of me assembling it. So you can download that at protrusive.co.uk/tmd, that’s protrusive.co.uk/tmd those goodies are there for you for free.

Now, before we join the main episode I just really need to emphasize the following; which is the supported self care part in there is the most important thing right? Let me explain why. There are so many different schools of thought for how to manage TMD. This is why patients get confused. This is why we as a profession are a little bit confused. There are colleagues who actively recommend orthodontics as the first line to manage TMD. There are colleagues that swear by neuromuscular methods and TENS or BOTOX as first line.

Well, I would say that the first line should always be supported self care. The foundational advice that you give for any type of joint injury, taking the load off. Applying heat, applying ice, self massage, there’s so much to it and it’s been all compiled in that document that I mentioned. So whilst I was lucky enough to have these two guests on today, I didn’t want to spend too much time on that because that is available to you and you should be giving that to your patient as first line.

Now a lot of what we discuss will upset some clinicians because we may have simplified it o...

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In this episode, Jaz dives into the complexities of Temporomandibular Disorders (TMD) management with Dr. Suzie Bergman, a US-based dentist and TMD sufferer. They discuss why treatments for TMD vary so much and examine the current state of evidence-based approaches.

https://youtu.be/r3QpkMYeTWkWatch PDP212 on YoutubeDr. Bergman shares her personal journey, highlighting conservative treatments, the role of occlusal appliances, and the power of multidisciplinary care. But just when you think you’ve got it all figured out—Dr. Bergman reveals a game-changing insight that could completely shift your approach to TMD management. Ready to find out what it is?

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

02:40 Protrusive Dental Pearl
04:32 Meet Dr. Susie Bergman: A Personal Journey with TMD
7:27 The Wild West of TMD Treatments
10:32 Challenges in TMD Research and Treatment
13:34 Suzie’s TMD Journey: From Trauma to Advocacy
21:42 Evidence-based Therapies and Occlusal Appliances
27:11 Orthodontics and TMD: A Complex Relationship
33:40 The Role of Occlusal Appliances
35:05 Debating Disc Displacement
39:17 Comprehensive TMD Diagnosis
44:09 Orthopedic Stability in Dentistry
51:04 Splints and TMD
53:52 Managing Bruxism Effectively
58:16 Suzie’s TMD Course and Final Thoughts

Listen to Dr. Suzie Bergman’s “Why is healthcare disjointed?” | TEDxStrathcona Women

Check out Dr. Suzie’s Course “21st Century TMD Protocols”

Looking for an Online course to allow General Dentists to treat 80% of TMD cases and 100% of Bruxists? Check out SplintCourse Online by Jaz Gulati

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject code: 200 Orofacial Pain (Diagnosis and treatment)

Dentists will be able to:

Recognize the multifaceted nature of Temporomandibular Disorders (TMD) and the various factors influencing treatment variability.
Evaluate current evidence-based treatments for TMD and their effectiveness, including conservative methods and occlusal appliances.
Discuss the importance of a collaborative approach in TMD management, integrating different specialties for optimal patient outcomes.

If you loved this episode, be sure to check out Deep in to TMD – An Orthopaedic Perspective – PDP172

Click below for full episode transcript:Teaser: I tell them T. A. T. U., which stands for Teeth Apart, Tongue Up, so during the day as much as possible, try to keep your teeth away from each other so that you're not clenching. I tell them, we want you to do the three S's, which are-

Teaser:I always tell people it’s unrealistic with chronic pain patients to think that there will be a day that you go to zero in pain. I don’t know what it’s like to not be in pain. Some days might be a little bit better, but there’s never a time that I’m not in pain. And part of that is because- When we have pain for so long, it can become a central nervous system issue. So when we have that central sensitization, our brain interprets non painful stimuli as painful.

We have patients who have discs that are either anteriorly and medially displaced, which is most common. It’s very uncommon for there to be a posterior displacement of the disc. We have to think about how that patient’s body has responded to the changes if the disc has been displayed. Some people will adapt beautifully and some people will not. And so, it’s really about the individual patient.

Jaz’s Introduction:The management of Temporomandibular Disorders is like the Wild West. I know for a fact that for the same issue you can go to one dentist who will suggest orthodontics, you can go to a surgeon who may suggest some form of surgery, even if it’s like an arthrocentesis, you can go to another person they might suggest some botox to calm those muscles, whilst the next two dentists are still arguing about which splint to make for this patient.

And so why does this happen? You see, the number one reason I think this happens is because we still don’t have clear protocols and clear guidelines because there’s a lack of evidence and there’s numerous reasons for that that we unpack in this episode with Dr. Suzie Bergman. She’s a dentist from the US who herself is a TMD sufferer and she’s had surgeries and orthodontics and all sorts. Which is why she can truly empathize with her patients and I love the fact that she’s willing to share her journey. This journey of chronic pain, which so many of our patients suffer with as well.

From this episode, what you are going to gain is an understanding of how we can manage temporomandibular disorders in ways that are evidence based and what should be considered from the evidence that we do have, by the way, and in a way that is not irreversible and allows a patient to do more fringe treatments, let’s say, in the future, rather than going in for more irreversible therapies, and you get a good flavor of that.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. Can you believe, by the way, that we’re almost at episode 200? There’s actually almost 300 episodes when you count all the group functions and the interference casts, but that magic 200 number is coming for the PDP as well. If you’re a new listener, welcome. If you’re thinking, why I talk about onions so much, keep listening and you’ll find out. And of course, if you’re a returning Protruserati, keep chopping those onions.

Dental PearlThe pearl today is kind of like an emotional one. One of my mentors, Michael Melkers, shared this with me and I want to share it with you because chances are if you clicked on this title then you may be used to seeing patients who suffer with TMD and oral facial pain and you more than likely have had this experience where the patient tells you their story, and disproportionately, this is a woman.

Disproportionately, this will be a woman, eight times more than it will be a male, and she will start crying. And this happens a lot in my clinics, and the nature of how we run things, and the referrals that we get with patients with long standing pain. And so what I used to do is me and Zoe would look at each other, and we’d get the tissues, and try to connect with the patient.

We’d we’ll be there for the patient at that moment. But what Michael Melkers suggested is that by giving the patient tissues, You’re kind of blunting their emotions. You’re kind of saying, actually, no, no, just dry your tears and let’s move on from this. You’re kind of not allowing the patient to express themselves.

So actually listen to that and I change what we do when a patient is vulnerable and they’re sharing such emotions and they’re getting a bit teary. I just listen. I just listen. I let them tell their entire story. And then at the end, I’ll help them with the tissues. But I really want to make sure I’ve listened to everything and I’ve connected and I haven’t missed an important part of their story.

And so like with everything, two ears. One mouth. Listen twice as much as you speak. I sound like my year eight history teacher. But it’s true for everything. This episode is eligible for CE and CPD. It’ll be worth one CE credit or one hour of CPD. You’ll be able to get that from the Protrusive Guidance app on the App Store or the Android Store.

If you haven’t already made an account, head to protrusive. app and join the geekiest and nicest community of dentists in the world. We’re sometimes a little bit slow by a couple of days to approve you because we actually manually approve each person. We want evidence that you are a dental professional joining our community because this needs to be a safe space. Anyway, let’s join the main interview with Dr. Suzie Bergman and I’ll catch you in the outro.

Main Episode:Dr. Suzie Bergman, welcome to the Protrusive Dental Podcast. How are you?

[Suzie]I’m great. Thanks for having me, Jaz. And please just call me Suzie.

[Jaz]I appreciate that, Suzie. Suzie, I’m so excited to speak to you. You’ve been on my radar for a few years. I know we emailed about some events in the past. And then you sent me recently your TED Talk. What a wonderful job. I’m definitely going to link that here. It’s something that every dentist should watch, but also there are some, unfortunately, so many patients who suffer with TMD who would also benefit from having that perspective.

And your story is so powerful. Could you spend a minute? Just tell us about you, your story. How did you niche into TMD? Are you still a general dentist or are you just like, have you niched into TMD? Tell us more about that.

[Suzie]Okay, great. So yes, I am technically a general dentist, but I like to call myself a primary care dentist. And I really don’t, I’m not someone who picks up a hand piece and does fillings and those kinds of things. What happened was when I was a teenager, I was involved in a fluke accident where basically I got run over by my friend’s car. And I became a TMD patient even before I became a dentist.

And back then the treatm...

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How far should you extend composite resin?

When does edge bonding become a composite veneer?

How do you decide where to finish the restoration?

And most importantly, how do you avoid that dreaded yellow-brown stain line that can form on anterior resins?

These are just some of the burning questions tackled in this episode with my guest, Dr. Mahmoud Ibrahim. We dive deep into the artistry and engineering of decision-making in anterior composites.

https://youtu.be/_q2O57-Y-d4Watch PDP211 on YoutubeProtrusive Dental Pearl: use a zirconia primer which contains 10-MDP (e.g. Monobond, Z-Prime Plus) on the intaglio of crowns to enhance bond strength, even with conventional cements like GIC. This low-risk, high-reward tip improves retention, especially for teeth with limited height. Incorporating a zirconia primer can significantly improve outcomes without switching to resin cement.

Interested in the Unchippable 2 Day Course? Click here to register your interest!

Key Takeaways:

Choosing between edge bonding or veneers is not a black-and-white decision.
The height of contour is key in cosmetic dentistry.
Seamless transitions between composite and tooth are pivotal.
Aesthetic considerations vary based on individual cases.
Material choice is influenced by patient risk factors.
Layering techniques enhance the natural appearance of teeth.
Patient previews are essential for managing expectations.
Thickness of composite affects durability and aesthetics.
Understanding angles is key to successful restorations.
Not all patients require the same approach to bonding.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:

02:43 Protrusive Dental Pearl
04:49 Personal Anecdotes and Health Goals
09:37 Anterior Composites: Edge Bonding vs Veneering
16:00 Importance of Finishing Composite Correctly
17:09 Understanding the Height of Contour
18:36 Importance of Layering in Dental Procedures
21:35 Choosing the Right Materials for Layering
23:56 Importance of Layering in Dental Procedures
27:14 Challenges and Solutions in Composite Layering
32:31 The Marshall Hanson Method
36:29 Mockups and Wax-Ups: Planning for Success
43:03 Treatment Considerations

This episode is eligible for 0.75 CE credits via the quiz on Protrusive Guidance.

This episode meets GDC Outcome C – Maintenance and development of your knowledge and skills within your field(s) of practice.

AGD Subject Code: 250 OPERATIVE (RESTORATIVE)DENTISTRY (Direct restorations)

Aim: To enhance clinicians’ understanding and decision-making in anterior composite restorations, focusing on when edge bonding transitions to a veneer, optimizing aesthetics and functionality, and minimizing common challenges such as staining and occlusal complications.

Dentists will be able to –

Understand the key factors that influence the transition between edge bonding to full veneers.
Apply guidelines for minimum composite thickness and bonding angles to enhance durability and aesthetic outcomes.
Identify high-risk patients and tailor material choices, layering techniques, and bonding approaches to individual needs.

If you loved this episode, make sure to watch Composite Veneers vs Edge Bonding – Biomimetic Dentistry with George The Dentist – PDP075

Click below for full episode transcript:Jaz's Introduction: How far should you extend your composite resin up a tooth, i. e. like when is it just edge bonding and when is it a composite veneer? Is it somewhere in between? How do you decide where to finish that resin up a tooth? And then how do you avoid that horrible stain line that can sometimes form on your resins anteriorly?

Jaz’s Introduction:So that horrible yellow brown line that you see around a composite. And when should you layer like different tints and shades? And when should you stick to monoshade? Just one shade. I’m a one shade one, the kind of guy, right? When is it okay to do one shade? When should you be layering? And related to that question is when can you do free hand and when do you need a wax up to be able to deliver the right result?

And something me, my guest Mahmoud Ibrahim also discussed is how the occlusal risk of a patient will also significantly impact what you should and shouldn’t do with your anterior aesthetics. And if you stick with us all the way to the end, Mahmoud will teach you about the minimum thickness, both on the incisal edge and labially, for optimal strength and aesthetics, and what angle should the composite be coming out of the edge.

So if you imagine the edge of a tooth and the angle on which the composite is bonded onto the tooth, there’s a specific angle that you should follow ideally. So you don’t mess up the patient’s occlusion.

Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Those of you who listening while you’re jogging or you’re on a train or you’re commuting, driving to work. Thanks so much for joining in. Hope you enjoy the show and those of you who are watching on either Procrucive Guidance app or YouTube or MedTube, you will notice that I’m looking a bit different. Well, I am sitting down, right? I’m usually standing for the last six years I’ve been standing and maybe I’m getting old.

But you know, I’ve decided now to take a seat, right? I usually feel like I have more energy when I’m standing up, but I want to do more episodes this year than ever before. I want to make more content this year than ever before for you guys. So I’m just looking at my body, right? Get used to me just sitting down a little bit more.

Hope that’s okay with you guys. And before we dive into this episode with Dr. Mahmoud Ibrahim, a very welcome guest, as always been on several episodes before and is my co presenter on the occlusion course. His composites are just out of this world. Like just check out his Instagram. He is a true artist and I’ve been encouraging for a long time to do more on composites.

So he’s going to branch into that a little bit more this year and I thought it’d be nice to tackle an episode about decision making. I want to tap into Mahmoud’s mind. How does he decide when’s it edge bonding, when’s it veneer, and the overall decision making, treatment planning guidelines he follows for his anterior composites. This episode is eligible for CE. We are a PACE approved education provider, and you’ll be able to do that by answering a few questions at the end if you’re on the Protrusive Guidance app.

Dental PearlEvery PDP episode, I give you a Protrusive Dental Pearl, and this pearl is related to an article I published on the app about top tips on bonding to zirconia.

You see, in 2017, I asked Dr Nasser Barghi at the STA convention Singapore. He’s a big shot in ceramics, right? And I said to him, look, now that zirconia is getting so good to bond with, should we now move away from lithium disilicate onlays and overlays, and should we move towards zirconia? And 2017, he said, listen, zirconia bonding is really good now, but why move away from this wonderful material, lithium disilicate?

I asked the same thing seven years later, so recently at the BACD conference, I asked the same thing to one of my idols, Dr. Chris Orr, and he said the exact same thing. He said, yes, you can bond to zirconia in this strict protocols. But why? When we can do beautiful partial coverage restorations posteriorly that have enough strength and bond just so predictably in lithium disilicate.

So just some food for thought there. I know some of us are doing zirconia onlays and overlays that’s fine, go for it. But I have yet to found a reason to deviate away from lithium disilicate. Well, I’m using the adhesive approach. Now, of course, for resin bonded bridges, I’m using zirconia as well as metal and for my vertical preparations. I am cementing zirconia crowns.

But the top tip I want to give you from that article I wrote summarizing what I’ve learned of the years about bonding to zirconia one top tip is even if you are cementing by using a zirconia primer for example monobond or z prime plus or clear fill ceramic primer something that contains that 10 MDP.

If you use it on the intaglio of the crown, even if you’re not using a adhesive cement afterwards, even if you’re not using resin cement to actually bond your zirconia by using the primer, the zirconia primer, you are actually improving your bond strengths, even with the GIC that you’ll use, for example.

So this is really useful. This is like low risk, high reward. If you have a tooth and you’re crowning it and maybe it’s got less height and you’re thinking is that retention form going to be enough, then perhaps you could still use your conventional cement system, but by using the zirconia primer, you actually get a better outcome. So that’s a top tip I want to pass on to you. Now let’s join this episode on decision making on anterior composites.

Main Episode:Dr Mahmoud Ibrahim, my brother from another mother, welcome back yet again to Protrusive Dental Podcast. How are you, my friend? Other than sniffly.

[Mahmoud]Oh, sniffly and coffee and I apologize everybody if I sound like a frog, but yea...

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What influences your decision when choosing ceramics?

What are the main ceramics nowadays—and do porcelain-fused-to-metal still have a place in dentistry?

Are the protocols different for various types of ceramics and crown materials?

How important is rubber dam isolation, and is a split dam good enough?

In this Back to Basics Protrusive episode, Jaz teams up again with Emma Hutchison, ‘the Protrusive Student’, to break down these critical questions and simplify the world of ceramics. From decision-making frameworks to practical rubber dam tips, this episode is packed with insights to elevate your practice.

Whether you’re a student navigating the foundations or a seasoned clinician revisiting the essentials, this discussion offers a fresh, evidence-based perspective on mastering ceramics in dentistry.

https://youtu.be/z4a8Hv6peVUWatch PS013 on YoutubeKey Takeaways:

Understanding the role of metal ceramic crowns is crucial in modern dentistry.
Monolithic ceramics are preferred for posterior restorations due to their strength.
Layered ceramics can enhance aesthetics but may compromise strength.
Proper crown preparation is essential for successful restorations.
Communication with lab technicians is vital for successful bonding.
The choice of ceramic material largely depends on the amount of enamel available.
Following manufacturer protocols is key to achieving optimal results.
Bruxism patients require careful consideration in material selection.
Rubber dam isolation is crucial for predictable bonding.
Digital scanning requires more aggressive tissue management.
Impressions are still valuable, but digital methods are advancing.

Need to Read it? Check out the Full Episode Transcript below!

Highlights for this episode:

03:52 Emma’s Exam Experience
07:28 Feedback on Previous Episode
08:00 Discussion on Ceramics in Dentistry
10:51 Practical Applications and Material Choices
19:45 Monolithic vs. Layered Ceramics
24:18 Exploring Milled Cobalt Chromes and Gold Crowns
26:14 Challenges in Fitting Restorations and Bonding Techniques
30:03 Rubber Dam Techniques and Benefits
37:01 Intraoral Scanners vs. Traditional Impressions
40:14 Effective Communication with Lab Technicians
44:25 Conclusion and Future Plans

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 010 BASIC SCIENCE (Dental materials)

Dentists will be able to –

Identify the suitability of ceramics based on their strength, aesthetics, and application.
Highlight the importance of proper crown preparation and manufacturer protocols for optimal results.
Emphasize the importance of rubber dam isolation and compare the benefits and challenges of analog impressions versus digital scanning.

If you love this episode, make sure to watch Composite vs Ceramic with Dr Chris Orr – PDP030 and make sure to read the Protrusive Notes!

Click below for full episode transcript:Teaser: I do not place lithium disilicate and I cement it. So for me, the way my mind works is if I'm cementing and not bonding, if I'm cementing just using a GIC based cement, so I'm not relying on enamel for adhesion, why would I use lithium disilicate? Using lithium disilicate posteriorly and bonding it, excellent strength, good, it's going to be fine, as long as you give it enough thickness, 1.5-2mm, you're golden, okay.

Teaser:If you don’t respect the thickness, or if you use cement and you don’t bond it, you’re going to really compromise on the strength, you’re not going to get the high strength. So therefore, the same material, lithium disilicate, cemented is a completely different ceramic to the same ceramic lithium disilicate, bonded.

You need to know your material and the correct protocol for your material. You’re not supposed to air abrade lithium disilicate. But I know some clinicians who whatever material they get back from the lab they will air abrade it. You do introduce micro cracks. Whether it or not it’s clinically significant or not, I don’t know, but I’m one of those people that I follow the rulebook for any material I use, any bond I use, like exactly how the manufacturer wanted it, I pretty much will follow that.

The other thing to bear in mind is, how important is it to you that this molar tooth, looks absolutely gorgeous. How important is it to you? And I wait for them to say the answer. Okay, and I say, okay, you want it to look gorgeous, but what if I told you that if you accept that it’s going to look good, but not gorgeous, it will last way longer because the chance of it breaking is way less. What’s more important to you? Longevity or beauty?

Jaz’s Introduction:When I was a student, like many things, ceramics were very confusing. And fast forward many years, when I qualified, they were still very confusing. What I present today in this back to basics series with Emma Hutchison, the Protrusive Student, is a simplified overview of ceramics and how I view them.

My views are based on the courses that I’ve been on, the evidence that I’ve read, and my daily clinical practice, which makes up a third of evidence based dentistry itself. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Hey, the last one on extractions. I mean, you guys loved it.

So thank you so much for everyone who liked it and commented. It really helps us to keep going. I was always unsure about this Protrusive Student series and going back to basics, but you guys are loving it. And I really appreciate that. I mean, Emma will continue to make dentistry tangible for students, but a lot of these episodes are very useful for dentists, like a back to basics, revisiting the foundations.

There’s something very validating about that. Sometimes you can only measure your growth when you look back and listen to an episode like this and feel that, you know what? I knew kind of everything and look how much I have grown. There’s a real beauty in that. So in this episode, we cover decision making in ceramics.

What influences your decision. What are the main ceramics that I’m using nowadays and do I still use porcelain fused to metal? Are the protocols different for the different types of ceramics and crown materials? How important is rubber dam isolation? Is split dam good enough? And we’ve even thrown in some rubber dam tips in there for you.

This episode, like the last one, is eligible for CE. Protrusive education is a PACE approved provider. And we also satisfy the criteria for the GDC. All you have to do to play and collect CPD is answer the five questions and get 80%. That’s only available on www. protrusive. app. Once you make an account, you can download it on Android and iOS, listen on the go, answer the questions, also answer the questions of the past episodes that you’ve listened to, and validate your learning.

An opportunity to reflect, which forms part of your personal development plan. We’ve also got the notes from this episode written by Emma, all about dental ceramics, like a cheat sheet for any student. It does go quite deep, but it’s all the stuff that you need for your exams. And that’s in the crush your exam section of Protrusive Guidance.

Once you join Protrusive Guidance, you just have to email student@protrusive.co.Uk so we can verify you’re a student and add you on there. Now let’s join the main episode and I’ll catch you in the outro.

Main Episode:Emma Hutchison, the Protrusive Student, welcome back. You’ve just had an exam. How did it go?

[Emma]It was okay. It was a structured clinical reasoning exam. And which was something that, it’s something that Glasgow only introduced. I think two years ago, it might’ve been last year, actually. So no one really knows what was going on. So.

[Jaz]An example question from there that was a tough one.

[Emma]Yeah, so you’re basically given a few cases, and you have like an assimilation time to sit in a room and look over these cases. You just get radiographs, clinical photographs, a bit about medical, social history. So you have 25 minutes per case to read over. You don’t know what questions you’re going to be asked, and then you go in, and you’ve got, for each station you’ve got two tutors or clinicians, and you sit in front of them, very closely actually, I thought they were going to be a bit further away across the room, but you were sitting right in front of them, and they just kind of grill you on your treatment plan.

If it’s oral medicine, they’ll ask you questions about histology, things about medications as well. Like, we had a patient that was on Warfarin, so they’re going to ask about all the INR, things like that.

[Jaz]You knew that. You knew all that, right?

[Emma]Yeah, yeah. It’s just hard because you have no idea what’s going to come up. So, a lot of it is reading over your guidelines, SDCEP, American Endodontics, things like that. So, it’s very intense. It’s very intense, but I’m glad it’s over.

[Jaz]Which was the question that stumped you?

[Emma]So, you get your topics two weeks in advance, so we were restorative and orthodontics as well. And for restorativ...

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What’s the best way to reduce post-op pain after extractions? And why should we never use the term “painkiller” with patients? What to do when you hear the dreaded crack of a tuberosity?

In this episode we talk about all things post-operative extraction complications! And I’m joined by one of the nicest guys in dentistry – Dr. Nekky Jamal

Complications are something we ALL experience, so this episode is great for any dentist. Whether you’re brushing up on dry socket prevention, mastering post-op communication, or just curious about advanced healing hacks, tune in for real-world advice to make extractions smoother – for both you and your patients

https://youtu.be/BvB3hDESYDYWatch PDP210 on YoutubeProtrusive Dental Pearl: The “Niche Kebab” concept encourages dentists to narrow their focus by reducing the variety of procedures they perform and prioritizing those they genuinely enjoy. By evaluating every new skill or treatment added and strategically dropping less-loved procedures, dentists can avoid overextension and the “jack of all trades, master of none” pitfall.

Learn how to Extract Impacted 3rd Molars, don’t miss out on Third Molars Online and use the coupon code ‘protrusive’ to get 15% off!

Key Takeaways

Pain management is about setting realistic expectations.
Dexamethasone can be beneficial but must be used cautiously.
Dry socket is often overhyped; proper care can prevent it.
Effective communication can alleviate patient anxiety and prevent misunderstandings and complaints.
Preoperative care can help manage pain expectations.
Understanding the signs of infection is essential for diagnosis.
Chlorhexidine rinses can significantly reduce dry socket risk.
Patients appreciate being informed about their unique dental situations. PRF can significantly reduce the incidence of dry socket.
Dentists should embrace new techniques like PRF to enhance patient care.
Patient involvement in post-surgical care is crucial for healing.
Dentists should not hesitate to refer complex cases to specialists.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

02:54 Protrusive Dental Pearl
04:05 Dr. Nekky Jamal
08:39 Managing Post-Extraction Pain and Swelling
21:37 Infection
25:02 Identifying Dry Socket and How to Prevent it
28:30 Case Selection and Communication
37:13 Mitigating Dry Socket with Platelet-Rich Fibrin (PRF)
39:47 The Importance of Nicheing in Dentistry
43:19 Cryotherapy and Post-Surgery Care
47:32 Handling Tuberosity Fractures
55:08 Patient Consent
57:55 Litigation and Patient Communication

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A, C and D.

AGD Subject Code: 310 ORAL AND MAXILLOFACIALSURGERY (Exodontia)

Dentists will be able to:

Identify and differentiate common postoperative complications, and recognise the key symptoms associated
Evaluate the ethical and clinical considerations of case selection for extractions
Communicate effectively with patients regarding potential complications

If you loved this episode, be sure to check out another epic episode with Dr. Nekky Jamal – Wisdom Teeth Extractions – SURGICAL TOP TIPS

Click below for full episode transcript:Teaser: Overexplain and then have them on your page, have them take ownership for their anatomy before you even start. You know what I mean? Dentistry is about talking to patients and Jaz, you've seen how I talk to my patients. I keep everything light, but after I joke around, I say, okay, but seriously, do you understand that this is a risk like this could actually happen and in this case scenario I don't want that to happen for you.

Teaser:I’ll do everything I can for you. But there’s things that are out of our control. Do you understand? And patients have to take ownership of it? Otherwise, I’m not doing work. I hate using the word painkiller because that’s just not realistic. It’s more of like a pain reliever. Okay, and so will you be in 100% pain free even with a painkiller or analgesic?

No, you won’t, right? And so the job of an analgesic is to make you more comfortable, not to kill the pain. Patients, they don’t want to be in pain, but if they feel like they’re constantly taking something for pain, maybe psychologically it’s helping. But for, I would say 99% of my cases, like I’m not going, I’m not veering away from my ibuprofen, paracetamol slash acetaminophen protocol.

If you’re really interested in extractions or if you’re really interested in endodontics, like, become obsessed. Like become obsessed to the point where you’ve read every single journal article out there. I want you to go home and I want you to dream of it. I want you to feel like, your patient is trusting you. So you need to know everything about it. And so many dentists have that passion. Like what other profession do you go to?

Jaz’s Introduction:In this episode, we’re one of the nicest guys in dentistry, Dr. Nekky Jamal. We’re going to revise together how to manage the common complications of extractions. There’s a bit of a bias towards third molars, but actually the advice given by Nekky and what we discuss today is pretty much applicable to any extraction or any type of dental surgery.

We’ll talk about the best strategies for post operative pain and why you should never use the term a pain killer. Nekky will also reveal why alveolar osteitis or dry socket is virtually non existent in his practice. He’ll tell you exactly what it does to prevent dry sockets. We also discuss the dreaded tuberosity fracture with golden advice on what to do if it happens to you and how to preempt it or prevent it.

Lastly, this episode is actually full of communication gems. And actually the last six minutes talk a little bit about some stuff, which isn’t really appropriate for the public eye. It’s real dentist talk, if you know what I mean. And that’s why the last six minutes will be on the Protrusive app only.

It’ll still be free, but we only on Protrusive app. It won’t be on Spotify, won’t be on Apple, and it is absolutely golden. So if you’re starting this podcast on YouTube or Spotify or Apple. And now that you know this information, you want to move over to Protrusive Guidance app, please do so now.

Dental PearlHello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. Some tip or advice that you can apply in your practice. This one’s about your mindset and something that we discussed in the episode. I call it Niche Kebab. The idea of niching down in dentistry and we talk about how by niching into a subspeciality or just reducing the amount of procedures you do and homing in on a few that you really enjoy.

This is what keeps the fire burning in dentistry. This is what helps you to fall in love in the details of dentistry and how to be a happy dentist. Me and Nekky truly believe that. So here’s how you apply Niche Kebab. For every new procedure that you offer or you learn, or a new skill set that you add on, which procedure or treatment will you drop?

I know that sounds a little bit scary or worrisome or maybe a bit extreme, but do you really want to keep adding procedures and adding procedures and spreading yourself out thin, becoming the jack of all trades, but the master of none? Protruserati, this is growth by subtraction. I just want to give you this idea or help you adopt this notion or this mindset that it’s okay to actually whittle down some procedures that you don’t love to give you the time and energy to focus more on things that you do love or things that you could potentially love or new skills that you can add on.

So remember, so don’t just keep adding and adding and adding. Think about what you will remove and eventually you can achieve Niche Kebab. I’m claiming that one by the way. Anyway, hope you enjoy the main podcast and I’ll catch you in the outro.

Main Episode:One of my all time favorite dentists in the world, generally one of the nicest guys ever. Dr. Nekky Jamal, welcome back to Protrusive Dental Podcast. How are you, my friend?

[Nekky]Jaz, this is a huge honor. Man, I listen to the podcast all the time. I’m just so proud to be a part of it, man. You’ve done some huge things across the world and help so many dentists. I’m just a fan boy over here, man.

[Jaz]No, no, no. Look who’s talking, man. Like we all love your stuff, and it’s your charisma is the way. You very much fall into the values, which I’m going for with protrusive, right? The kind of dentist who are nice and geeky and like, you’re solely geeky. Like you love everything you do.

It’s just so clear and you’re funny and you’re very likable. And so it’s just great to build these connections, transatlantic connections with yourself. And it’s just great to have you back again. You’re messaging the way you speak. It’s all brilliant. So very excited to delve into third molar extraction complications today, following on from the previous episode that we’ve done.

...

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In this special recap, we’ll explore 12 key lessons from 2024 —insights that have shaped our practice, validated our protocols, and sometimes, inspired small but meaningful changes.

Happy New Year from Team Protrusive! As we kick off 2025, we want to express heartfelt gratitude for your incredible support throughout 2024.

What were the standout moments that shaped your learning this year?

Which episodes gave you that “aha” moment?

Whether you’re a seasoned listener or just jumping in, this recap will help solidify the lessons that you can apply to your practice every day.

https://youtu.be/OxfRmNhQ7WkWatch PDP209 on YoutubeProtrusive Dental Pearls:

Take time to reflect on your goals for 2025 and consider what sacrifices you’re prepared to make to achieve them. Emphasizing the importance of writing down both your objectives and the trade-offs they require, align your time and priorities with your personal and professional aspirations.

“You overestimate what you can achieve in a year and underestimate what you can accomplish in ten years.” Productivity is about knowing how badly you want something and what you’re willing to sacrifice to achieve it.

Take a deep dive into this literature: Clinical considerations for increasing occlusal vertical dimension: a review

Australian Dental Journal – 2012 – Abduo – Clinical considerations for increasing occlusal vertical dimension a reviewDownloadNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

01:08 Protrusive Dental Pearl
06:25 Value Your Skills
11:54 Importance of Photography and App Launch
14:42 Audio Notes in Dentistry
16:41 Rubber Dam Mastery
18:07 Composite Techniques and Innovations
21:07 Onlays vs Full Crowns
25:54 Best Bonding Agents
28:55 Digital Dentures Revolution
31:24 Mastering Vertical Dimension
32:29 Perfecting Posterior Composites
34:58 Creating Awesome Dentures
36:27 Extraction Techniques and Avocado Analogy
37:47 Looking Forward to 2025

Here are some episodes and webinars mentioned in this episode that are definitely worth checking out:

Value Your Skills – How to Stop Underselling Yourself – AJ006
Your Occlusion Questions Answered by Dr Michael Melkers – PDP015
Cracked Teeth and Dentistry’s Tough Questions with Dr Lane Ochi – PDP175
NEVER Write Notes Again! How I Use AI for Awesome and Efficient Dental Records – PDP181
Canine Guidance vs Group Function – Does it Matter?! – PDP182
Class II Composites WITHOUT a Wedge + Contact Opening Technique – PDP188
Onlays Vs Full Crowns – Decision Making 2024 – PDP189
Quick and Slick Rubber Dam
Vertipreps for Plonkers
Premium Clinical Videos
My Productivity Secrets Revealed Webinar REPLAY
Deep and Dark Class III Restorations
Which Generation Bonding Agent is the Best? 2024 Adhesive Systems – PDP192
Digital Dentures for Every Dentist – The Death of Impressions? – PDP195
[OCCLUSION MONTH] Vertical Dimension – Don’t Be Scared! – PDP197
How to Place Posterior Composites without Destroying Your Anatomy – PDP200
Making Awesome Dentures – Border Moulding and Beyond – PDP205
Exodontia for Beginners – Extractions via Avocados! – PS012

Take your practice to the next level with DigitalTCO, Dental Audio Notes, and the Greater Curve.

Click below for full episode transcript:Jaz's Introduction: Happy New Year, Protruserati. 2025, from all of us here at Team Protrusive, honestly, thank you so much for an awesome 2024 and looking forward to so much in 2025. In this episode, we're going to look back at all the gems from 2024 and looking forward to 2025. So I'll give you at least 12 takeaways, 12 key lessons from the episodes of 2024.

Jaz Gulati:Things that I took away that I’ll be changing in my practice or sometimes things that were validated, lessons and ideas and protocols that were validated. Validation is a really beautiful thing. As you gain more experience in your career, the more courses you go on, you realize that you get to a point where you’re not learning as many new things anymore.

And sometimes you go to a course and it’s just one little thing you picked up. And it was all worth it. And so much of it is actually validation. It’s really lovely sometimes to know that there are other people doing it the same way that you’re doing it, or the advice that you were taught a few years ago is still current and best practice according to someone that you really respect.

Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Now as this is a PDP episode, before I start, I will give you your protrusive Dental Pearl. And as it is January 1st, it’s 6am as I’m recording this before the kids wake up. And I’ll tell you something really sad, right?

Last night was the first time in my living memory, like literally since I was like six years old, I’ve always seen the new year end. I’ve always seen the clock strike midnight. And to wish those around me a happy new year. Last night, me, the kids, everyone were asleep by 10 p. m. And I guess it’s a sign of maturity, it’s a sign of growing up.

It’s a sign of a season of life I’m in. You know, life is all about family and the two young boys that we have. And by 10 p. m. we were absolutely exhausted. Which is why I was able to be up at like 4 something this morning to get the studio ready to record this. And the reason I’m telling you this is because it’s very relevant to the pearl I’m going to give you.

See, this time of year is really important to me because it was around about this time, six years ago, that I started the Protrusive Dental Podcast. At that time, I had every reason in my mind not to do this, to not start a podcast. Who’s going to listen? I hate the sound of my voice. I don’t have the budget for a studio and I can’t even buy a green screen.

What do I do? I don’t even know how to get started. But then I came across a book all those years ago. It was called Start Now, Get Perfect Later by Rob Moore. And that book really motivated me to just get started. Even if one person listens, that I will get something started. Fast forward so many years and we’ve crossed 1. 1 million audio listens, over 2 million views on YouTube in total, and thousands of Protruserati just like you all over the world that me and Team Protrusive are absolutely indebted to. Thank you so much for supporting the show by watching, by subscribing, by commenting and liking. It really means so much.

Dental Pear...

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Are you focusing enough on pink aesthetics in smile design?

What role does gingiva play in achieving a truly stunning smile?

When should you refer for recession around lower incisors or upper canines?

Can you get the gum to grow back through orthodontics? And how about class 5 restorations? Should we do them, or should we work on the gingival recession first?

In this episode, Jaz is joined by the expert Dr. Tidu Mankoo, who shares his extensive knowledge on the importance of gingival health in aesthetic dentistry. They dive into the crucial role of the dento-gingival complex.

https://youtu.be/Ao_vgJ-IbOgWatch PDP208 on YouTubeProtrusive Dental Pearl: Shade Matching

Composite button technique – a small blob of composite is applied to a dry tooth without etching or bonding to assess shade match and translucency, avoid excess thickness, which can affect opacity and aesthetics (Jason Smithson’s Tip: take a black-and-white photo to evaluate the composite’s value and ensure it matches the natural teeth)
Using a custom composite shade guide like Smile Line by Style Italiano for more precise shade matching.

Key Takeaways

Gingival architecture plays a vital role in aesthetics.
Dentists should focus on patient-centered care.
Understanding tooth position is key to treatment planning.
Orthodontics can sometimes resolve gingival issues without surgery.
Communication with patients is essential for effective treatment.
Aesthetic dentistry requires a comprehensive approach.
The dental field is evolving, and practitioners must adapt. Root coverage procedures can be effective with proper techniques.
Understanding prognosis is crucial for successful treatment outcomes.
Aesthetic considerations are a primary reason for root coverage.
Restorative dentistry should consider the position of the gingiva.
Crown lengthening should not expose root surfaces unnecessarily.
Mucogingival surgery plays a vital role in implant aesthetics.
Education and training are essential for dental professionals.

Need to Read it? Check out the Full Episode Transcript below!

Highlights for this episode:

4:29 Protrusive Dental Pearl
6:16 Dr. Tidu Mankoo’s Journey and Inspirations
11:48 Reflections on Comprehensive Dentistryand Lifelong Learning
15:59 Balancing Work and Family in Dentistry
17:52 Understanding Gingival Architecture
19:49 Creating a Harmonious Smile
21:52 Addressing Gingival Aesthetics & Limitations
26:56 Orthodontics and Surgical Interventions
29:40 Root Coverage Procedures
33:49 The Value of Early Diagnosis and Referral
35:01 Indications for Root Coverage
36:03 Root Coverage vs. Class V Restorations
39:50 Managing Gingival Zenith Irregularities
41:23 Role of Mucogingival Surgery inImplant Success
47:47 Course on Mucogingival Surgery with IAS

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 780 ESTHETICS/COSMETIC DENTISTRY

(Esthetic diagnosis and treatment of intraoral soft tissues)

Dentists will be able to –

Discuss when and how to manage gingival recession, including the role of root coverage procedures.
Explore the anatomy and function of the dento-gingival complex and its influence on smile aesthetics.
Promote the value of early diagnosis and timely referrals to specialists for successful treatment.

???? Join the Ultimate Masterclass on Implant Soft Tissue and Complex Cases! ????

???? Dates: April 2024???? Event: Implant Soft Tissue and Complex Case Masterclass

Join this two-day masterclass to elevate your skills in:

✅ Implant soft tissue management

✅ Root coverage and crown lengthening

✅ Complex case planning and aesthetics

If you loved this episode, be sure to check out PDP035 – Case Acceptance in Smile Design with Dr Gurs Sehmi

Click below for full episode transcript:Teaser: Young dentists are limiting their knowledge and experience because there are cases where you're not going to have simple wear and simple misalignments. You're going to have complications. You're going to have teeth that are structurally compromised or endodontically compromised or periodontally compromised.

Teaser:What are you going to do then? Then it’s not just edge bonding and composite bonding or injection molding or whatever that’s in the current fad. And it’s not only tooth position, it’s root talk. So sometimes, particularly in a lot of, we see this in a lot of orthodontic cases, patients who’ve had ortho, particularly in lower interior region.

You see, sometimes the roots have been placed too far buccal outside of the bony envelope and you see clefts and recession typically in the lower incisal region, often as a result. And in those scenarios, if you’d correct the torque, will the gingiva settle?

Jaz’s Introduction:If you get the white aesthetics right, what I mean by that is having the incisal edges in the right place, the correct anatomy and surface texture and alignment of your teeth, yes, that’s going to give you a good smile.

But what’s going to give you an amazing smile is getting the pink esthetics right. Think of the gums. Think of the dento gingival complex. That’s when your smile design really goes up. And in your career, as you become more comprehensive, you realize that having the gum line and the gums in the right place is so important to an esthetic outcome.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast, where I’m joined by an absolute legend today, Dr. Tidu Mankoo. Dr. Mankoo is a world renowned expert in all things dentistry. He’s got so much to share, so much experience, extremely comprehensive dentist, super experience in advanced cosmetic dentistry, and so very excited to share this episode all about getting the pink esthetics right.

As a foundational thing, when should we consider referring for that lower incisor with that recession? How about the upper canines that got recession because they’re too buccally placed? Can you get the gum to grow back down by doing orthodontics? And how about class 5 restorations? Should we do them or should we work on the gums first?

Should you never do a class 5 restoration? And if you did do a class 5 restoration, where should you finish it to make sure that any future gingival surgery is going to work better? At the very least, Protruserati, let this episode inspire you to think beyond just the white esthetics, to consider what the gingiva is doing and to allow you to read more about gingival esthetics, listen to more about gingival esthetics, inspire you to learn and grow in that field.

Dental PearlNow every PDP episode I give you a Protrusive Dental Pearl and today’s pearl is inspired by the community. Dr. Arti on the Protrusive Guidance asked about a scenario where she’s trying to match Genial Composite to the teeth and she’s finding that she’s struggling to get the right shade match. For example, the B1 of Genial was not quite matching the Vita B1 shade.

So what I did is I made a quick little video. I went live on Protrusive Guidance, which by the way is our community. It’s a community of of the nicest and geekiest dentist in the world. I don’t pump any money into ads. I don’t advertise this community. I try and keep it to those people who listen and watch the podcast because those people like you who choose to spend some time with me and the guest, really going geeky, really immersing themselves with deep education, wanting to constantly be better and to reinvigorate your passion for dentistry.

These are the kind of dentists I want parts of the nicest and geekiest community of dentists in the world. So they are living on Protrusive Guidance. There’s over 2, 000 of us already on our community. So do join us on protrusive. app if you’re not already there, especially if you ever feel lonely in our profession.

The Protrusive Guidance community is an absolute far cry from the BS you see on the Facebook groups. We seem to attract the nicest and most caring and most empathetic dentists there are. Anyway, so I went live in the community really quickly during lunch, and I explained that acrylic shade guides, which is what they are, you know, the Vita shade guides are acrylic.

How can they accurately represent a composite shade? They can’t. And the other truth is that all composites are built differently. Certain brands of composite will have naturally more value. A B1 of one brand will have more value than the B1 of the other brand. Venus composites, which I use a lot of nowadays, Venus Pure, for example, is more opacious.

Estilite, which I also use, is more translucent. So you’ve got to kind of match it to what kind of tooth you have in front of you. So you’re thinking, okay Jaz, what’s the pearl? What’s the pearl beyond recognizing that you can’t just go with a Vita Shade Guide? Well, here are two ways. One which is cheap and easy, an...

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In this episode, we focus on the link between periodontal disease and the systemic effects on the human body. There’s more to oral hygiene than just saving our teeth, so let’s dive into this fascinating episode with Dr Reena Wadia to learn more about the importance of perio and how it is associated with the rest of our health.

https://youtu.be/fldpB_8h2DcWatch GF024 on YoutubeKey Takeaways:

There is a strong link between gum health and systemic health.
Diabetes and cardiovascular disease are key conditions linked to gum health.
Understanding correlation vs. causation is crucial in dental practice.
Effective communication with patients can improve treatment outcomes.
Treating pregnant patients for periodontal health is safe and beneficial.
Proper diagnosis is essential for effective dental treatment.
Patients are often unaware of the links between gum health and overall wellness.
Motivating patients with health benefits can enhance compliance.
Evidence-based dentistry is vital for accurate patient information. Add the word diagnosis to templates for clarity.
Team collaboration (dental and medical practices) enhances patient care effectiveness.
Screening for conditions like diabetes can save lives.
Holistic care in dentistry is becoming increasingly important.
A periodontal protocol is crucial for consistent care.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

3:50 Introduction to Dr Reena Wadia
7:14 Systemic Link
12:24 Under Investigation
13:54 Using this with our Patients
17:04 Birthweight-related Studies and Pregnancy
20:14 Make a Periodontal Diagnosis
23:34 Medicine and Dentistry Collaboration
26:29 Understanding the Patient
29:14 HbA1c Machine
32:19 The Perio Handbook

This episode is eligible for 0.5 CE credits via the quiz on Protrusive Guidance.

This episode meets GDC Outcome A, B and D.

AGD Code: 490 PERIODONTICS (Pathophysiology of periodontal disease)

Aim: To enhance dentists’ understanding of the link between periodontal health and systemic diseases, enabling them to integrate evidence-based periodontal care into their clinical practice.

Learning Outcomes:

Knowledge and Application: Dentists will gain a thorough understanding of the bi-directional relationship between periodontal disease and systemic conditions such as diabetes and cardiovascular disease, and learn how to apply this knowledge in clinical practice to improve patient outcomes.
Patient Education: Dentists will acquire practical strategies for effectively educating patients about the systemic implications of periodontal health, using analogies, visual aids, and evidence-based communication methods.
Holistic Treatment Planning: Dentists will learn how to incorporate systemic health considerations, such as screening for diabetes or collaborating with medical professionals, into their periodontal treatment plans to deliver comprehensive care.

Enhance your knowledge with Dr. Reena Wadia’s Perio School and establish a habit of implementing Perio protocols in your practice. Don’t forget to grab a copy of the Perio Handbook by Dr. Reena for valuable insights!

If you enjoyed this episode, check out: Communication Masterclass for Periodontal Disease [B2B] – PDP086

Click below for full episode transcript:Teaser: When you hear stories like that, it's like, could that have been undiagnosed diabetes, heart attack, et cetera, et cetera. So I feel so privileged being able to have that ability to do that test on our patients. And yeah, it's not the nicest thing to say to someone, you might have diabetes, but actually like that could save someone's life.

Teaser:The guidelines now are, for example, for diabetics, once they’ve been diagnosed with diabetes, they’re supposed to see their dentist, but they need to push it more, because they definitely push the eye appointments, the foot appointments, but what happens to dental? It’s absolutely fine and safe to treat pregnant patients.

Jaz’s Introduction:A really great trend we’re seeing is the integration of dentistry back into the body. Because for so many years, since the inception of medicine, dentistry has been like on the sidelines. It’s as though the mouth is not part of the body and how little communication there is between medicine and dentistry.

Now all that is changing, especially when it comes to things like airway, right? Sleep disordered breathing has really started to connect medicine and dentistry, and now with strengthening evidence base of certain dental conditions and how they link to medicine. It’s a very exciting time. Now this episode, we’re focusing on the perio and systemic link.

Hello Protruserati, I’m Jaz Gulati. Welcome back to your favorite Dental Podcast. This one’s called Group Function, but we find out one burning question. Burning question, I want to find out from Dr. Reena Wadia, perio specialist today. Is in a world where there’s so much about correlation versus causation? Just because some things correlate does not mean that one causes the other.

However, when it comes to periodontal disease, do we have enough evidence to suggest that there is a true link between periodontal disease and general health? And which links are those. How can we harness this? How can we motivate our patients and what claims can we make to our patients safely? And actually towards the end of this episode what we develop into is really quite good because what we talk about is the number one error that general dentists make and that is a lack of diagnosis, even a periodontal diagnosis of healthy is still a diagnosis.

And an even bigger overview is, does your practice have a periodontal protocol in place? Are your hygienist and dentist singing from the same hymn sheet? And are you talking about general health and those links? Well, hopefully after this episode, you will be.

This episode is eligible for 0. 5 CE credits. Protrusive Education is a PACE approved provider and those in the UK, the GDC is going to be asking for your CPD anytime soon, every December. We distribute a shed load of certificates, because those Protruserati that have been listening to the podcast, been claiming CPD, are sleeping easy, because they’ve got so much CPD.

If you go back all the way six years to Protrusive Archives, you can collect over 300 hours of CPD just from the podcast episodes. So if you’re not already on our platform, answering our quizzes to validate your learning from these episodes, it’s so easy. Just head to protrusive. app, make an account, choose your plan, as well as gaining CPD or CE credits, you support Team Protrusive and our educational movement.

This month we also launched the sixth lesson of VertiPrep for Plonkers. First five core lessons. I essentially teach you how to place your first ever vertical crown, how to ditch the shoulder and ditch the chamfer for the vertical margin, especially good for teeth with subgingival caries and limited tooth structure because you’re so conservative with a vertical preparation.

Once you go verti, shoulders feel dirty. And in this sixth lesson, I went over a full case in full detail, every little facet of the video. I also talked about quality controlling your lab work and generally revised all the principles for the first five lessons. If you want to check out this mini course as well as all my other mini courses, check out protrusive.co.uk/ultimate. That’s protrusive.co.uk/ultimate. Learn to fall in love with dentistry all over again. Now let’s join Reena for this main episode and I’ll catch you in the outro.

Main Episode:Dr. Reena Wadia, welcome back again to the Protrusive Dental Podcast. You did such a wonderful job in a crown lengthening tutorial. That was, I don’t know, a couple of years ago. Now I didn’t know, I lost track, but as I mentioned that podcast, you’ve been a true mentor to me, even an inspiration. I’ve been attending your talks and reading your blog since I was a student. Fast forward so many years, I’m the one with the gray beard and you look like you’re still, just freshly qualified. I don’t know how you do it. How are you doing?

[Reena]I’m good. Thank you. So great to be back. And you’re too kind. I don’t agree with all those points. I’ve got plenty of pages, you just can’t see them.

[Jaz]Well, I can’t see them on the studio here, but you can announce that since your last appearance, you’re now a mum.

[Reena]I am.

[Jaz]You’re a clinic owner and also now an author of a published book as well. We were talking about that? So how do you squeeze it all in, Reena?

[Reena]I’ve got a great team around me. Team being my family, but also my work team. That’s the key ingredient, I think, that’s made it all happen. So I’m super grateful for them.

[Jaz]And for those who haven’t heard of you, but living under a rock, tell us about you, the dentist, the family person. Just about you, Reena.

[Reena]Yeah, sure. So I’m a specialist periodontist and I’m the founder of RW Perio, which is our clinic based at 75 Harley Street. It’s probably the largest Perio clinic now in the UK, because we’ve got six Perio specialists working with us, five h...

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What are the steps involved in Functional Crown Lengthening?

Which scenarios/teeth are best for this type of surgery?

What is biologic width and why should we care?

Is Bone sounding a diagnostic test, or just a genre of music?

The answer to these questions and a lot more can be found in this packed episode with Dr Hiten Halai. We cover the right protocols when crown lengthening and understand the difference between aesthetic and functional crown lengthening.

https://youtu.be/KRlEtz16I8cWatch PDP207 on YoutubeProtrusive Dental Pearl – Bone Sounding

Using a periodontal probe, go into the depth of the sulcus, pushing deeply until you hit bone, all while recording the measurement with the probe. This measurement will then guide you on how to carry out your crown lengthening procedure. Push hard to pass the connective tissue and ensure you are touching the bone.

Not using AI to write your notes and letters for you yet? Save hours every day and save money using this affiliate link for DigitalTCO: Click Here

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:03:19 Protrusive Dental Pearl06:10 Introduction – Dr Hiten Halai12:56 Functional Crown Lengthening15:41 Understanding Crown Lengthening Types18:42 University of Dental Instagram22:38 Biologic Width aka Supra-crestal Tissue Attachment25:51 Functional Crown Lengthening: Practical Considerations31:09 Assessments & Keratinised Tissue35:47 Understanding Tissue Phenotypes39:16 Case Study: Premolar Treatment43:17 Bone Sounding and Biologic Width46:58 Shape of Gingivectomy50:31 Flap Designs52:37 Burs for Crown Lengthening56:13 Healing and Restoration Timelines58:31 Learning and Training Opportunities

Key Takeaways:

Hiten’s journey began with a passion for periodontics during dental school.
Managing time effectively is crucial for specialists with busy schedules.
Functional crown lengthening is often underutilized in practice.
Aesthetic crown lengthening can lead to complications if not done correctly.
Understanding biologic width is essential for successful crown lengthening procedures.
Preoperative assessments are critical for determining candidacy for crown lengthening.
The type of gingival tissue affects surgical outcomes and healing.
Proper surgical techniques can prevent complications and ensure better healing.
Postoperative care is vital for achieving desired aesthetic results.
Continuous education and mentorship are important for dental professionals.

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcome C.

ADG Code: 490 PERIODONTICS (Mucogingival management)

Aim: To enhance knowledge and practical understanding of crown lengthening procedures, with a focus on distinguishing between aesthetic and functional crown lengthening, and the importance of biologic width in achieving predictable clinical outcomes.

Learning Outcomes:

Identify the key differences between aesthetic and functional crown lengthening and the clinical scenarios in which each is most appropriate.
Demonstrate an understanding of biologic width and its significance in the success of crown lengthening procedures, including the impact on long-term periodontal health.
Apply the principles of bone sounding to accurately assess the need for crown lengthening and ensure optimal restoration outcomes, minimising risks such as gingival recession and bone loss.

If you liked this episode, check out: PDP079 – Crown Lengthening

Click below for full episode transcript:Teaser: Despite what the University of Instagram tells you, all cases cannot be treated by laser gingivectomy. And that is the truth. Four or five years down the line, when there has been enough time for that tissue to relapse, what happens is they'll come back with that persistent inflammation. And actually the management of it is much more complex now.

Teaser:If you’re going to remove an extensive amount of bone and you might even cause mobility, that is probably not indicated in that situation. If your alveolar bone all of a sudden grows from incidental peaks to a really low trough on the mid palatal, the soft tissues will not be able to follow that margin there, okay? And if you cut them to that, post surgically, there will be rebound. It’s kind of like, the way I describe it, it’s like-

Jaz’s Introduction:When you think of crown lengthening, what do you first think of? Do you perhaps think of aesthetic crown lengthening? That’s when we’re trying to make the gingival levels match up. For example, a lateral incisor, we want that gum to go a little bit higher. So that’s aesthetic crown lengthening. We’re lengthening how much tooth we’re showing for the primary benefit of aesthetics.

The other type of crown lengthening, which I personally have more experience with, is functional crown lengthening. Think of an upper premolar, which is the example we use deeper in this episode today. And this premolar, it’s got good amount of buccal tissue, but palatally, it’s got very little tissue. It might even be broken sub gingivally. And yes, in this world of implants, there is a place for titanium therapy, but I like to save teeth where possible.

And if the general endodontic prognosis is good, A good way to improve the restorative prognosis is by doing functional crown lengthening. And so this would be necessary because, yes, you’ve got good tissue buccally and you get good ferrule. Ferrule is like that tooth structure that the crown can grab onto.

Now, if you haven’t got any structure palatally, and your palatal tooth structure is broken subgingivally, how is the crown supposed to grip that tooth structure? We need at least two millimeters 360 degrees, maybe 1. 5 millimeters with care, but two millimeters is ideal in the literature. So if we can get rid of some gum palatally and a bit of bone, and then now everything heals so that you can now grab on to two millimeters of tooth structure, you have lengthened how much crown you have available of the tooth to be able to restore.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. I’m joined by specialist periodontist Dr. Hiten Halai, and you’ll find out the funny way which Hiten had a big role to play in the birth of this podcast many years ago. Now we discussed everything from indications and contraindications and actually came to guide us through the technique step by step from assessment, bone sounding, the incision, and the bone removal down to which burs you should use for the bone removal.

And if you’re a Student or a young clinician who’s never done this before then this should inspire you to seek out more education and learn more. Pick up those books or go on a course. But it’ll give you a really sound understanding. And if you have a bit more experience under your belt, with a little bit of mentorship, I think you could do this.

I think functional crown lengthening, if you pick your case as well, like an upper premolar, and you’ll see why an upper premolar is ideal for this. This is fun dentistry. This is fun. You get to breathe new life into a tooth, which was otherwise of poor restorative prognosis. And once in a blue moon, when I get to do this, I quite enjoy it.

Dental PearlNow, Protrusive Dental Pearl Time. As you know, every PDP episode, I give you a pearl. And if you think back to a few episodes ago, I told you about accessing through a molar before you do your sectioning of that molar for extraction to give you more practice of accessing molars for endo. So the more you access, the more you improve with your access cavity.

Now in a similar vein, in the perio crown lengthening field, one skill that we talk about in this podcast is bone sounding. Now, I’ve talked about bone sounding on this episode four. That episode of Dr. Jason Smithson on Ovate Pontics, absolutely brilliant. Do check it out if you haven’t already. And I talked about the edentulous site and how to bone sound there.

Actually, bone sounding can happen around any tooth. You want to figure out where is that bone relative to that gingival margin? And don’t worry if it’s not quite making sense of why you do this, that’s all to come later in this episode. But essentially you want to get a perioprobe, you want to go into the depth of the sulcus, and then you want to go really hard until you hit bone.

And that measurement will guide you in terms of how to do your crown lengthening. And if you’ve never done this before, you want to get like a feel of what it feels like to actually hit bone. Because sometimes you get to the connective tissue and you think, ah, I’m there. But actually, if you really push a bit more, you’ll sink in another millimeter or two more.

And that’s when you’ve truly done bone sounding. So how can you practice bone sounding without doing it for no reason at all? Okay. So if you’re doing an extraction, then I kind of regularly bone sound for extraction because it’s one of the ways I check that the patient is sufficiently numb. So whenever I’m doing an extraction, I will probe really hard with a sharp probe.

Buccal, mesial, distal, lingual, to make sure that the patient is fully anesthetized. And actually what I’m doing is very often I’m getting down to the bone. And so I have ...

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Application points, luxation vs elevation, avoiding common mistakes – this one’s an episode that I wish I had when I was at dental school!

How do you know when you’ve found the application point during extractions?

What are the key protocols that can help make your extractions more efficient?

https://youtu.be/rOBPnCTyAwMWatch PS012 on YoutubeThis week’s Protrusive Student episode is all about exodontia – and again I’m joined by Emma Hutchison, our Protrusive Student Ambassador, to discuss some tips and tricks on how to make extractions that little bit easier.

Jaz also shares a memorable analogy—could removing a stone from an avocado be the perfect way to describe an extraction?!

Key Takeaways

Tactile feedback is crucial during tooth extractions.

Understanding application points can improve extraction techniques.
Using the right amount of pressure is essential to avoid breaking teeth during extraction.
Luxators are typically used to sever the PDL before extraction.
Atraumatic extraction techniques are important for preserving bone for future implants.
Luxators should not be used as elevators.
Understanding the mechanics of elevators is crucial for effective extractions.
The ‘six second rule’ helps in assessing extraction progress.
Having a plan for extractions can prevent complications.
Communicating with patients about the extraction process is essential.
Avoid tunnel vision; consider the surrounding teeth during extractions.
Breaking interproximal contacts can simplify extractions.
Always check the patient’s medical history before procedures.
An audible checklist can prevent mistakes during extractions.

Need to Read it? Check out the Full Episode Transcript below!

Highlight of this episode:

00:00 Introduction
02:07 Catching Up with Emma
05:58 Teeth are like avocados!
11:13 Understanding Application Points in Extractions
17:01 Luxators vs. Elevators: Techniques and Safety
24:10 Extraction Technique
25:08 The Six-Second Rule
28:04 Having a plan
29:58 Common Mistakes and How to Avoid Them
38:17 Conclusion and CE Certification

This episode is eligible for 0.75 CE credit via the quiz on below.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 310 Oral and Maxillofacial Surgery (Exodontia)

Dentists will be able to –

Recognise essential steps to establish secure application points
Develop approaches for patient communication around extraction procedures, potential risks, and expected outcomes
Implement the “6-second rule” and other practical techniques to streamline extractions and troubleshoot common challenges

If you loved this episode, make sure to watch Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth [B2B] – PDP085

Click below for full episode transcript:Jaz's Introduction: This episode on basics of extractions is the episode I wish I had when I was learning extractions when I was a student. But also what I've found from this Protrusive Student series is that so many dentists are listening to them and they're commenting and they're enjoying and they're liking it.

Jaz’s Introduction:What I’ve discovered is that it’s so good to just reconnect with basics and actually by listening to these kind of episodes you do sometimes pick a few things up or it’s validation.

It helps to validate some techniques, some ideas, some protocols that you’re already using. It’s also a wonderful way to see how far you’ve come. Sometimes we move so far in our career that we forget what it’s like to have those struggles like we did when we were a student. So the reason I gave you that little preamble is because now from this episode, most Protrusive Student episodes, I think, will be eligible for CPD or CE credits.

And so this one is eligible for 0. 75 CE credits or 45 minutes, if you’re in the UK. Protrusive Education is a PACE approved education provider. So that satisfies everyone in the States and the rest of the world as well. The only place to get CE points is on our app Protrusive Guidance. So if you find yourself listening to us while you’re running or while you’re driving or watching on YouTube or on the app, you’re just literally a few clicks away from validating your learning and certifying it so you get a certificate emailed to you by our CPD Queen Mari.

Enough about certification. In this episode, we’re going to give you some real world tips with Emma Hutchison, who is the Protrusive Student. We’ve done so many great episodes just looking into the basics, the perspectives from a student, and Emma had absolutely fantastic questions today, such as, how do you know when you found an application point?

I also give my analogy, my first time I ever gave this analogy, which is how you could liken an extraction to removing a nut from an avocado. I actually think it went really well. Please comment below on what you think of that part, and I won’t take up too much time. Let’s now join the main episode. When we catch up with Emma a little bit, she’s now in her fourth year at Glasgow, and then we get into the meaty bits of the episode.

We talk about how to make your extractions better on Monday morning. The tips I share on here are absolutely timeless, and it will improve your expenditure. Catch you in the outro.

Main Episode:Fourth BDS Emma. Welcome to the show again for the second season, if you like, of the Protrusive Student Series. Please. How’s it going? How’s fourth year?

[Emma]Fourth year’s good. I was just saying to Jaz that I’ve not cried yet this semester, which is a good sign. Fourth year’s quite fun now. Like, you are like a little mini dentist. The difference between third and fourth year is you really need to know your stuff. So it’s stressful in that aspect. But, you do sort of have a bit more freedom on clinics and I think the clinicians like to hear what you have to say that little bit more. So it’s fun, but I’ve got my final exams this year.

[Jaz]Give me an example of what you mean by like, having a feeling like you need to know a bit more. Have you got like a real world clinical example recently that you were preparing for or experiencing clinic?

[Emma]I suppose, like in third year. It’s your first time seeing patients, like in Glasgow anyway, it’s your first time having your own patients. The clinicians will be a bit more lenient with you and your background knowledge and your reasoning behind why you’re doing things or what you know about your guidelines, all this sort of thing.

You can sort of get away with it but in fourth year when you’re doing your competencies. And you’re having that discussion with the clinician. They will get on with you a bit more if you don’t know what you’re doing. I don’t know how it is in other universities. I know in Glasgow and a lot of other places down in England, they use something called LiftUpp. Have you ever heard of that, Jaz?

[Jaz]No, never. No, I haven’t.

[Emma]I can’t remember what it stands for but basically after every patient interaction you’re given scores by your clinician, graded one to six, like one being could cause potential harm to the patient, like not good at all, and six being that you did good whatever, independently.

So, it’ll be communication with the patient, communication with your tutor, infection control, background knowledge, like literally everything. And in 4th year you’re expected to start getting 4s and 5s, some 6s, that sort of a thing. But in 3rd year you can get away with 3s and 4s. So you just need to know a bit more of what you’re talking about, which is the scary bit. It’s fine. It’s all going okay so far.

[Jaz]Good. I know you were worried about fourth year as being the big one. So I’m so pleased to see a smile on your face and that you said you’re enjoying it, which is really, really important. When you’re in dental school, there’s a message to those dentists out there who are reminiscing about dental school.

Or those who are looking to get into dental school or you’re in dental school at the moment. It’s so important in any phase of life you’re in, right? To stop thinking about, oh, when I qualify or when I this, it’s really important. Tomorrow’s never promised, right? So it’s important to enjoy moments of today.

And I’m so, so, so happy for you that you are looking like you’re enjoying it. So please continue. Remember that learning is a privilege. Learning is a wonderful thing. Mahatma Gandhi said, live as though you were to die tomorrow. Learn as though you’re going to live forever. Have you heard of that?

[Emma]Yeah. Yeah. Yeah. I have.

[Jaz]Did I say it correctly?

[Emma]I think so. Yeah. Yeah. Makes sense anyway.

[Jaz]Fine. Good. Well, today we’re talking about extractions and with the extractions, we’ll talk a little about the clinical side of things, but also we’ve got your student notes, which you always add to the crush your exam section.

We’ve seen Emma do a lot more on social media. So she’s had a little bit of a takeover on our Instagram and Facebook and the app and whatnot. So if you’re liking what she’s doing, come and join us on the student section of the app or check us out on Instagram. Some of your posts have been getting so much engagement.

Like they’re just basic things, but I think there’s a beauty...

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Are you confident in diagnosing white patches?

Which white patches need an URGENT referral?

How do you tell the difference between lichen planus, lichenoid reactions, and other common lesions?

Dr. Amanda Phoon Nguyen is back with another amazing episode, this time diving deep into the world of oral white patches. Jaz and Amanda explore the most common lesions you’ll encounter, breaking down their appearance, diagnosis, and management.

They also discuss key strategies to help you build a strong differential diagnosis, because identifying the right lesions early can make all the difference in patient care.

https://youtu.be/xlQpuQu2Hl0Watch this full episode on YouTubeProtrusive Dental Pearl: A new infographic summarizing Dr. Amanda Phoon Nguyen’s key teachings. Jaz describes it as an easy-to-follow “cheat sheet” designed to simplify complex ideas and make it easier to apply the concepts discussed in the episode.

You can download the Infographic for free inside Protrusive Guidance ‘Free Podcasts + Videos’ section.

Key Takeaways

White patches in the oral cavity can be classified into normal variants, non-pathological patches, and potentially malignant disorders.
It is important to identify the cause of the white patch and differentiate between different types.
Referrals should be made based on the characteristics of the white patch and the urgency of the situation.
Clinical photographs are valuable in referrals and can aid in triaging patients.
Ongoing monitoring is important for potentially malignant disorders. Lichen planus can have different types and presentations, and a biopsy may be necessary for certain cases.
Enlarged taste buds, particularly in the foliate papillae, are usually bilateral and not a cause for concern.
Oral lichenoid lesions can be triggered by dental restorative materials or medications, and a change in dental material may sometimes improve the condition.
Smoker’s mouth can present with white patches and inflammation in areas where smoke gathers, and counseling patients to reduce smoking is important.
Oral submucous fibrosis, often caused by areca nut chewing, requires regular review and counseling patients to stop chewing the nut.

Need to Read it? Check out the Full Episode Transcript below!

Highlights for this episode:

01:22 Protrusive Dental Pearl
05:13 Dr. Amanda Phoon Nguyen Introduction
07:39 White Patches Introduction
09:16 Understanding Geographic Tongue
12:44 Keratosis vs. Leukoplakia
19:02 Proliferative Verrucous Leukoplakia
22:18 Referral Tips for General Dentists
29:56 Understanding Leukoplakia
33:17 Urgent and Non-Urgent Referrals
34:37 Patient Communication
39:17 Discussing Erythroplakia
41:03 Oral Lichen Planus: Diagnosis and Management
47:50 Enlarged Taste Buds
49:47 Oral Lichenoid Lesions vs Oral Lichen Planus
53:43 Smoker’s Mouth
55:14 Oral Submucous Fibrosis
57:23 Learning more from Dr. Amanda Phoon Nguyen

This episode is eligible for 1 CE credit via the quiz below.

This episode meets GDC Outcomes B and C.

AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Diagnosis, management and treatment of oral pathologies)

Dentists will be able to –

Identify the cause of a white patch and differentiate between different types.
Understand when and how to make referrals based on the characteristics of the white patch and the urgency of the situation.
Appreciate the importance of ongoing monitoring for potentially malignant disorders, including when to consider a biopsy.

For those interested in visual case studies and deeper insights into oral lesions and conditions, follow Dr. Amanda on Instagram and Facebook!

If you loved this episode, be sure to check out another epic episode with Dr. Amanda – Prescribing Antifungals as a GDP – Diagnosis and Management – PDP151

Click below for full episode transcript:Teaser: You may have some patients that haven't been to see the dentist in a long time. They're fairly cavalier. They don't think it's going to be anything serious. They will go see the oral medicine specialist when they get some time off work or when it suits them. Those are the patients that you probably have to sit down and actually have a conversation with them, tell them that you're worried that it's cancerous, they've got these risk factors, it is much better than it gets picked up early.

Teaser:Sometimes you get patients that are very anxious and as soon as you use the C word, that’s all they’re going to see, that’s all they’re going to hear, they can’t sleep for two weeks. You still have to give them the information and educate them on it, but there are ways to do it gently, where you can say, like you’re thinking that it potentially could be quite serious. You’re not saying that it’s cancer, but, you’re a little bit worried. There are ways that you can do it. I actually tell people this story. So I was a registrar training in oral medicine.

Jaz’s Introduction:It’s November, which means it’s oral medicine and oral pathology month. You know what? I actually really regret having these months. Like, to try and be organized enough, to have enough episodes or at least one episode to dedicate for that month. It’s been tough for me. So I think once we finish all the months, I’m probably not going to reintroduce this specific theme month because it’s just too much pressure on us as a team. But I do hope you’ve enjoyed the past months and having a little bit of focus.

Even if it was just one or two episodes that month, it’s been nice on the Protrusive Guidance Community app to have some like themed polls and themed questions. Thank you all for getting involved. Today’s episode is on white patches. It was going to be white patches and red patches, but it was so much to cover on white patches that our amazing guest Amanda and I decided that actually let’s just focus on white patches.

Why? Because white patches are so much more common than red patches. I know red patches are scarier, but you’ll see way more white patches day in and day out. Think about it, right? Lichen planus, lichenoid reactions, both of those get a huge amount of coverage in this episode, as well as smokers mouth and some lesions that you can get on the tongue.

The mission of this episode is to help you identify and get a differential diagnosis. And importantly, recognize which type of these lesions warrant a referral and which one of these referrals should be urgent. Stay tuned for a really educational episode.

Dental PearlNow, every PDP episode I give you a Protrusive Dental Pearl, and today’s pearl is the infographic that you’ll definitely want to grab for this episode. As per our previous infographics, it’s just an incredible summary of everything Amanda teaches us in this episode. We made it visual and easy to follow. It’s like a little cheat sheet, just like some of the other, like the antifungals one that we have or how to choose a ceramic one. And this one is available on Protrusive Guidance for free.

So if you want a copy of this one, you just have to click on this episode within Protrusive Guidance and you’ll be able to get it. Anyone can join for free on Protrusive Guidance. If you identify yourself to be a Protruserati, one of us, you’ll If you’re geeky and if you’re nice make a free account and if you want CPD or CE credits while you’re at it. Make a paid account.

We’d love to see you on there. And there’s so much education that we’re constantly adding. You’ve got pretty much 300 plus hours of CE credits available for you. But more powerful than that, is the power of community. It’s been so nice to be moved away from Facebook to our own app and how people have just engaged in the most wonderful way, in a helpful way.

The kind of toxicity you see on those other social media platforms, Facebook, you don’t get that on Protrusive Guidance. Because the kind of person that’d be listening to an episode on oral medicine. Yes, you know who you are, you’re so geeky. That’s the kind of person I want on our group. So to get that infographic, head on over to www. protrusive. app on your browser, make a free account, then you can download it on Android, iOS, and use those login credentials to access the platform. And then of course, you can make a community account or a CE account, or just keep it as a free account and access all the free parts of the podcast in the best way possible.

Now, while we’re talking about Protrusive Guidance, I want to introduce this new thing called Community Insight. Every now and then I post a poll and I’m just amazed about the variation of responses that we get from the Protruserati. So recently I put a poll up asking how do you guys manage a symptomatic, okay, so symptomatic cracked molar.

What is your most likely management assuming the crack is not a true vertical fracture, so basically it’s a restorable tooth, you think. And it’s symptomatic, so obviously the pulp is upset. The kind of pain when someone says, Oh yeah, when I bite together, when I chew something hard, I feel a pain right here. Or when you use a tooth sleuth, and they bite down, and they re...

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What are the key steps and nuances to make awesome Dentures that your patients will love?

In this episode, Jaz probes Removable Pros legend Dr Mike Gregory to break down the process. From border molding to primary impressions and the teamwork between dentists and technicians, Mike reveals the key steps to making great dentures.

https://youtu.be/snM3PerQ1koFor example, be sure to include a note on the lab sheet for the technician: “Preserve full peripheral depth and width of the sulcus on this impression, to about 2-3mm.” This ensures the correct functional width is maintained when the final tray or denture is created.

Protrusive Dental Pearl: When checking denture occlusion, it’s crucial to keep the patient relaxed. Mike suggests one simple trick: ask the patient to close their EYES before closing their teeth. This can sharpen their senses, helping to improve the bite assessment.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:

02:07 Protrusive Dental Pearl
03:31 Mike Gregory’s Journey into Dental Technology
10:09 Understanding Border Moulding
13:19 Technician’s Role in Denture Creation
15:45 Improving Communication with Technicians
18:34 Special Trays and Custom Trays
25:58 The Role of Green Stick
29:04 Denture Impressions
31:35 Boxing and Beading Techniques
35:08 Additive vs. Reductive Rest Seats
40:46 Guide Planes
42:43 Creating Undercuts for Dentures
45:10 Final Tips and Best Practices
48:54 Learn More with Mike Gregory

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject code: 670 REMOVABLE PROSTHODONTICS

Aim: To explore the intricate process of denture creation and provide practical insights on improving denture fit, occlusion, and collaboration between dentists and technicians.

Dentists will be able to:

Understand the key elements of denture creation, including border molding and primary impressions.
Learn the significance of maintaining peripheral sulcus depth and width in denture impressions for functional accuracy.
Gain insight into the role of special trays, custom trays, and impression materials in denture fabrication.
Recognize the importance of clear communication between dentists and technicians in achieving optimal denture outcomes.

If you liked this episode, you’ll love Suction Lower Complete Dentures – Improve your Removable Prosthodontics – PDP073

Click below for full episode transcript:Teaser: This huge misconception that if you get suction on an impression, that impression is the perfect impression to make a denture. But you know, and I know if you take an impression, you fill somebody's mouth with algae, you get suction. You have to break the seal to get it out. That doesn't mean you've got the right depth.

Teaser:It doesn’t mean you’ve got the right borders. You’ve just created a vacuum and that’s the worry that people create suction. I think this is it. This is going to be the great denture. But if you create suction, take the impression out of the mouth and look at it. It’s going to be big. You can picture this, can’t you?

It’s going to look big, it’s going to look like you’ve just pushed everything out the way. I used to think dentists were rubbish, which is really tough, but as a technician you’ve seen model after model that’s garbage. And then you think, these poor guys are taking impressions, but they don’t know what they’re doing wrong.

How do I do it better? If you were taught maybe not brilliantly as an undergraduate, or you didn’t love it as an undergraduate, so you didn’t really focus on it. How do you ever get better? You need to be re taught.

Jaz’s Introduction:Let’s face it guys, dentures are a bit of a dark art. You only get so much exposure at dental school, and when you come to the real world, you’re faced with flabby ridges, resorbed ridges, patients with high expectations, and often you’re at the mercy of the impression materials that the practice has, and not the ones you were trained on.

Welcome to the crazy world of dentures, and I am absolutely stoked to introduce you to Mike Gregory today. So many of you have already seen his work on Instagram. His Instagram is like a free encyclopedia for dentures. I love how he’s sharing everything he knows, and this episode is no exception. We talk about border molding, like, this was so confusing using green stick.

I messed up so many times at dental school. I didn’t really know what the purpose of green stick was, or what it should look like if it was done well. But the way Mike breaks it down today, I think, everyone will understand and actually he’ll share his secrets. So you don’t have to use very much of it. Just in a few select areas, making our job even easier.

We’ll talk about nailing primary impressions and why your primary impressions should be overextended, but what’s the special advice you should give to your technician to make sure that the special tray is on point. And that you’re not having to modify the special trace so much. And like with many other episodes, we talk about communication and we emphasize the communication between dentist and technician.

So that we can benefit our patient with the best dentures possible. We also talk about guide planes and how they improve your dentures, but also rest seats. And Mike actually has some slightly different views about rest seats. Views which are very actually conservative, minimally invasive, and I think you’ll like this. How can we do more rest seats that are no prep?

Hello Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. And this one is one of the geekiest ones I’ve done on dentures, and I absolutely loved it. My enjoyment of dentures has grown year by year by year. Initially found it very confusing, a dark art.

Now after going on some CE, some courses, I’m liking it more and more. It’s becoming, dare I say, predictable. And for someone like me who doesn’t place implants, I can also get that kick out of replacing multiple teeth. I guarantee you that if you make it to the end of this episode, you will improve your dentures. And if you’re on Protrusive Guidance, you can claim an hour of CE credit. So one CE credit or one hour of enhanced CPD by answering the quiz.

Dental PearlEvery PDP episode, I give you a Protrusive Dental Pearl. And this one you’re absolutely going to love because it combines occlusion and dentures. Something taken from this episode. It’s something that I’d heard a long time ago, and I just got out of the habit of practicing it. And when Mike reminded me of this. I was like, whoa yes, I love this. I want to share this with everyone. So here’s the tip, right? When you’re checking the occlusion on dentures, let’s say complete dentures for argument’s sake, right?

So complete dentures are in, and we know that an ideal world, our condyle should be in a centric relation or a stable condylar position. It just helps to make sure that we are in a repeatable position. And so the tip that Mike shared with us is when you are checking the occlusion on complete dentures, of course, you get them to relax.

And in some schools of thought, you get them to tip their tongue to the back to try and encourage them to get to centric relation. But whatever technique you’re using, just do this one thing, okay? Get the patient to close their eyes. That’s right. The patient will close their eyes and then close together. And try it for yourself.

Please don’t try it if you’re driving. But if you’re not driving, then try it for yourself, okay? Bite together and then shut your eyes and bite together. It’s like with everything. When you shut off some senses, other senses get heightened. And who knows how much of a difference this makes, but it makes sense to me.

And I’ll be reintroducing this to my protocols for dentures. I may even try it for my dentate patients. If you’re someone who’s been doing this for years, please comment below. Let me know. And so with that, I’m not going to ramble on anymore. I really want you to get into this episode. You’re going to absolutely love hearing about his journey, but all the nitty gritty clinical details. You’re going to absolutely love Mike. I’ll catch you in the outro.

Main Episode:Mike Gregory, welcome to the Protrusive Dental Podcast. I absolutely love what you’re sharing on your social media. I love your raw content. I love how much you care about helping people learn dentures and your selflessly giving of so many gems and pearls. It’s an absolute pleasure to have you on. How are you today?

[Mike]I’m great. I’m really good. Yeah, I’m just conscious the dog might be set off in the background, but like you say, my content’s raw, so is my presentation. So if the dog’s in the background, it’s still authenticity, isn’t it? It’s just real world.

[Jaz]Exactly. That’s a great way to describe your content and everything you stand for, everything you do. I don’t even know where you work. Tell me about your sort of work setup. Tell me about your love for dentures. I remember going to a Finlay Sutton course actually, and on his photos of you and lots of other people who’ve been learning the Scandinavian design many, many years ago.

And so that I came to my radar then as well. And with Rupert, and obviously just seeing your educational stuff on social media is absolutely mind blowing, but...

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Implant crowns should be out of occlusion, right? Think again!

In my experience, single tooth implant crowns when I see them are IN occlusion and holding shim – even when this was not intended by the Restorative Dentist.

When this happens, should we be adjusting the implant crown? Or perhaps the adjacent tooth? shock horror

And how often would this need to be repeated?

This podcast will show you a better way to manage implant occlusion!

https://youtu.be/l8WOiamk06MWatch PDP204 on YoutubeIn this episode, I’m thrilled to chat with Professor Riaz Yar, an occlusion expert and mentor who greatly influenced me early in my career. Together, we’ll debunk common myths and dive into practical approaches to managing implant occlusion.

Even if implants aren’t part of your practice, understanding occlusion on implants is crucial for patient care. Tune in as we uncover best practices and clear up misconceptions to help you achieve better results for your patients!

Protrusive Dental Pearl: Dr. Pav Khaira has created a free implant assessment form, now available to the Protrusive community. Accessible at www.protrusive.co.uk/implant – this responsive PDF includes key areas like patient goals, biotype, and occlusion, with an 8-minute video guide for easy use.

Key Takeaways

-Implant occlusion is a major factor in implant failure.-Understanding the biology of the implant system is crucial.-Functional loading is more important than static loading!-Chewing dynamics can reveal important insights about occlusion.-Guidelines for occlusion should be followed but adapted to individual cases.-Patient education on post-implant care is essential.-Shared loading on implants is vital for their longevity.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:

01:34 Protrusive Dental Pearl
02:47 Introducing Professor Riaz Yar
05:07 Understanding Implant Failure Causes
08:04 Analyzing Implant Occlusion and Peri-Implantitis
10:27 The Chewing Gum Test
13:20 Guidelines and Challenges with Implant Occlusion and Lab Protocols
17:33 Bone Regeneration and Functional Guidance
19:22 Dynamic Movements and Occlusion Analysis
23:48 Practical Tips for Implant Bridges
28:19 Patient Guidelines for Implant Care

Join Riaz for an innovative implant restorative program developed with top dentists (Nik Sissodia, Martin Wanendeya, Sanjay Sethi, and Nik Sethi), designed to enhance your skills in implant restoration.

Check out Riaz’s one-day course on implant occlusion at profriazyar.com and Elevate Dental. Sign up now and boost your implant expertise!

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject code: 690 IMPLANTS

Dentists will be able to:

Recognize key factors that contribute to implant failure and how occlusion plays a role.
Utilize practical approaches, such as the Chewing Gum Test, to assess and manage implant occlusion (function) effectively.
Discuss guidelines for implant occlusion and understand the challenges involved in lab protocols.

If you liked this episode, be sure to watch An Idiot’s Guide to Restoring Single Implant Crowns Part 1 and Part 2

Click below for full episode transcript:Teaser: If you overload it, the risk is that you're going to get bone loss around the neck of the tooth, just from a biological perspective. That then means, okay, how do you apply those forces? And so if you apply those forces to a tensile at an angle, that's definitely going to occur. But static forces, it's still going to get some transference through it.

Teaser:So it’s about understanding how to manage those forces. The one, the thing that I noticed, if it’s an issue is screw loosening of the crown and an implant that tells me straight away, I have some of axia loading on my implant. So I need to deal with that straight away. As soon as I fix it, I am not tightening that screw for, I’m just not tightening it, maybe years before an issue arises.

When you then look at the literature on risk for those category of people that are more likely to damage your implants, for example, bruxist patients, parafunctioning patients, they are three times more likely to cause failure. So when we look at met analysis, it says, occlusion in those patients that really damage the teeth, so they are more likely to damage your implant.

Jaz’s Introduction:Maybe, like me, you were taught that your single implant crown should be out of the occlusion, i.e. it should not be holding shim and there should be approximately 30 microns of clearance. What if I told you that’s false? That’s a lie! Because every time I see patients come back with implant crowns and I check the occlusion, you bet that that implant crown, which probably initially was out of occlusion, is very much in occlusion.

So what should we be doing? Should we be adjusting ceramic or adjusting the opposing tooth and doing this every year so that your implant crown is always out of occlusion? Let me suggest a better way to you through this podcast. I am joined by Professor Riaz Yar, one of my oldest mentors in the sense that he was my first first educator.

Like, when I qualified, the first course I went on, the first workshop you had as a DF trainee, was his. And he gave me the bug of occlusion, he inspired me to no end, and it’s a great pleasure to have him back again on the podcast. Even if, like me, you don’t place implants, you don’t even restore implants. There’s so much to gain. As general dentists, we owe it to our patients to understand because our patients have implants and we want to know what a good occlusional implant looks like.

This episode is eligible for CE credits and enhanced CPD as per GDC criteria, but also we are a PACE approved provider. All that happens through the quizzes on Protrusive Guidance. If you literally listen to every single episode, it is the best value for education you will ever get because now you get to reflect on the content and test your knowledge and retention. You get to download the premium notes and the PDF transcripts and all the goodies that come with the episodes.

Dental PearlSpeaking of goodies, today’s Protrusive Dental Pearl is related to implant assessment. I’ve been on the hunt for a really good form. So if you’re someone who’s placing implants and you’re having that initial consultation, what should we be looking for when we’re assessing our patients? Now it’s been under my nose the whole time because one of our own Protruserati, Dr. Pav Khaira, who’s so active on our app, on our community, Protrusive Guidance, he has a wonderful form.

And as part of the pearl, we’re giving it away to you for free. Head over to www.protrusive.co.uk/implants. Just simple as that. Implants. And we’ll show you a fantastic form. It’s actually a really responsive pdf because you’ve got like drop downs and you can complete it on your mobile phone, on a laptop.

It covers everything from the patient expectations and goals, the biotype, the occlusion, very relevant to today’s episode, and it’s all for free. Plus you get an eight minute video of Pav Khaira just going through the entire form with you. That itself has so much educational value. If you’re someone who’s placing implants or restoring implants, or just a humble general dentist who’s referring, it is a great thing to familiarize yourself with.

So I want to thank Dr. Pav Khaira for allowing me to share this with you. And the website is protrusive.co.uk/implants. Hope you enjoy that download. I’ll put the link in the show notes, but let’s join our guest, Professor Riaz Yar, and I’ll catch you in the outro.

Main Episode:Oh man, all that heartfelt stuff I said, Riaz.

[Riaz]I know, I know. Now we’re going to have to fake it. Now we have to fake it.

[Jaz]Guys, if you’re listening to this, right, Literally, we just had a lovely, like, 7-8 minute exchange. I gave, like, an amazing intro that Riaz deservedly. He just deserves this beautiful intro. I have to, like, fake it again. And so, here we are again. It’s pitch black outside. Told my wife I’m recording in the morning. And she was like, okay, who’s the guest kind of thing? Where’s the guest from? And I said, It’s Riaz. Okay. It’s Riaz. He’s been on the podcast for, he’s a very welcome guest on the show.

And it’s because usually it’s Australians that like to book this sort of 6. 15am slot if you like, but it’s great to have you Riaz. I said before, unfortunately, that unfortunate event of the recording not happening is you have inspired me in such a huge way. You were the first sort of a workshop or course that I did as a VT.

So, the sort of plan program, and that was absolutely amazing. It mentioned it in our previous episode that your teaching style inspired me to no end the way that you like to really ask and help us to understand why it really inspired me as someone who eventually, I always wanted to get into education always from the beginning.

I did my PGCert in dental education very early on, but you were really the catalyst that really confirmed to me that, you know what? When I grow up, I want to be like Riaz. So for t...

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Why are principals and associates always at loggerheads with each other? Why can it be almost impossible to find the right associates to work at our amazing practice, but also almost impossible to find that amazing practice to work at as an associate?

Join myself and Dr Sarika Shah on this episode where we learn more about self leadership and the ways to prioritise our values to help us find the right working relationships and places of work to be a part of. Let’s figure out how to bring all members of a team together and create the zen we are all in search for while working in our day to day lives.

https://youtu.be/-ua1PAB6A90Watch IC054 on YoutubeProtrusive Dental Pearl:

Be willing to accept rejection. A ‘no’ from a patient today is often a yes tomorrow. Plant seeds for high quality dentistry and you will find yourself harvesting many of these seeds at a later date. Those who fear rejection routinely offer less than their best, which cheats patients out of rightfully making their own economic decisions – inspired by Dr Lane Ochi (the ORIGINAL Dental Geek!)

Check out Flourish as a Female: https://www.flourishasafemale.com/

Use discount code ‘protrusive’ (No financial interest)

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:02:18 Protrusive Dental Pearl04:30 Introduction – Dr Sarika Shah10:10 Transition to Private Dentistry13:40 Practice Ownership17:20 Managing the Practice24:55 Internal Leadership29:40 Principals vs Associates Friction41:56 Women in Dentistry47:15 Supportive Partners55:25 Top Advice from Sarika58:28 Flourish

This episode is eligible for 1 CE credit via the quiz on the Protrusive Guidance App.

This episode meets GDC LEARNING OUTCOMES A and B

AGD Subject Code 550 Practice Management and Human Relations

Aim:To explore the importance of self-leadership and effective communication in building successful relationships between dental associates and principals, enhancing teamwork, and optimising practice performance.

Dentists will be able to:

Identify key principles of self-leadership and apply them to improve personal and professional development within their practice.
Understand the impact of effective communication and aligned values on maintaining strong, respectful relationships between associates and principals in a dental setting.
Develop strategies to enhance emotional intelligence, ensuring improved patient care and better collaborative relationships in their practice environment.

If you liked this episode, be sure to check out IC025 – Parenthood and Dentistry

Click below for full episode transcript:Teaser: And when this respect is gradually lost, that relationship is most likely going to break down within three years. Okay, there's research behind this. I've read a lot around this. So what it there is, is there's three phases to this. The first phase is like- because even when I went out there to approach women, to approach some of these women are still around. And I think they're awesome. They're powerhouses. But when I went to them to ask for help, I got nothing. And it's not like I just asked once. I asked a few times. I asked several women and I got nothing. So the majority of my mentors and coaches have now been male.

Jaz’s Introduction:Principals versus associates. Why is there so much beef? I’m constantly seeing on the dental social media groups that principals are bashing associates. They’re saying like, where are all the good associates gone? I’m really struggling to find a decent, honest, hardworking associate. On the flip side, the associates are searching for trustworthy, kind, caring principals that are willing to mentor and provide an environment where you can flourish.

That seems to be a bit of a pipe dream. So who’s right? Are they both right? Or maybe all the associates and principals that are happy, that are in very, very happy teams. Maybe they’re just having some popcorn watching all this unfold. I don’t know. I personally have had some wonderful principals throughout my years.

I’ve also had some not so good ones, so I can totally resonate with some of the things that I said. So in this episode, we will cover how do we promote a good relationship between associates and principals? Where does it begin? How do you know if a principal and an associate are a good fit even at the interview stage?

And if you lead a team, especially if you own a practice, I’ve got Dr. Sarika Shah, who’s all about the systems, and I really admire her. Like, Sarika’s one of these dentists who I seem to always bump into at courses. It makes me think, right? Why is it that I always see the same people at the courses? Why don’t I see any new faces at courses? It’s as though there’s like a 20% of the dentist population that goes on all the courses and everyone else is not going to the courses. I don’t know. But Sarika is someone who I’d always see around.

Well, hello Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Some of the other themes we discuss are leadership in dentistry, particularly self leadership. And if you’re thinking, hey, I’m not a leader, I’m just an associate, then you are totally wrong. We are all leaders. We also talk about starting your own practice and the challenges particularly faced by women in dentistry who are looking to start their practice.

Why is it that the lecture podiums have less women? Why is it that less women end up owning practices? But these are very worthy themes that we discuss towards the end as well. So make sure you make it all the way to the end. This episode is eligible for CPD or CE. And as we are a PACE approved provider, the subject code for this one is 550. That’s practice management and human relations. We also, as ever, satisfy the GDC’s criteria for enhanced CPD. So all you have to do at the end is answer a few questions on the quiz. The quiz is accessible from Protrusive Guidance, which is our platform.

Dental PearlAnd speaking of platform, it’s the platform that gives us our Protrusive Dental Pearl today. You’re going to love this piece of advice. On our app, on our community, I asked our community, what’s the best advice you ever received in our profession? And I talked about not owning the patient’s problem. Like, I’ve talked about this a lot. But so many of you chipped in with such brilliant pieces of advice. I’m going to highlight one from Dr. Lane Ochi.

And in his contribution, he gave like five or six absolute golden nuggets. But the one I’m going to share with you today is where he learned to be willing to accept rejection. He said that most who practice dentistry successfully recognize that a NO from a patient today often is a YES tomorrow. Plant seeds for high quality dentistry and you will find yourself harvesting many of those seeds at a later date.

Those who fear rejection routinely offer less than their best, which cheats patients out of rightfully making their own economic decisions. So another way to make this tangible and explain it is sometimes we know that a indirect restoration may be the best for that patient, but for some reason, whether we think the patient is just not going to say no, or we think we have this silly perception that patient can’t afford it, while the patient’s just unlikely to go for this treatment option, we give them something suboptimal.

Maybe it’s a cheaper option, maybe it’s a direct restoration, but really you know that this tooth would scientifically benefit from an indirect cuspal coverage restoration. Now, if you think bigger picture, think of the patient with generalized wear, and you are concerned that one day the wear will get so bad that it’s going to become even more expensive to fix, and maybe the patient may need more root canals or more complex treatment.

But maybe you don’t suggest a comprehensive plan. Maybe you don’t suggest any treatment for that wear. Why? Because you’re afraid of rejection. I think forget about rejection. And if you treat every patient with your best intentions, and I know we always have our best intentions, I truly believe you have the best intentions, but don’t hide your cards.

Just show, well actually, ideally, Mrs. Smith, we should be doing A, B, and C. And it will cost this much, but the benefit of this treatment for you will be X, Y, and Z. And having some of those difficult conversations, even if you know you’re going to get a no, but once you get that no now, just as Dr. Lane Ochi says, when it’s the right time for that patient to have the best and the correct treatment, they will come back to you. So start planting those seeds today, Protruserati. And it’s another good reason to join the app. There’s so many good things in just that one post alone. Anyway, let’s join the main episode. I’ll catch you in the outro.

Main EpisodeDr. Sarika Shah, welcome to the Protrusive Dental Podcast. How are you?

[Sarika]I’m really well, Jaz. Thank you so much for having me on.

[Jaz]I’m very excited to cover these topics because it’s a little bit about the animosity that we feel and we can sense between principals and associates. But actually what I want to do is just take a step back and learn about a bit more about you as a business owner, a practice owner, someone who has a team, because I feel as though the podcast hasn’t covered those themes as well as it shoul...

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Is Sodium Hypochlorite still the best irrigant for endodontics? Or do we have something novel and superior?

How can we improve the efficacy of our endodontic irrigation?

What % of NaOCl should we be using?

https://youtu.be/z5h2FzHpG68Watch PDP203 on YoutubeDr. Brett Gilbert rejoins Jaz Gulati to tackle all things endodontic irrigation after a brilliant episode on pre-emptive endodontics.

Advanced activation and delivery systems could change the game—are we on the brink of a major shift in endodontics?

Protrusive Dental Pearl: Before performing a molar extraction, challenge yourself to first complete an endodontic access on the tooth. This will enhance your understanding of the canal anatomy and improve your precision in sectioning the tooth. By visualizing the canals and the pulpal floor, you’ll refine your angulation for more accurate sectioning.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:

02:09 Protrusive Dental Pearl
04:23 Is Sodium Hypochlorite Still The Gold Standard?
06:54 The Role of Surfactants in Irrigation
07:58 Concentration of Sodium Hypochlorite
09:47 Chlorhexidine: Is There Still a Place?
11:32 Advanced Disinfection Technologies
21:31 Evidence-Based Techniques in Endodontics
25:22 GP Pumping

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject code: 070 Endodontics (Endodontic infections, microbiology and treatment)

Dentists will be able to:

Gain insight into the role of sodium hypochlorite in endodontic disinfection and assess its effectiveness compared to new innovations.2. Discover the cutting-edge irrigation methods, including surfactants, ultrasonic activation, and laser-assisted irrigation, and their impact on endodontic outcomes.3. Explore emerging technologies and innovations that could revolutionize endodontic irrigation.

If you liked this episode, be sure to watch the 1st Part – ‘PDP202 – Elective Endodontics? It’s all about Communication’

Click below for full episode transcript:Teaser: When you use a lower percentage, you really aren't reducing or eliminating the risk of sodium hypochlorite accident. If you get 3% sodium hypochlorite out the end of the root, it's going to cause a sodium hypochlorite accident, as will 6%. If you're trying to eliminate risk using a lower concentration, I don't think it's as effective as you think, but you are taking away some of the strength that you're looking for to kill the bacteria and dissolve the tissue. So my advice would be go full.

Teaser:We recognize that training our general dental colleagues on endo is paramount because we don’t want the option of implant to come in place of saving the natural tooth simply because of fear or the fact that they just don’t feel well enough trained to do the endo. So I believe as a dental community, the more we feel comfortable and proficient in endo, the more teeth we save and the better our patients are.

Jaz’s Introduction:Is sodium hypochlorite still the best thing in irrigation? If it is, what percentage should we be using? This one might actually surprise you. Is there ever a time when to use chlorhexidine. Whatever irrigant we’re using, how can we improve its effectiveness?

Hello, I’m Jaz Gulati and welcome to the part two with Dr. Brett Gilbert. How awesome was he? Please do check it out if you haven’t already. We talked about elective endodontics or preemptive endodontics. I love the clarity and the passion in which he speaks with. And he definitely continues it on into this episode. He’s so knowledgeable, he’s so passionate about endodontics in general, but especially the innovation in irrigation.

Because after all, endodontic success is all about killing those bugs. And Brett has so much experience in trying all the different things out there. And towards the second half of this episode, he really talks about what are the innovations. What’s around the corner? What’s the next best thing in irrigation?

But then I also squeeze out of him the all important real world question, which is no matter what clinic you are in the world, how can you improve your irrigation? So we also talk about GP pumping right towards the end. This episode is eligible for CPD or CE credits. This one’s 0. 5 CE credits under the topic of 070 endodontics as Protrusive Education is a PACE approved provider. Make sure you’ve got the Protrusive Guidance app, so you can just answer the questions after this episode.

Dental PearlEvery PDP episode, I give you a Protrusive Dental Pearl, and can you believe we already have 291 episodes? That’s across all the group functions and the interference casts. And combining all the stuff we do in the podcast, we’re almost at 300. We’ve also reached a really cool feat recently, whereby we now we’re ranked in the top 1% of podcasts worldwide in any genre. So I really want to thank you, the listener, the watcher for supporting Team Protrusive. Your support, your subscriptions, your wonderful engagement has meant so much to us and allowed us to create this content and bring on guests just like Brett and all the 200 plus guests we’ve had on. I want to thank all the guests who come on the show as well.

But before we join the main interview, let me give you today’s Protrusive Dental Pearl. How can you improve your endodontic access? Well, let me tell you the secret of improving anything in your dentistry. Any technique you want to improve in dentistry, you just have to do more of it. Now, what I don’t mean is every patient start accessing their first molar, trying to find MB2 just for the fun of it. That would be wrong, but here’s a really cool idea. As you know, every time I extract a molar, 95% of the time I will be sectioning that molar.

So for a lower molar, section around the middle to separate it into its mesial and distal root, and for an upper molar, more often than not, it’s separating it into its three roots. So I’m very pro sectioning, it’s kind to the bone, it makes your extractions easier. Makes extractions more predictable. I already have podcast episodes on this, and I also have sectioning school, my mini masterclass on Protrusive Guidance, if you want to learn more about sectioning.

But here’s how we can kill two birds with one stone. How can you improve your sectioning? Because when you start sectioning, the most difficult thing is getting that angulation of the bur correct, so that you cleanly cut through the fication or the root exactly where you want it. So how about this? The next time you’re going to do a molar extraction, How about you challenge yourself to first do an endodontic access?

The tooth’s coming out anyway, right? So how about with your bur, you go in for the kill. You get to the canals. What this will do is teach you about endodontic anatomy. It’ll teach you about where the canals live. And the more you do this, the more you’ll end up improving when you actually have to do a real access.

It’ll actually make you quicker as well. Because you have nothing to lose in that scenario because the tooth’s coming out anyway, you’re not going to be afraid to perforate. Because the point is, for sectioning, once you can see the canals, you know exactly where to section. When you see the pulpal floor, it makes the angulation of your section so much better.

So, now with the sectioning, you’ve improved your extractions, and now by the fact that you accessed it first, you’ve improved your sectioning, but you’ve also gained more experience in doing an endodontic access. So I hope you enjoy that pearl. Hopefully it’s applicable to you. Any limiting beliefs you have, oh I can’t do this in my clinic for x, y, and z, just do it.

Even if it just means you book an extra five minutes and that five minutes is what you spend on the access. Oh, and please use some good burs. It makes a huge difference to being efficient. Anyway, let’s join Dr. Brett Gilbert on how we can improve our endodontic irrigation.

Main Episode:Irrigation! Okay, so I know you’re really hot on this. So the proper disinfecting protocols, let’s talk about where we are in 2024. Cause I was taught that sodium hypochlorite is the gold standard. So the first question is, is there anything better yet? Are we still relying on 3%, 5.25% wherever it is sodium hypochlorite?

[Brett]We are, but what we’ve learned is a few things that are important to know, which is that the commercial store bought household bleach is not the way to go. And the reason is, is that what we’re dependent on for the antimicrobial bacteriology is to actually have free chlorine ion and the amount of free chlorine ion in bleach, it’s very unstable. It’s very fragile. We think of bleach as this noxious, hardcore substance, but it’s actually very fragile. It’s sensitive to air to light.

It can become contaminated. And even though it’s still, unfortunately, we’ll put a bleach stain on our beautiful new fig scrubs like you’re wearing there Jaz. It doesn’t mean that the free chlorine ion concentration is high. So we want you to be using a proprietary blend sold by a dental company where there are controls, there’s an expiration date.

And most importantly, what we found through our studies is that adding a surfactant to sodium hypochlorite really changes its effectiveness because surfactant lowers the surface tension of the solution, allowing it to flow into th...

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What’s the difference between radiolucency and burnout?

When’s the best time to use a bitewing vs a periapical radiograph?

When should we pick up the bur for interproximal caries?

Have you heard about the 4 white lines an OPG radiograph?

https://youtu.be/wCV3U8-OAvIWatch PS011 on YoutubeThis episode is packed full of great tips and techniques that will help you understand how to produce great radiographs as well as being able to properly figure out what they are trying to tell us. Radiographs can be tricky, whether that’s due to them being flipped, upside down or due to cone cut, that’s why this will help shine some light on how to get comfortable with radiographs as well as how to manage our patients after we know what we are dealing with.

Need to Read it? Check out the Full Episode Transcript below!

Don’t miss the special notes on Radiology and Radiography for Students available exclusively in the Protrusive Guidance app! (Join the free Students Section)

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App!

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, check out PS003 – Routine Checkup

Click below for full episode transcript:Teaser: This episode is the bare basics of radiography and radiology, i.e. the taking of the radiograph and the interpretation. How do you really know if that radiolucency you see is cervical burnout or is it actually caries? What are the four white lines on an OPG radiograph and why are they important? And why you should be really careful with radiographic interpretation? And it's really important to marry the clinical picture, because that's how you come up with a clinical diagnosis.

[Jaz]Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. This is for young dentists, students, but a lot of qualified dentists have been really enjoying this basic series, this Protrusive Student series.

And so what we’re going to do from the next episode is we’re going to make it CE eligible. The next episode is actually on basics of extraction, but before we do that extraction, we need a radiograph. And it’s a topic that you guys asked for on the YouTube comments. So there we have it. And remember, if you are a dental student, make a free Protrusive account.

Go to protrusive.app and then email your username or your name on the platform to student@protrusive.co.uk. And you’re going to get access to a secret area, which has a bit more of the premium goodies inside. Every PS episode, we have some student notes to provide you as well, made by Emma Hutchison, our Protrusive student. And the ones today are all about radiography and radiology. Hope you enjoyed the main episode, I’ll catch you in the outro.

Main Episode:Emma Hutchison, our Protrusive Student. Welcome back to the student’s edition of the podcast. I know you’ve got exam results coming up and you’re going on your elective soon. How exciting.

[Emma]Yes, very exciting. So I’m just finishing up the last bits and bobs of my elective project and then I’m going traveling for two months. So, I should also get my exam results next week sometime when I’ll be away. So, hopefully everything’s good.

[Jaz]We’re all rooting for you. We know, you know, fingers crossed you’ll do well and you’ll report back to us. If anyone in Asia is a dental student or a dentist, and you happen to see Emma walking in a mall, an air conditioned mall, take a selfie with her and tag us on Protrusive. Let’s see if this social experiment works. Let’s see how much we’re spending. That’d be cool, right?

[Emma]Yeah, it would have to be an air-conditioned place because I’m from Scotland, so I’m not going to do well with the heat over there at all.

[Jaz]Excellent. Well, today’s chat and the subsequent protrusive notes which will go on the Protrusive Student Section at of Protrusive Guidance, which is our app, our community, is about radiology and radiography, right? And before we go further, I kind of have like to put a disclaimer and a lot of the Protruserati are used to me using this disclaimer now and again.

There are some things that I teach and there are just a small part of dentistry. Most of dentistry, that I do, I share. I don’t teach, I share, because to be honest with you, I’m not in a position to teach that kind of stuff, but I’m there to share my own experiences, and there’s some that my unknown unknowns I’m always just seeking to learn more and more and more.

So when it comes to radiology and radiography, I’m sharing, and what I have on you, Emma, is I’ve got like, 13, 14 years of experience over you. And that’s why I have to offer you in terms of the kind of things that used to bother me when I was a student. But I want to just say that take everything with a pinch of salt what I’m saying, because I’m trying my best to guide you and students and young dentists listening, but I’m not the radiology expert here. So it’ll be just to unpack the experience that I have.

[Emma]Yeah, not a problem. Not a problem. I think in dentistry, there’s always so many opinions and everyone has so many different experiences. So everyone will have an opinion, everyone will think differently, this, that and the next thing. So yeah, we’re all just learning. So.

[Jaz]Well said. Well said. So come at me, Emma. What have you got?

[Emma]So first question, I’m going to say. For yourself, Jaz, we’re always taught to be really methodical. Let’s say you’ve got a pair of bite wings there. What are your essential steps in reading and interpreting dental radiographs? Like, what should students look for?

What does your method look like? Because it can be really overwhelming, especially in an exam. I was faced with full mouth peri-apicals, and it was just questions, boom, boom, boom, boom, boom. And you just had to be really methodical. But what does that look like for you?

[Jaz]Great question. I think I’m a big believer in checklists when it comes to radiographs. So first thing to do is make sure it’s rotated and flipped correctly. The right way, like usually I don’t have to flip it, but make sure it is correct and it’s orientated correctly. The next thing to check for is that is it good enough quality doesn’t need repeating and you’d hope that 95 percent plus a time it’s acceptable quality.

So you have to grade your radiograph. So it used to be like grade one, two, three. Now it’s like A or N. So it’s either acceptable or not acceptable. And you have to obviously justify in your notes the reason for taking a radiograph. So Emma, what would be the typical reason to justify a bite wing from what you’ve learned?

[Emma]Caries and bone levels, perhaps?

[Jaz]Yeah. And specifically, it’s interproximal caries, right?

[Emma]Interproximal caries, yeah.

[Jaz]What I say to my patients is that, I need to take these x rays because there are bits of teeth that I can’t see. I can’t see between the teeth. This is where x rays help me. And so it’s very important when writing the justification.

It’s interproximal caries. And so really interesting point. Early on in practice, you just get into a rhythm of doing things and you need to start questioning why we do certain things. Why do we take this bite registration? Why do we do a certain stage in dentures? And so, I remember being a newly qualified dentist and just, oh okay this patient hasn’t had bite wings in like three years, let’s take some bite wings.

And you take a bite wing and you see that actually this patient has like every other tooth missing and no history of periodontal disease. So if I can see the interproximal surfaces, why did I just take this bite wing? You see what I mean? So you really have to think critically and I’ll share a, I guess an honest mistake I made recently.

Okay, I’ll share an honest mistake. I know this is deviating a little bit, but I think it’s really nice to learn from the failures and mistakes of others. Had this really nice gentleman who has had an issue whereby the wisdom tooth was causing decay in the second molar. So low wisdom tooth impacted, that wisdom tooth was removed.

Okay, and the decay seemed minimal and it was really deep down. It was like covered by the gum. So I thought, okay, maybe we can just safely monitor this. When we came around to the interval of taking bite wings. Okay, I did not capture the distal of that second molar.

[Emma]Right. Okay.

[Jaz]Didn’t capture it. And so lo and behold, he came in an emergency and he had pain from that tooth and there was a much, much bigger caries than what we initially had some years ago. And so it’s really important that, yes, we want to see the interproximals, but we have to tailor it to the individual. If we know that actually someone’s not got any restorations or no historical caries, or you’re not watching the premolars, then maybe in that patient, the distal of the second molar for those patients is more important.

And sometimes you can’t capture everything. So it’s important to tailor it to that individual. Going back to what you asked, though, in terms of the checklist and actually being systemati...

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Does ‘elective’ or ‘pre-emptive’ endodontics have a role in Restorative Dentistry?

It almost feels dirty to me as I try my best to PRESERVE pulp vitality!

But sometimes this bites you, and you wish you had carried out root canal treatment before cementing that crown.

At what point can pre-emptive root canal be justified in a world where MTA and biodentine exist?

https://youtu.be/9Gc_yik9fDUWatch PDP202 on YoutubeIn this episode, Jaz sits down with renowned endodontist Dr. Brett Gilbert to delve into the intriguing world of elective or pre-emptive endodontics. Together, they explore challenging cases where teeth with uncertain pulpal health may require root canal treatment, whether due to caries or crown prep. Dr. Gilbert sheds light on patient communication strategies, the role of bioactive materials like biodentine and bioceramic sealers, and how to make crucial decisions about preserving pulp vitality.

Protrusive Dental Pearl: Dr. Pav Khaira suggests using Alvogyl, commonly used for dry sockets, to treat pericoronitis! After cleaning and disinfecting the area, place a small amount under the operculum for immediate relief and to soothe inflammation.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:

3:01 Protrusive Dental Pearl
03:55 Dr. Brett Gilbert’s Journey and Philosophy
07:17 Elective or Pre-emptive Endodontics
11:06 Radiographic Measurement
11:40 Real-Life Encounters
15:29 Discussing Treatment Options and Patient Communication
20:28 Can Biodentine Prevent Root Canal?
22:45 Materials and Techniques in Endodontics
26:16 Death of Gutta-percha?

This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject code: 070 Endodontics (Endodontic infections, microbiology and treatment)

Dentists will be able to:

Learn what elective or preemptive endodontics entails and recognize scenarios where root canal treatment may be required due to caries or crown preparation, and how to approach them.2. Discover effective strategies for explaining treatment options to patients, improving trust and decision-making.3. Gain insights into the use of bioactive materials like biodentine and bioceramic sealers, and their benefits in preserving pulp vitality.

If you liked this episode, you’ll love Post Operative Pain after Endodontics – Prevention and Management – GF017

Click below for full episode transcript:Teaser: I do believe in these instances, you are justified to recommend the treatment. You're not demanding it. You're not saying it's dogma, but you're having a conversation so the patient understands. Because what happens if you don't is you do your work, you're doing it in best faith. Patient winds up in pain, and they become very angry.

Teaser:They become agitated, and they want to blame the dentist. And without a conversation, without a dialogue, they’re clueless, and all of a sudden, they just think you did something wrong. You are a human, and you are the doctor. Speak to yourself. Let the words flow out so that you can explain all the different possibilities in a way that the patient feels heard, understood, but also nurtured, and at the same time you realize this is biology. We are not in control.

Jaz’s Introduction:In a world where we want to do everything to preserve pulp vitality, is it ever appropriate to carry out elective endodontics? Another terminology that our guest today, Dr. Brett Gilbert shared with me is preemptive endodontics.

For example, you have a tooth with dubious pulpal prognosis. And you know that by prepping it for a crown or by removing the caries, this tooth may need root canal treatment. Is it okay to just go ahead and do the root canal so it doesn’t bite you in the behind in the future? You see, I was always taught to do everything possible to preserve pulp vitality.

So I started my career being very much against it. And yes, I burnt my fingers a few times. So we’ll ask our guest today, who’s a specialist endodontist, and you know what, Protruserati, you’re going to absolutely love him. He’s so direct, he’s so quick, he’s so punchy with his answers. And whilst this episode is just half an hour, it’s part of a two part special.

So this half an hour we focus on elective or pre emptive endo. We talk about things like biodentine and bioceramic sealers. And this is worth 0.5 CE credits or half an hour’s worth of enhanced CPD. The subject code for this one, because we are a PACE approved provider, is 070 endodontics. And in the part two of this episode, we’re going to discuss irrigation.

Is sodium hypochlorite still the best thing around? How can we improve the efficacy of our irrigation? How can we get all those bugs? Because endo is all about getting rid of the bug. So that’d be in part two. So don’t miss that one next week.

Dental PearlHello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. And this one comes straight from the protrusive community. As you know, we have our platform, it’s called Protrusive Guidance. It’s been going strong for about seven months now. There’s over 2000 dentists on our community now that have been approved.

So there’s hundreds of people who want to join, but we manually approve each one because A, we want there to be only dental professionals in our group. You want this to be a safe space and I want the nicest and geekiest dentists in the world. So if you identify yourself as that, please join us because today’s pearl comes straight from the community.

We have a very busy chat section of our community, and someone was asking about the management of pericoronitis. And then came Dr. Pav Khaira, who’s like the implant guru, but he dropped such a powerful pearl that I really want to share this with you all. He says that you can use a bit of Alvogyl. You know that stuff we use for dry sockets, we put inside the dry socket?

He suggests putting just a tiny bit of that under the operculum. So where that inflamed tissue is, just tuck it under. Obviously you’ve got to do this after you’ve irrigated, you got rid of the debris, you’ve disinfected the tissues, and now you leave a bit of Alvogyl. And this stuff gives immediate relief to patients.

Now, this was so good that community member Dr. Nikhil Misra said that he’s used this technique for three patients this week with immediate relief. And he’s very grateful that that tip was shared. So thank you to everyone on Protrusive community. Thank you Pav for sharing such a powerful little tip. It’s something we virtually all have in our clinics.

And now we have another use for it. So once again, if you missed it, Alvogyl for pericoronitis. Now, totally unrelated, let’s get back to endodontics and let’s join our wonderful guest, Dr. Brett Gilbert. You’re going to absolutely love him. I’ll catch you in the outro.

Main Episode:Dr. Brett Gilbert from the U. S. So, so good to have you on the podcast. You were recommended to me by Dr. Tom Levine, who’s a member of the community, and he did some CE with you, which I love to hear about. And the more I research and look into you, the more amazed I am. So I’m super, super excited in a geeky way to chat endo with you today. Specifically irrigation, but there’s so many communities, so many, so many questions the community has actually asked, and I can’t wait to dig in.

But for anyone who hasn’t heard about you before, tell us about yourself. I see you’ve got your lovely little box there on the cusp podcast and you do so much in education, but tell us about you, Brett.

[Brett]Yes. So thanks so much. Jaz excited to be here. And I do think Tom, he was at my AGD presentation and within, after the first break, he came up, he goes, do you know, Jaz? And I said, I’ve heard of him. I’ve seen his podcast. He said, well, you guys have to meet. Cause there’s so many just synergies between your energy and your message. So very grateful to be here.

So I’m a full time clinical endodontist. I’m board certified. I’ve been in practice for 21 years. I have a ton of passion for the profession, but as I’ve gotten a bit older into my career and dealt with burnout and the mental distresses and the burdens of the stress of being a dentist, I’ve also become super passionate and a student of personal growth and development and just sort of that ability to manage our stress.

And so I really try to balance them both out because I really feel it’s really important to have the opportunity as a dentist to study the X’s and O’s to understand technique, rationale, the way that we approach dental treatment in whole, but before we do that, we really have to make sure we’re also focusing on the human being inside the scrubs.

And that’s another area of passion that I have. And so I know you share that and I’m really grateful to be here and to meet your audience and to talk it up a little bit and let’s get into some endo.

[Jaz]Absolutely. What I’d love to start with is your journey from the perspective of did you spend much time as a GP before you niched into endo or for you was it like you’re always you’re calling since after dental school?

[Brett]Yeah, interestingly enough, so I’m a son of a dentist, general dentist and my whole life I w...

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Are single-use diamond burs more efficient at cutting?

When should we throw away a bur and pick up a fresh one? How long are they supposed to last? (it’s measured in minutes!)

Are expensive brands a con?

Tiny, but one of the most important tools of our trade…BURS! In a world full of different identifying numbers and names, it can get confusing and even overwhelming.

https://youtu.be/Ol0_XcIbSD8Watch PDP201 on YoutubeThat’s why on today’s episode, we welcome Günter and Marcela from Intensiv, a globally recognised manufacturer of dental burs, where they take great pride in bringing the latest tech to help make our dental procedures that much easier and effective.

In this episode, we cover how diamonds are sourced, what the differences are in colours of burs and how the grain size of diamonds can change our results. There’s lots of amazing tips and tricks here given by the team at Intensiv, so you’ll definitely walk away from this one with something new up your sleeve.

Need to Read it? Check out the Full Episode Transcript below!

HIGHLIGHTS of this Episode:

01:24 Protrusive Dental Pearl

02:03 Introduction to Team Intensiv

05:40 Understanding Bur Codes

10:49 Bur Colours

15:10 When to Use Different Grit Diamonds

18:40 Single Use Burs vs Reusable Burs

24:59 Sourcing Diamonds

29:18 Fixing the Diamonds to the Metal Shank

32:40 Is my bur fit for purpose?

37:30 Drilling Zirconia

39:30 Final Tips

41:20 Contact Intensiv

This episode is eligible for 0.75 CE credit via the quiz below.

AGD Code: 250 Operative (restorative) Dentistry (Preparation Technology)

GDC Learning Outcome: C

Learning Outcomes

Identify the appropriate dental burs for different procedures, considering grit size and material composition, to ensure efficient and safe treatment.
Evaluate the impact of bur selection on patient comfort and procedural outcomes, minimising trauma and maximising efficiency during dental treatments.
Implement best practices for the maintenance and replacement of burs to ensure optimal performance and longevity, thereby improving clinical results and patient satisfaction.

If you liked this episode, you will aslso like: PDP117 – Dental Ceramics in 2022 – Which Ceramic Should I Use

Click below for full episode transcript:Teaser: Are single use burs better or really more cost effective than our traditional multi use burs? I think the answer is actually going to surprise you. And my biggest pet peeve, the thing I hate the most, is using a bur and it has like zero cutting efficiency. I work in a clinic where we share our burs and we have like different bur kits made up.

Jaz’s Introduction:And so sometimes I use a bur and I hadn’t inspected it and I find that, oh my goodness, this is taking way longer than it should. And of course I have to ask my nurse to go to the stock room to get a brand new bur. But this is frustrating. Like when you are using a bur with less cutting efficiency. It is annoying and it’s actually downright dangerous for the tooth. So how can you tell? Is there an objective way to tell and subjectively, how can you tell exactly the moment when you should bin a bur? So you avoid that horrible scenario.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. I’m joined today by Günter Smailus and Marcella Roba who represent Intensiv. Intensiv is a Swiss based company which specializes in diamonds, so who better to find out more about the use of diamond burs and everything to do with diamonds. It’s a very geeky episode, but I feel diamond burs and diamonds in dentistry, we use them so much, we rely on them so much. I think it’s worth an episode, it’s worth discussing about different diamonds in dentistry.

I have no financial interest with Intensiv, this is not a sponsored episode. But this is very much for the pursuit of knowledge and disseminating information to Protruserati, i. e. you guys, and making everything to do with diamonds clinically relevant.

Dental PearlThe Protrusive Dental Pearl I have for you is when you’re cutting off a zirconia crown. I know that dreading feeling, that anxiety you get about drilling off zirconia crowns. And the top tip is, do not be tempted to use a coarse or a super coarse bur. Maybe you know this already, but actually when you use a coarse bur or a super coarse bur on a zirconia, you are not being efficient. You will be slow and it will generate too much heat.

Instead, go for finer diamonds, go for standard blue grit or go for even red grit diamond. You will actually end up being more efficient at cutting that zirconia. To find out the scientific explanation of why this happens, you’ll have to wait till the end of the episode to find that out. Let’s join now the main interview and I’ll catch you in the outro.

Main Episode:Günter Smailus and Marcella Roba, welcome to the Protrusive Dental Podcast. I mean, for those of you listening right now, Günter is this tall man wearing this lovely red bow tie and in a slightly difference in height, but probably just because Günter’s so tall. We have Marcella and they’re both looking very slick and they’re joining us today from Switzerland. How are you guys?

[Marcella]Thank you very much. Doing great. Thanks.

[Günter]You’re great on the sunny side.

[Jaz]Well, I’m fantastic. I’m really looking forward to a nice geeky discussion about diamonds, because as I was telling you before we hit record, trust me, no matter what you think. When we qualify, we know nothing about the bur codes, about which diamonds indicated when there’s little intricacies.

I think this would be a nice geeky chat and there’s a lot in there for any dentist, because we rely so much on our tools. We rely so much on diamonds. And we ought to know a little bit more and this will actually, I think, make us better clinician. The most frustrating thing ever is when you’re drilling a tooth, removing caries, right?

And things are going slow. And that is not only damaging to the patient’s pulp and the tooth, but it’s also losing us money because time is money. So there’s so much we can gain from this conversation by using the right materials in the correct way. And diamonds are a big part of that. Before we delve in deeper, Günter and Marcella, please can you tell us about yourself? Günter, let’s start with you. Tell us about yourself.

[Günter]Okay. My name is Günter, as we said. I’m in dentistry since more than 40 years now. Let’s say I grew up in dentistry. I’m running this company and the third generation, the company that was more than 80 years on the market. And my background is not dentistry, my background is economics.

So I get it. I’m running the company here with 45 people. And as I said, the third generation and I took already 20 years duty and still I have to do one other 10 years because the first one gets 10 years, 10 years, 30 years, and then myself 30 years or 90 years is my goal here.

[Jaz]Very good. And Marcella, tell us about yourself.

[Marcella]Hi. So I’m Marcella and I come from Italy, but I live here in Switzerland. I’ve been working in Intensiv since 11 years now. I started off as quality manager and now I’m responsible for regulatory affairs. My background is biomedical engineering and surface science, and I’m in this field since, yeah, 11 years.

[Jaz]Fantastic. And I first met you Günter recently, in Valencia. I know we saw each other online and stuff, but we saw each other in Valencia. We did a really cool IPR workshop working with the Swingle and that’s creation by Intensiv. So, before I discovered Intensiv diamonds, I just saw, oh, the Swingle.

And then I discovered that, oh my goodness, Intensiv is this huge brand in diamonds and burs and stuff. And so that kind of came to me like, whoa, that’s so fascinating. In terms of the range of products that you guys do. So you are in a great position to teach us about diamonds. And what I like about you Günter is when I had that chat with you in Valencia planning this, the position you came from was very much education.

Let’s educate the dentists about diamonds and stuff because it’s an important topic rather than from a commercial background. Yes, you represent Intensiv. Yes, you own a company. But you were very much on board that yes, education, education is so important. And I saw that in action teaching with you in Valencia.

That was real good fun. And there was so much I’ve never seen anyone. I told you this. I’ve never seen anyone plan a lecture minute by minute by minute. Please. I was amazed. You literally made all the slides for me. I just had to enter my photos. That was fantastic.

[Günter]Yeah. And then growth by growth almost.

[Jaz]It was phenomenal. It was a lesson on leadership as well. So I admire you as a person, as a leader as well. And it was great to have some good food and drink with you there as well, but getting back on topic. Okay. Where do we start? I think we should start here, right? Basic, basic, basic bur codes, right? So when we are using, let’s say a bur for a crown preparation or a round diamond, for example, to remove some caries, can you just tell us about how the bur codes, the system of naming a bur?

[Günter]Okay. The system of the bur is historical. Historical because in the beginning, when it starts with the burs, we had only let’s say five or seven different forms. And I just said the ball, the cylinder, or as you see here, the football or the egg, we had onl...

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Last Live Occlusion Course of 2024 – Book Now: https://courses.iasortho.com/courses/gb/occlusion

POV: You spend a fortune on a composite anatomy course and are excited to implement on Monday morning.

However, every time you apply those concepts, you end up drilling it away because it’s proud in the occlusion!

It essentially now looks like a tooth coloured version of the amalgam you just removed!

Your nurse’s eyes are like pools of fire – that’s half her lunch break gone.

This happens a few more times until you realise that you’re missing a trick…

Enter this podcast to save your career! ????

https://youtu.be/5MVvknCNV-8Watch PDP200 on YoutubeDr Jaz Gulati and Dr Mahmoud Ibrahim will teach you how to radically minimize adjustments on your daily restorations.

Key Takeaways:

Always check the patient’s occlusion before starting any restoration.

Utilize shim stock to ensure accurate occlusal contacts post-restoration.

Pre-op visual checks are crucial for successful composite placement.

Don’t compromise on the anatomy of the restoration for aesthetics.

Use thinner articulating paper for more precise occlusal markings.

Communicate effectively with your dental nurse about new protocols.

Involve your senses to assess the quality of your restorations.

Document occlusal marks pre and post-restoration for reference.

Adjustments should be minimal if pre-op checks are thorough.

Educate patients about their occlusion to manage expectations.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:05:24 Introduction – Dr Mahmoud Ibrahim08:42 Posterior Composite14:15 Shim Stock Foil16:35 Effects of Numbing on Occlusion18:23 Lower First Molar Example22:06 Shim Stock revisited26:22 Lateral Excursions30:32 Fissure Staining?31:56 Old Restoration as a Guide35:33 Restoration Techniques and Adjustments38:03 Tips and Tricks43:28 Event Discussion45:09 The Importance of Marginal Ridges46:25 Anatomy or aNOTomy?48:17 Post-Op Checklist: Final Adjustmentsand Polishing Tips54:19 Wrapping Up: Using Your Senses in Dentistry56:43 Outro

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance App.

This episode meets GDC Outcomes A and C.

AGD Code: 250 Operative (Restorative) Dentistry (Direct restorations)

Dentists will be able to:

Evaluate and manage occlusion during posterior composite restorations, ensuring that patient bite and interdigitation are maintained post-procedure.
Effectively use shim stock foil and articulating paper to achieve precise contact points and occlusal balance, minimizing the need for post-restoration adjustments.
Apply practical techniques, such as using occlusal stamps and soft flex discs, to streamline posterior composite restorations while improving the durability and aesthetics of the final result.

If you liked this episode, check out: IC046 – 4 Ways and 6 Great Reasons to Document Your Dentistry

Click below for full episode transcript:Teaser: The cuspal inclines and using visual references that I take before I prep the tooth. So I'll look at where the marginal ridge is compared to the base of the cavity. Where's the bottom of the fissure pattern on the adjacent tooth, for example. Use those visual references and then the angle of the cusp. The angle of the cusp is probably, for me at least, one of the most important ones.

Teaser:Some patients are like princess and the pea, whereas other patients are like everything feels amazing. And the very last thing you check is how does that feel? That’s like the last. Why are we getting patients to feel their bite?

They shouldn’t like become obsessed about their bite. We’re kind of edging them closer every time we say, how does it feel? How does it feel? They’re feeling their bite. Something that really should be not really present for them, if you like.

Once you get quicker and slicker, I would urge you to start checking front teeth as well. Because it’s actually going to inform you as to how often front teeth do and don’t hold shim stock. And I think you’ll be surprised.

Jaz’s Introduction:So you go on a posterior composite course, you brush up on your anatomy and you’re excited to place posterior composites that actually look like teeth instead of just white amalgams. And so what happens is that you have like the best fun ever, trying to create all the fissures and the inclines and anatomy. And with rubber dam on, you take that photo and you just stare at it for five seconds and you think, yeah, this is a work of art. I’m going to post this one on Instagram. And then you already know where I’m going with this.

You already know what I’m going to mention next, which is you take off the rubber dam and you get the patient to bite together. And literally like the bite is so open, right? You have to get the big bur, right? You have to get a big bur throughout and just grind away all the anatomy. Now you have a white amalgam left.

Obviously, it’s composite, but it’s now flat. It may as well just been a white amalgam. All that fun you had was wasted and you’re getting evils from your dental assistant because you just wasted up to anything up to 20 minutes. Earlier in my career, it could take that long to get the bite right.

And you think, wow, what a waste. What a waste of time to doing anatomy. What a waste of clinical time. What a waste of my DA’s lunch hour. And this is not profitable. This is not fun. It’s depressing. So this is why this episode will give you such a good framework to eliminate or at least significantly reduce how much adjustment you have to do for your composites.

So they can still look good. Like I’ll be honest with you. Sometimes you just can’t do a beautiful composite in that scenario, because guess what? All the other teeth in that arch are quite worn and you can’t give a 70 year old a 12 year old’s tooth. But in our daily scenarios, we give you some really tangible pearls and tips and technique advice to reduce the amount of adjustment, be more purposeful in your composite placement, but still take some degree of pride in the anatomy that you’re placing.

Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. If you’re a regular watcher or listener, please do hit that subscribe button. You’ve been listening to us for so many years, you might as well give us some love. And if you’re new to the podcast, definitely hit subscribe because you don’t want to miss another episode and you want the algorithms to show you all the other episodes we’ve done over the last six years.

This is an important episode because this is episode 200 of PDP as a podcast we have almost 300 episodes including all the other branches of the podcast we do. But in terms of the original PDP it’s such an exciting number and I’m especially grateful to about five to eight hundred of you who’s literally stuck by me from episode one.

So when I used to make my first 10 episodes, so there’s about five to 800 people that would listen to watch full stop back then we were audio only. And now I look at the numbers and it’s amazing. We are a top 1 percent podcast in the world, in any genre. And it’s thanks to you guys sticking with Protrusive, the feedback and the guidance you give me, to allow us to make great content. I’m not going to take up too much time. I just want to say thank you again for being a Protruserati.

Dental PearlNow every PDP episode I give you a Protrusive Dental Pearl. This one’s regarding our basic posterior composites. So it’s very much in line with the theme of today, getting the occlusion right in your posterior composites, but actually this is due with cavity configuration.

We want these proximate exit angles, which are smooth and flowing. And so recently I posted a pre molar I did, and I was quite happy with the anatomy I achieved, and yes, it was perfect in the occlusion. And I posted my cavity prep on Protrusive Guidance, and I said, guys, please do critique me. Is there anything I could do better?

And despite me using an old science scaler to remove the Friable enamel. I’m using like a needle diamond bur just to smooth out those exit angles. One of the Protruserati Sai still said that, you know what, we can get this a bit smoother. Have you considered using a soflex disc? And I’m like, whoa, I use soflex discs all the time.

So at the end of every composite, I will always use a soflex disc. And for my anterior dentistry, I’ll reinforce my bevels with a soflex disc. I find discs great to get rid of the friable enamel, the unsupported enamel. But I did remember now that I’m out of habit of using these discs posteriorly at the time of cavity configuration.

I usually pick them up after I’ve completed the composite restoration. And so really it’s reinforcing what I re learned and reminding you guys that a flexible coarse disc used in the backhand stroke can really help you to get nice, smooth, flowing enamel, those lovely exit angles that we desire for our composite bonding.

So thank you Sai and thank you everyone who commented on that post on Protrusive Guidance. If you’re not already on there, it’s the home of the nicest and geekiest dentists in the world. There’s no such thing as a silly question. I’m really enjoying seeing the chat thriving and people posting more. Now we’ve already got six years worth of podcas...

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It’s Friday and you’re fitting the last patient’s crown. It is completely shy of the bite – but it looks good. The patient says ‘it feels great! I can hardly feel anything!’

Do you cement it (plant it low?) and let it grow? Is that acceptable?

How about the ‘GABS occlusal philosophy?’

Is ‘centric relation’ full of unicorns and rainbows?

What is an efficient protocol in ‘checking the occlusion’?

https://youtu.be/Nmx1C8WDSjAWatch PS010 on YoutubeJoin us in this episode where we discuss some key techniques to help ensure we are managing occlusion as a primary focus when dealing with restorative treatment. This episode is packed with essential tips that are perfect for dental students and professionals alike.

Don’t miss the special notes on Occlusion, CR & All Things Confusing available exclusively in the Protrusive Guidance app! (Crush Your Exams section)

Need to Read it? Check out the Full Episode Transcript below!

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App!

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, be sure to recap PDP109 – Articulating Paper is Lying to Us

Click below for full episode transcript:Teaser: Here we are, a little bit late, but this is the Protrusive Students version for Occlusion Month. We've got our Protusive student, Emma Hutchison, who once again has done a wonderful job to create these student notes.

Jaz’s Introduction:You can download these for free on the community, there’s a special students area, and you can also catch up with the previous nine other Protrusive student notes, bespoke notes, just for students. Very visual and written by Emma herself, inspired by what she’s learning at uni and also what she’s learning online. Head over to protrusive. app to check that out.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This episode is huge. Like when I was a dental student, anything to do with occlusion was mega confusing. Like even down to adjusting a basic composite. Like you’ve just placed a composite, and you’re picking up the bur, and you have no idea what you’re doing. Was it just me, or is that you as well?

Well, how about we cover in this episode for the benefit of students, and of course, anyone in dentistry, or dentists can actually learn something from this episode, I think. We need to talk about some specific protocols taught to me that I’m sharing with you guys, and we go deeper into what actually happens if you start leaving teeth out of occlusion, i. e. You restore a tooth and now that tooth is no longer actually touching the opposing tooth. It’s no longer contributing to the patient’s occlusion.

Is it always a sin? Is it acceptable? And how do you actually go about avoiding that? Like, how can you actually be more precise in your occlusal adjustment? We also, of course, talk about the influence of different thicknesses of articulating paper and why you should avoid using thick papers. There’s a lot to unpack here, so let’s join the main interview and I’ll see you in the outro.

Main Episode:Okay, Emma, you just had some exams. Okay, so welcome back. How was it? How did it go?

[Emma]It was okay. I think they’re always going to be a bit rough. This year I had two written papers. I had one multiple choice paper, which was okay. And then the second one was like a multiple short answer, which is always the trickier of the two, I think, for me anyway.

But they changed the format of our MSA short answer one this year. So it was just a wee bit different. They changed it from, I think, 20 questions worth 10 marks to 15 questions worth 13 marks or something like that. So it was just a wee bit different to what I’m used to.

It meant maybe things went a wee bit more into debt, which is difficult for dentistry because you need to know, I think for the exams, you need to know a wee bit about everything, and then sometimes that’s enough to sort of get you the marks that you need, but especially this year, less questions more focused. So it was a bit of a shock to the system, but I think it was okay.

[Jaz]Good. And the OSCE was?

[Emma]The OSCE was okay.

[Jaz]So just because there might be some international students who maybe they don’t have OSCEs in their uni. I don’t know. Like, can you just tell us about what an OSCE is?

[Emma]Yeah. So our OSCE is quite similar in the UK for your entry to dental school. You’ll have what’s called an MMI, Multiple Mini Interviews, I think it is. And you are in a clinic or a group of rooms, you stand outside the door and you have one minute to read whatsoever’s on the door. And it’s the worst feeling in the world.

And you have to go in, do this station. Sometimes there’s actors there, like paid actors that you’re interacting with, and you’ve got a clinician there who’s marking you on what you’re doing and in Glasgow. In third year you have 10 stations and each of them are five minutes long and then you get one minute each to read your instructions. So it’s just boom, boom, boom, boom, boom.

[Jaz]So it could be like a Paeds thing, then a perio thing, then a restorative thing, like study models on the table. Give us an example of a one OSCE station that you remember.

[Emma]I can tell you all of them. So this year I had rubber dam. Three to three on the upper, canines to canine, and you had five minutes to put it on wedjets in each side and floss ligatures on the two centrals.

[Jaz]Nice.

[Emma]And we had the exact same station-

[Jaz]So, well, I think it’s impressive that as a student you’re doing floss ligatures. That’s pretty cool. Right? Okay. You don’t think so?

[Emma]Obviously. Well, everyone got it finished. The thing is, like, with the OSCEs, you don’t have to do the station perfectly to pass. I think all of them are marked out of, like, 10 or 15. So last year, we didn’t have a nurse there to help us. So I managed to get the dam on, but I didn’t get any ligatures on at all. And it was my, I think it was, one of my last stations last year, I was fatigued.

I was tired. But this year it was my first station and I don’t think I’ve done rubber dam since my last OSCE a year ago. So I went in to this station and it was my mentor James Don standing there. I was like, oh no, what is this going to be? Some end of station ended on six stations. So I’m standing there and I’m reading it and it’s like rubber dam three to three. Floss ligatures, but we had a nurse there to help us this time, which was good. So like getting the nurse to tend to the dam for me, she helps me floss and I managed to see-

[Jaz]You’re probably getting marked on also the communication with the nurse or how you are instructing them to help you. So that’s good. I think it’s really good that you got to do that in your OSCE. I never had a rubber dam station in OSCE. I remember having some orthotic models. No, it sounds like a good one. Is it like a phantom head? Is that what it was?

[Emma]Yeah, bonafide some hedge, yeah. We had an ortho one as well this year, yeah, so writing a prescription for a upper removable appliance, yeah, which was okay.

[Jaz]Lab prescription, yeah?

[Emma]Yeah. Yeah.

[Jaz]Okay. Very good. There was a four letter acronym or whatever, or the way to remember. What’s it called when you use four letters, mnemonic. There was a four letter mnemonic for-

[Emma]We use ARAB.

[Jaz]That’s it.

[Emma]We use ARAB, A R A B. That’s what we use.

[Jaz]Go on, you have to say now what it is now. It’s like Anchorage?

[Emma]The first A, well in Glasgow anyway, is your active components. R is your retentive components. Then your anchorage and then your base plate.

[Jaz]Yep, yep. Very good. Well done. Let us know how you get on with the results. I’m sure it’ll be fine. Well done. So today we are catching up after a little while because we had a little break for exams and stuff. Obviously this is coming out much later in the year. But you got some exciting things planned. Is it a good point to tell us about? Actually, I think when you come back from your elective, it’ll be good for you to tell us about how it went and what you got up to and stuff. But just give us a flavour of what you got planned for elective.

[Emma]Yeah, so we have changed our electives in Glasgow to the end of third year rather than fourth year, so that you don’t have such a big gap in between your fourth and final year. So basically you get a mentor. As I said, my mentor’s name is Mr. Don, and he’s an endodontist. So I’m going to be doing, what’s the word, a literature review. I’m going to be doing a literature review about hypochlorite injuries. And putting together some statistics for that and hopefully constructing a guide for students and maybe other dentists on how to communicate this sort of risk with your patients.

So that’s mine. I’ve got friends that are doing all sorts of things. I’ve got friends that are going to the other side of the world, which I am going to be doing, but I’m going to be finishing my elective before I go away. And then I’m going to be traveling Southeast Asia. ...

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“Defensive Dentistry and the fear culture is the number 1 cause of anxiety amongst Dentists”

How can we instead foster a culture where we can focus on growth and supporting each other?

Does Dentistry have a social media problem?

https://youtu.be/wsiENbuIXcEWatch IC053 on YoutubeJoin us on this episode with Dr Mehy Lo-Presti as we navigate dentistry and social media, the pros and cons of using the online world as part of our portfolio and how we can remove anxiety through effective communication.

2 Events to Attend:

DentoRama 18th October

Treatment Planning Symposium (Hybrid Event) 16th Nov

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:02:05 Introduction – Dr Mehy Lo-Presti06:42 Mehy Early On12:04 Dento-Rama15:30 Social Media in Dentistry20:35 Life Before Social Media21:25 Social Media is a Business 23:40 What Causes Anxiety for Dentists?29:45 Overcoming the Fear Factor34:45 Fast Tracking to Success41:20 Wrapping Up47:14 Booking the Event and Getting in Touch

This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.

GDC LEARNING OUTCOMES: A

AGD Code 770 (Self Improvement)

Dentists will be able to:

Gain insights into how social media affects clinical practice, patient perceptions, and professional image, learning how to use these platforms responsibly.
Manage the pressures of online validation, minimising the impact on their mental health and maintaining a healthy work-life balance.
Develop stronger communication methods both online and offline, ensuring clearer patient education, reducing complaints, and fostering better relationships within the dental team.

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. This includes videos on Overlay preps and the famous ‘Vertipreps for Plonkers’ series.

If you liked this episode, check out IC035 – Best Practices in Social Media for Dentists

Click below for full episode transcript:Teaser: It depends again, what you want to show, who you want to be in social media. I always have this debate. I asked this many times in my events. Is it okay to share your personal life and your professional life at the same time? And some people will say yes. And, but there are consequences of that. And the consequences is that-

Teaser:I don’t believe in fast tracks. I don’t believe in that things can go very quick because you’re going to miss a lot of learning in the process. So I think exploring and making mistakes and allowing yourself to fail. It’s something that. It will make you grow way faster. People are happy in their jobs when they feel that they are treated as adults.

And this is something I learned from the employees from Google and Netflix and all these super fancy offices. They understood that people don’t care if you give them free food, they have a gym, you have cinema, you have all this super cool things in their office. So if you don’t treat them as adults and you don’t give them this freedom, they won’t be happy.

Jaz’s Introduction:What’s the number one thing holding you back as a clinician? What’s holding you back from growing as a dentist and actually sleeping well at night time? It is an F word. Me and my guest today, Dr. Mehy Lo-Presti, we believe that fear is holding us back. When all of our decision making and all of our judgments and our communications are processed through this filter of fear and our dentistry is fear driven and therefore defensive. This is what may thought was the number one contributor of anxiety for dentists.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to the Protrusive Dental Podcast. This is an interference cast, where we discuss more of the non clinical themes, which are super important, because we touch on communication, we touch on fulfillment, and we also touch on social media, because we can’t avoid it. Is there a place on social media for us all? Should we all be on there? And how do we conduct ourselves on social media? And how do we avoid the negative stuff on social media? I. e. the anxiety that social media itself actually brings.

This episode is still eligible for CPD or CE credits. There is one CE credit or one hour of enhanced CPD, and the AGD code for this one is 770. That’s self improvement. And I truly think if you make it to the end of this podcast, you will feel so uplifted.

You will appreciate that the themes we discuss on this episode are so real, so current, and they’re the kind of things that just need to be discussed more in dentistry. Two events that I recommend on the back of this podcast is October 18th Dentorama by the Global Dental Collective. This is like a combination of theatre, comedy and dental debate for the entire dental team.

That’s in London and also in London on 16th of November is the Treatment Planning Symposium. This is where Lincoln Harris and Dr. Michael Frazis will be coming from Australia to London and I’ll be joining them as well to talk all about failure and then Lincoln will take over with a treatment planning masterclass.

We’ve got a live patient consultation plan, like an unseen case for Linc, as well as asking the sauciest and the hottest questions on the live panel debate. For both those events, I’ll put the link in the show notes. Now let’s join the main podcast and I’ll catch you in the outro.

Main EpisodeDr. Mehy Lo-Presti, welcome to the Protrusive Dental Podcast. I’ve been following you for a while. I don’t know if you remember the first time I actually met you, right? Was that, it was a Pascal Magne. I think it was in Glasgow. I think, right. It was a BACD and then you were there with extra Rupert Munkhouse, right? And I was like interviewing you, right? And then that’s when I first got exposed to you.

And then I didn’t realize you were just like mega superstar. Then I see you on the stage. You’re like, gosh, I don’t want to say Jerry Springer, but like the male Oprah Winfrey, you’re just like completely ruling it. And now here we are recording today. So for those who don’t know about you, Mehy tell us about yourself.

[Mehy]Wow. Wow. That’s, what an intro actually, no, the expectations are very high, maybe not as funny, but yeah, I can manage an audience.

[Jaz]Edinburgh.

[Mehy]Well, yeah, that’s true. We met in Edinburgh, right? It was at the BACD and then you were recording and interviewing people and then I already was following you because I think you have one of the best educating content in the dental world.

So the pleasure is mine. Well, I’m a dentist. I was born and raised in Spain. I practice in London now. And basically I got to the point where dentistry was a struggle for me. I got a lot of people around here and I found healthcare events very boring in general. So I needed to find a way to make them more fun.

I needed to find a way to also talk about everything that goes around dentistry that can help us to have a happier-

[Jaz]What aspect of it did you struggle with most? So the common ones we hear is, just like the clinical, the big step that we have from dental school to real world, that’s a huge knowledge gap, right? And then you realize actually, in dental school, you really barely scratched the surface, right? And which is very disheartening to all our young listeners. I know, but that’s the real world. And, or was it the managing expectations of patients or was it just transition to adulting? What aspect of it did you find trickiest?

[Mehy]I think what creates a stress in ourselves, it’s the not knowing what is going to happen. I’m not having a hundred percent control of what is going to happen in any scenario, right? And in dentistry, especially in the first years. This is very common. You don’t know how well your treatment is going to go because you’re not as good. You don’t know how the patient will react. You don’t manage your team that well. You take your work to home. So it’s a never-

[Jaz]You own the patient’s problems, which is something I talk about. You end up owning the patient’s problems. A lot of young dentists, people still do it all throughout their career. But that for me was very peak when I was a newly qualified, this patient had this really tough decision to make between a root canal and extraction. And I felt it was me having to make a decision. I take that home with me, maybe in my stomach in bed, even like a minor thing like that, or a patient has a dry socket and it’s almost as though you had the dry socket.

And this is a sign of a caring practitioner, so anyone’s resonating with this, it’s kind of a good thing that you have that compass inside you and you are sympathetic, you’re empathetic. But we must learn to detach ourselves and be there to guide the patient in their journey, but not to own their problems.

[Mehy]A hundred percent. And not having those tools to do so was basically what took me to have the decision to make the decision to like, okay, maybe this is not for me. And especially after COVID, like COVID and going back in th...

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JOIN US on 16th November for Treatment Planning Symposium 2024 – Online Event OR In-Person – you decide!

https://youtu.be/G5ebbUl0sDgWatch PDP198 on YoutubeImplants are great but they are not always the best solution for our patient.

There are many times a bridge or denture may serve the patient’s goals, aesthetics and budget better.

So how do we decide between bridges and dentures?

Is it acceptable to use root filled tooth as a bridge abutment?

Are single tooth posterior dentures risky? Or do patients love them?

How do we begin to communicate aspects of replacing teeth with our patients?

Join me with our guest Dr Michael Frazis as we discuss the art form of communication with our patients and some outlandish cases including roundhouse bridges. This will really help upskill you on dealing with patients with missing teeth.

Protrusive Dental Pearl: Failure is inevitable for our Dentistry, but try to set yourself up for smaller failures and not giant catastrophes! The real magic is in proper case selection. Practise at the EDGE of your comfort zone, but NOT out of your depth.

20% OFF Guaranteed on RipeGlobal Fellowship Programs + Free access to their portal – Click here to register for this! protrusive.co.uk/rg20

Follow Dr Michael Frazis on Instagram

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC LEARNING OUTCOMES: A and C

AGD Subject Code: 610 Fixed Prosthodontics

Dentists will be able to:

Demonstrate improved decision-making skills in treatment planning, particularly regarding non-implant tooth replacement options.
Apply communication strategies to better explain treatment options, manage patient expectations, and gain informed consent, especially in high-risk cases involving implants, bridges, or challenging restorations.
Recognize red flags and understanding the risks involved in specific dental procedures (such as implant failure or the use of root-filled teeth as abutments) and how to mitigate these risks through careful case selection and patient education.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:00:01:37:00 Protrusive Dental Pearl00:03:51:05 Introduction – Dr Michael Frazis00:10:43:10 Growth in Dentistry00:14:10:10 Non Implant Tooth Replacement Options00:18:15:10 Treatment Planning Bridges and Dentures00:24:35:10 Ideal Treatment vs Budget00:30:15:10 Single Tooth Dentures00:36:58:10 Thin Implants vs Bridges00:39:25:10 Bridge Spans00:49:20:10 Root Filled Teeth as Bridge Abutments00:55:35:10 Failures01:05:35:10 Wrapping Up – Contact Michael

If you liked this episode, check out PDP132 – Resin Bonded Bridges

Click below for full episode transcript:Teaser: I'm doing that bridge 11 times out of 10. If they're a patient that has money to burn and they want their teeth to be individual, they want to be able to floss their teeth because that's just what they have as their goal. I will go crown implant- And I don't think we as dentists tell patients that. If there's something you can do as a clinician to mitigate that risk, could you use that word, tell them what it is. So to give you a concrete example, when I'm taking out a tooth, I will say-

Jaz’s Introduction:Implants are awesome, but they’re not for everyone. Now this could be financial. This could be something to do with their medical history. And actually there are some scenarios where a bridge or a denture can be superior. And so many of these scenarios, we need to help the patient decide between a denture and a bridge. We’re going to do a deep dive into decision making and treatment planning when it comes to these modalities. I’m joined by Dr. Michael Frazis from Adelaide, Australia. He’s one of the educational directors for Ripe Global. And very soon he’ll be coming to our event in the UK to talk about treatment planning and failures which will be a live in person event and also a live stream.

In today’s episode, the real world questions we cover are ones like, is there ever a place for a single tooth posterior denture? Can you ever justify using a root filled tooth as a bridge abutment? And how big of a bridge is too big of a bridge? Is there ever a place for a roundhouse bridge? And generally bigger picture stuff. Implant considerations, denture and bridge considerations.

Dental PearlHello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. This one’s actually full of some great communication gems and one of them today is what I’d like to make the Protrusive Dental Pearl. To highlight the event we’re doing on the 16th of November on treatment planning and failures. I want to take this opportunity to pitch the notion that you’ve already heard before, which is failure is part of life.

It’s part of dentistry. All our dentistry will eventually fail. And sometimes you make poor decisions and we learn from them and they’re powerful teachers for us. And we experienced all sorts of different modes of failure. And every time we fail, we hope that we will learn and improve as clinicians. But I want to take this one step further by encouraging you that when you fail, try and fail as safe as possible.

And the way you can do that is case selection, but also just generally making sure that you are pushing your boundaries and challenging yourself, but make sure you are challenging yourself at the very edge of your comfort zone. You want to be at the edge of your comfort zone, but not to beyond your comfort zone because that fall from when you go too far beyond can be quite big and when you fail you can fail hard. Let me give you an example. If you’ve never done veneers before, please don’t pick a class 3 patient with crowding who’s got features of a high force bite and a high smile line. Do you get what I’m trying to say?

You’re setting yourself up to fail hard. And sometimes we take these cases on because we really want to do them, but I would encourage you, it’s good to challenge yourself. It’s good to be out of your comfort zone, but please don’t be out of your depth. Now, if you’d like to join the live stream and the 30 day replay of our Treatment Planning Symposium with Lincoln Harris and Michael Frazis, and my very clinical lecture and all the different failures and mistakes you can make in restorative dentistry.

Then please do head over to protrusive.co.uk/rx. The early bird rate is almost over and I don’t want you to miss out. It is an absolute steal at the moment. If you’re able to attend live and network, enjoy that magic of people. Then it’d be great to see you there. But if you can’t come to London, then do join us on the live stream and, or the 30 day replay.

One of the things we’re going to have is a live patient, unseen case. So Lincoln Harris will do like a live consultation on stage and we’re hoping to learn some communication skills, but he’s going to dissect that with us. So we get a better understanding of treatment planning in the real world. And sometimes by going through a case, that’s when we learn the most.

So please do head over to protrusive.co.uk/rx and pick the in person or the live stream pass, whatever suits you best. Now let’s join the main episode. I’ll catch you in the outro.

Main Episode:Michael Frazis from Adelaide, I believe it is Australia. Welcome to the Protrusive Dental Podcast. How are you mate?

[Michael]I am very well, Jaz. Thank you for having me.

[Jaz]I’m really excited to talk about all things non implant replacement like the nitty gritty questions we usually have about, can I restore this with a denture? Can I do a bridge here? But also talk about the overarching theme of replacing teeth, but I just want to fanboy a little bit, man.

Your content that I see, your development that I’ve seen over the years, even back in the day we used to have this page, you should probably still have it, Everyday Dentistry with Michael Frazis. I’ve been following you for probably 10 years now, man. I love what you do, you bring great value to profession, and I’m so excited that you’ll be coming to London as well to share that passion live with us. So I guess I want a little bit of an origin story. How did you get into this sphere of making this educational content?

[Michael]Well, I was actually making a completely unrelated webinar for some like dental students for next week. And it’s advice to my graduating self. And I’ve been looking through old photos that I’ve taken, back when I first graduated, and old videos that I took, like the first kind of videos that I was doing.<...

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Treatment Planning Symposium 16th November Hybrid event: https://www.protrusive.co.uk/rx

Are you still afraid of raising the Vertical Dimension? You cannot break free from the shackles of single tooth Dentistry if you don’t get comfortable with vertical dimensions changes in Restorative Dentistry.

https://youtu.be/Nb-LTyzRKuUWatch PDP197 on YoutubeIn this episode, Dr. Jaz Gulati and Dr. Mahmoud Ibrahim simplify the complex topic of increasing vertical dimension.

What is a safe limit of increasing the vertical dimension?

They cover the essentials of joint health, muscle stability, and the importance of centric relation (does it actually matter?)

Protrusive Dental Pearl: Use Duralay copings for guide planes to ensure stable dentures with a single path of insertion. While eyeballing the prep can be challenging, he suggests requesting acrylic copings from the lab for precise preparation. He explains that technicians survey models to identify undercuts and determine the path of insertion, and instead of manual prepping, he advises using lab-created reduction copings and acrylic jigs to simplify and accurately guide the preparation process.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

02:05 Protrusive Dental Pearl Acyrlic Copings for Guide Planes
03:57 Dr. Mahmoud Ibrahim’s Introduction
06:05 Personal Experiences with Vertical Dimension
08:45 Challenges and Techniques in Vertical Dimension
14:17 Clinical Considerations (Restorative Dentistry) and Research
21:15 How to Assess OVD Loss?
24:35 Factors to Consider in Increasing the Vertical Dimension
28:41 Treatment Planning: Orthodontics vs. Restorative Management
32:21 Assessing Cases for Vertical Dimension
34:39 Joint Position and Vertical Dimension
39:47 Occlusal Appliances Prior to Increasing Vertical Dimension
45:26 Joint Relationship
50:49 Reproducibility and Stability in Occlusal Planning
53:00 Summary and Final Thoughts on Vertical Dimension

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

AGD code: 180 Occlusion (Occlusal therapy)

This episode meets GDC Outcomes A and C.

Dentists will be able to:

Explore key clinical considerations and current research in restorative dentistry related to vertical dimension, enhancing your ability to make informed decisions.
Understand the relationship between joint position and vertical dimension, and how to assess and manage this relationship effectively.
Recall the guidelines for assessing the vertical dimension and the safe limit for this in dentate patients.

If you liked this, you will also like Functionally Generated Path Technique – Conforming to Funky Occlusions – PDP168

Click below for full episode transcript:Teaser: But it can also help you stage treatments, right? It's a great technique to learn because it allows you then to stage those more comprehensive cases. So one of the most useful things about opening vertical dimension is gaining space for your material without having to prep teeth that they're usually already quite worn. Now that is a huge benefit for anterior teeth, but also can come into play on back teeth.

Jaz’s Introduction:I used to be petrified of opening the bite, i.e any kind of treatment that would increase the patient’s vertical dimension would be way out of my comfort zone and it really made me worried like, is the patient going to adapt?

Are they going to get joint pain? Am I perhaps increasing the vertical dimension too much? And so for the first 18 months of my career, I was focusing on conformative dentistry. Not having to change the vertical dimension, just accepting the patient’s bite for what it is and working with it. You know, a filling here or a crown there.

And back then it mostly was small and large composites. I was still finding my feet, I wasn’t confident with indirect dentistry, and like I said, occlusion is confusing to all new grads. And I remember the first couple of cases where I started to think about this, whereby the only way I can solve this patient’s occlusion and give them what they want, be it denture or some new restorations, would involve opening the vertical dimension.

I was speaking to my principal and I said, okay, are you sure this is going to work? Is it going to be okay? What if the patient has pain? And I think a lot of you have also been through this and some of you may be in that place right now. Which is why with Dr. Mahmoud Ibrahim, we’ve created this episode specifically devoted to vertical dimension.

Look, this short episode, whilst we’re going to really make sure it packs a punch, is not going to allow you to open the vertical dimension, but it’s going to inspire you to think about it more. It’s going to give you some guidelines in terms of how much you can raise the vertical dimension. Is there a magic number?

And how is it measured? Which patient should we not be thinking about raising the vertical dimension? And which patients may need an occlusal appliance, and for how long, before we were to think about raising the vertical dimension for that patient.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. It is Occlusion Month, it is September 2024, devoted to occlusion, and this episode we’ve got something for everyone. We’ve got something for the new grads, really reconnecting with those feelings I used to have as a new grad. And for those of you who have a little bit more experience, we’ll give you a few more ideas about me and Mahmoud record the vertical dimension to make sure we have to do as little adjustment as possible.

Dental PearlNow, every PDP episode, we give you a Protrusive Dental Pearl. This pearl is inspired from the last episode about digital dentures. It was a request we had in a YouTube comment. I’d mentioned these duralay copings for the guide plane. So know how we do dentures. We try to build in these guide planes to allow your denture to have one path of insertion. And that generally gives you a more stable denture, one with more retention and stability. But again, when I was a new grad, I had no idea about how to prep for a guide plane. But I’d like to share with you now how I do it currently.

And this is something that we can all do. And I think if you get your technician involved, it makes your life a little bit easier. I mean, yes, you can eyeball it. Because as long as you can remove that maximum bulbosity of a tooth, and you can really picture that path of insertion. And kind of like when you’re doing a bridge, you want the surfaces nice and parallel against each other.

But sometimes that’s tricky to do, which is why you can ask your lab to make some acrylic copings. So what’s happened is that the technician has surveyed the models, found out where the undercuts are, decided on the path of insertion along with your guidance, and instead of you just prepping the guide planes, you can ask for these reduction copings, whereby the technician has actually prepared the guide planes on the model, actually drilling the teeth on the model, and making this acrylic jig so that all you have to do is put the jig on the tooth, and it will highlight the exact area you need to prepare.

So those of you who are listening and commuting right now, if you’ve never done this before just visualize a little like a sleeve going on the tooth and now the belly of the tooth is exposed and you just get like a nice long carbide bur and shave that away until you’re flush against the coping.

If you’re watching on Protrusive Guidance app where you can get CPD as you know or on YouTube then you would have seen a visual for that. It’s a cool thing to do, especially when you have loads of guide planes to worry about. As always, as was the theme of the last episode, make sure you have a good relationship with your technician. Have a chat with them. Pick up the phone before you do this kind of work. Anyway, back to occlusion now. Enjoy the episode and I’ll catch you in the outro.

Main EpisodeDr. Mahmoud Ibrahim, my occlusion brother from another mother. How are you doing, my friend?

[Mahmoud]I’m good, man. How are you, Jaz? You good?

[Jaz]I’m all bunged up, as you know, with the kids getting one bug to the next bug. But the show must go on, as they say in Hollywood. And so will this educational podcast. Today we’re talking about the vertical dimension of occlusion. And I think it’s fair to say, Mahmoud, that this topic, podcast topic, when I suggest it, just scared us just a little bit, because it’s so vast, like, how do we even begin to tackle this topic?

So, what we did is we came up with some sensible topics that we think is realistic to cover in a podcast, that’s going to give a lot of value to everyone who makes, listens to this, and can take away enough nuggets to really improve their standard of dentistry. So we have a tough one. For the very few people, maybe they’ve just googled occlusal, vertical dimension occlusion, they’ve landed on our podcast, and then you, Protruserati, hello.

[Mahmoud]Hello, hello.

[Jaz]Just tell us about yourself, Mahmoud. Remind us about you as a clinician, what you stand for, your love of occlusion.

[Mahmoud]Ah, yeah, so,...

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Plant it low and watch it grow? Is that serving our patients?

Should we keep our crowns flat to avoid ‘interferences’?

How about guiding teeth – how can we recreate and build in guidance and the correct cuspal inclination in our indirect work?

https://youtu.be/b2KA84dXhnIWatch PDP196 on YoutubeAs part of Occlusion month I am joined by my dental technician Graham Entwistle and Occlusion geek Dr Mahmoud Ibrahim. We discuss foundational occlusal concepts relevant to our daily indirect restorations.

Protrusive Dental Pearl: Bleeding papilla? Use the HOW technique to QUICKLY stop bleeding – insert a Wedge obliquely (Haemostasis with Oblique Wedge technique) as taught by Dr Sunny Sadana from Drecomposite.com

Treatment Planning Symposium 16th November HYBRID EVENT

Basics of Occlusion Live 2 Day Hands-On Course with Jaz and Mahmoud

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode: 0:00 Introduction 03:31 Protrusive Dental Pearl 05:16 Introduction – Graham Entwistle + Mahmoud Ibrahim 08:25 Guiding Teeth 11:40 Why is Guidance important? 16:35 What information should we provide our technicians? 20:00 Excursions and Patient Case 28:00 Complex crown creation 33:33 To Facebow or not to Facebow? 34:40 A Technician’s POV 49:50 What is the Technician aiming for? 51:06 Perfect Contacts – technician perspective 53:23 Final Thoughts

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes B and C.

AGD Subject code: 180 Occlusion (Occlusal functional concepts)

Dentists will be able to:

Understand the importance of guidance and occlusion in crown design, ensuring restorations contribute positively to occlusal function and patient well-being. 2. Improve communication strategies with dental technicians, including providing crucial details such as shim holds and occlusal plane guidance, to ensure optimal restorations. 3. Make informed decisions about the distribution of occlusal forces to prevent damage and maintain functional integrity in prosthetic designs.

If you liked this episode, you’ll love PDP137 – Q&A with a Dental Technician

Click below for full episode transcript:Teaser: If there's one thing people take away from this podcast, it's this point right here, which can easily be missed, okay? When we send a bite to our technician, whether it's a physical bite or a digital bite, more often than not, okay, it's wrong.

Jaz’s Introduction:Welcome to Occlusion Month on Protrusive Dental Podcast 2024. I’ve just been a little bit excited for this theme. It’s one of my favorite themes to discuss because it was Occlusion, learning Occlusion. It’s what allowed my dentistry to become more fun. Allow me to move away from single tooth dentistry and through a series of episodes this month, we’re going to help you do the same. Ultimately occlusion is just really good restorative dentistry.

It’s part of the package, but It’s perceived as it’s like this dark art, this incredibly confusing thing. I think sometimes it’s pitched that way to sell more courses, etc. But me and Mahmoud want to convince you that occlusion is easy. It can be simplified. Have faith, stick with us this month, and we hope to demystify some elements of occlusion.

In today’s episode, we’re covering a theme whereby when you have a guiding tooth. Now, when I said guiding tooth, what did you think of? You probably thought of a canine, canine guidance. So let’s talk about that scenario, okay? Let’s say you’re replacing a canine either with direct restorative material or a crown.

Crown’s easier to discuss. If you’re replacing a canine with a crown or even an implant, how do you design the occlusion on that tooth? How do you ensure that you get the correct guidance from that tooth. Now, actually the real world scenario is not canine guidance because very few of our patients are actually canine guided.

Most of our patients are in some sort of group function. And so let’s say the next time you’re replacing a molar or a premolar, you check the occlusion beforehand, you get the patient to grind left and right, recreate their power functional movements. You see these wear facets lining up and you realize that this MOD amalgam that you’re about to replace with an overlay or a crown is actually serving that patient in their occlusion. That tooth is being used as a guiding tooth.

So you’re probably thinking, okay, so Jaz, where are you going with this? The theme of today is how do we ensure that that is replicated in the final crown? Do we want it replicated in the final crown? Because let’s agree on one thing, right? If a molar is a guiding tooth, it’s involved in group function, and now you’re going to put a crown on it, do you want that tooth just to be completely flat? Of course you don’t, that’s not adding anything to function, it’s not serving the patient anyway. So really what it boils down to is how do you get the lab to give you the right anatomy to give you the right occlusion?

Both in static and in dynamic, i. e. moving the jaw around. Which is why I’m joined by not only Dr. Mahmoud Ibrahim, but also one of the technicians I work with, Graham Entwistle. He does all my overlays and vertiprep crowns, and he does a wonderful job, and he has his own ideas and philosophies around occlusion.

And so I’m so grateful that he joined us today. Some of those episodes in the past where we’ve had a technician, including him when he came on an episode we did, Five Things Your Technician Wished You Knew. They’ve been received really well. We need to do more collaborative episodes with technicians.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. This episode is eligible for CE or CPD. We are officially PACE approved, so all the docs in the states and around the world can also have that validation, and we submit it to the AGD on your behalf as well. The way you get CE or CPD for listening or watching these episodes, It’s through our app, Protrusive Guidance.

If you’re on Android, make sure you make an account on protrusive. app first, probably the best way. Go on that website, make an account, and then you can use that login on your app that you download from the Play Store or from the App Store.

Dental PearlEvery PDP episode, I give you a Protrusive Dental Pearl. Today’s one is really cool. I think you’re going to really love it. It’s very, very applicable. When you have that gingiva that just does not stop bleeding and it’s really annoying you and it’s ruining your day, it’s ruining your plans. What are you going to do? You could use some astringent, you can maybe get a cotton pellet, soak it in ViscoStat™ Clear and apply some pressure for three minutes, or you can get your laser or something fancy, but a really easy thing that you could do that every dentist in the world has access to is use a wooden wedge, but not in the way that you think.

You see, this is called the HOW technique. H O W. It stands for Haemostasis Oblique Wedge, as taught to me by Dr. Sunny Sadana. So a little turban tip to Sunny. So what you do is if you have a papilla that’s bleeding a lot, instead of inserting the wooden wedge, it has to be a nice meaty wooden wedge, instead of inserting it in like the normal way, right, when you go completely through, from the buccal to the palatal, for example, this time you’re going to angle it so the tip is angled towards the gingiva.

Can you imagine it being angled down towards the gingiva? Now, you’re going to get your tweezers, the back of the tweezers, and push. What you’ve essentially done is you’ve kind of stabbed the gingiva. Can you imagine just the gingiva being stabbed? I jokingly call this in a WhatsApp group, I call it stab-o-dontics.

But you know what? How is probably a nicer way to frame it. And what you’ll find after about a minute is that the bleeding just stops. The vessels are essentially temporarily occluded or the pressure just stops the bleeding and it can get you out of jail. If that’s not tangible enough, the second part of this pearl is that I will be adding a video.

The video will first go on Protrusive Guidance. Because that’s where everything always goes first, to our community, the community of the geekiest and nicest dentists in the world. And then I’ll add it on YouTube as well, so do check that one out. If next time you’re stuck with a bleeding papilla, use the how technique with the wedge in an oblique fashion. Hope you enjoy this episode, I’ll catch you in the outro.

Main Episode:Graham Entwistle and Mahmoud Ibrahim. Welcome back Protrusive Dental Podcast. Today’s a special one. We don’t usually do like a, well, I don’t want to call it a three way, but let’s call it a threesome. threesome, a dental threesome. Good to see you guys again.

It is a special because very rarely do we get to have a technician input. So it’s great, Graham, we’re always privileged to have you speak. Mahmoud, always a pleasure. And it’s a great topic because it’s something that we don’t talk about enough, right? Guiding teeth. Okay. And we’ll talk about what guiding tooth is and basic crowns.

Now, before we hit the record button, there was a few things that we discussed, right? Between us three, we have 10 kids, right? With most of the heavy lifting being done by Graham with five, 10 is good. It’s probably the most number of children, most number of offspring on this podcast ever ...

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There is something very satisfying about a well fitting denture.

I am joined by our resident Dental Student, Emma Hutchison, to demystify removable prosthetics.

https://youtu.be/1hQGjKUa6MUWatch PS009 on YoutubeWhich joint position should we use for dentures? Is this important?

How do you calculate the freeway space?

What are we actually recording during a Wax Jaw Registration for complete dentures?

Don’t miss the special exam revision notes on Removable Pros available exclusively in the Protrusive Guidance app! (Join the free Students Section)

Need to Read it? Check out the Full Episode Transcript below!

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App!

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, check out PDP162 – Occlusion for Complete Dentures

Click below for full episode transcript:Jaz's Introduction: I think we all remember that phase at dental school where we were just confused by everything related to dentures. It was especially confusing because dentures are kind of like one of the first things you do as you're a dental student. So to you it felt like being thrown in the deep end anyway.

Jaz’s Introduction:For many of us the denture confusion lives on and continues throughout our career. Hopefully with some of the older episodes in Protrusive we managed to make dentures more tangible. And I myself have been enjoying doing some cobalt chrome dentures, something I didn’t get to do much during dental school. But today in this Protrusive Students Section, and I mean students lightly because this whole segment, the Protrusive Students Series, whilst we release some revision notes for students every time we release an episode, what we discover here is revision.

Sometimes good to revise topics, go back to basics, so if you’re a young dentist or revisiting back into dentistry, or at any stage of being a dental student, this episode and all of the series of protrusive students should be relevant to you. Especially one we did a while ago about adhesive dentistry for beginners.

Lots of qualified dentists said how much they enjoyed that one because it was nice to just go back to basics. In this one, once again with our protrusive student Dr. Emma Hutchison, she asked me about all things that confuse her as a student when it comes to dentures. And because she’s relatively new to clinic, Most of the questions he asked was related to complete dentures.

So I hope you enjoyed this recap and this revision on the different stages of complete dentures. What are we actually trying to achieve in the various stages and what is important and what’s not important? Hope you enjoy and I’ll catch you in the outro.

Main Episode:Emma Hutchison, welcome again to the Protrusive Student section. This time we’re going to cover removal. But just tell us, we’re recording this way in advance because we don’t want to interfere with your exams and stuff. How are you getting on? What’s your last few weeks been like?

[Emma]Yeah, the last week I’ve only seen one patient, which was actually my flatmate, and didn’t need anything done. And so he just got a scaling polish, a bit of PMPR, and that was him really. So nothing too exciting in terms of patients, but just I’ve got my exam dates now, so it’s really becoming real, so just keeping my head down and getting through lectures and really starting to study now, so.

[Jaz]What kind of learner are you, Emma? You know there’s different types of learners and stuff, I won’t give you any ideas, just in terms of self discovery, how do you like to learn?

[Emma]I’d say I need to listen to things, I need to be told by someone who’s talking to me, and I need to be able to translate that into something that I can understand myself, so in my notes. That I make and that I’ve shared with people. That’s all come from listening to lectures and watching these lecturers live, like I need to hear it. I’m not too good with just reading things off of a slide. I need to be there, whether it’s a lot of our lectures are pre recorded. So yeah, very audio for me, listening to it and then putting that into something that makes sense to me on paper. And then I revise from that, really.

[Jaz]I’m very much the same. When I was at dental school, very much audio based. Now back then, we didn’t have, it was everything was face to face, right? There was no like a watches on demand thing back when I was a student. However, I used to have this software on my iPad were a newish thing then.

And so I had the software called SoundNote. And so I’d be able to make my notes and it’s recording the audio at the same time. Anywhere I click on the notes, it’ll take me to that relevant part of audio. That was instrumental for me. That was really a big help. I’m also someone who likes to write and make notes. And just like you, make something make sense in my own language, in my own way. I feel like you said that.

[Emma]Yeah, definitely. Like, you can say whatever you want to me, but I need to put it into a context that makes sense for me. And that’s what I work from. Yeah, yeah, definitely. Make it make sense for me. Yeah, definitely.

[Jaz]Let’s make removable prosth sense for you as much as we can in the next 20 or so minutes. As a student’s perspective, I know you’ve had a few patients when it comes to removable prosth. So, come at me, what’s on your mind, Emma?

[Emma]So the first question I’ll ask, probably because it’s the biggest, and I know you’ve done episodes on this before, I know you’ve done episodes on this before, and it’s all about a bite reg. If we’re in the locker room getting changed and you’re talking to your friends, what do you have today? I’m on Prosth Clinic. If someone says, oh, I’ve got a bite reg in, you say, God bless you, good luck. Because it just seems like absolute witchcraft, I don’t know what’s going on. So just a bit, quite basic, what am I trying to get out of that appointment?

Maybe some steps to help me along the way. But that’s definitely from a few people that I’ve told about what we’re doing with protrusive students. They say, can you please make a bite reg episode, because I don’t know what I’m doing.

[Jaz]I love it. I love this because it’s bringing back memories of me playing. So I was in third year. I was playing FIFA with my flatmate in fifth year. So we’re playing FIFA. And I had my denture patient in for a bite reg. And I was kind of like revising. So what am I checking for again? Like what am I doing? I remember having the controller in my hand. I’m like asking these questions.

I remember this very vividly, actually. So, to answer this question, and I’d love to make it tangible for all, firstly a disclaimer, I am no removal pros guru. There are, in the top five things I’m good at in dentistry, removal pros is not in them, just because I haven’t done enough of it. Even though I did quite a lot of complete dentures and stuff during my time as a DCT, it was as a restorative dentist DCT.

That was pretty good. But that’s been some years now, but I’m not scared of dentures and I’m happy to, I quite enjoy the cases when they come through, but they don’t seem to come through as much anymore, but I’m definitely happy to answer that question because that’s related to occlusion and we can definitely do that.

So first thing to distinguish Emma is, are we talking dentures without teeth? Or are we talking partially dentate? We’ll explore both of them, but which one would you like me to go first?

[Emma]Complete dentures, yeah. Dentureless patients.

[Jaz]Okay.

[Emma]If we can.

[Jaz]Of course we can. All a bite registration is, these wax jaw registration rims, is where the technician has to put some teeth. They need to know how the teeth need to meet together when the patient bites together. They need to know how big to make the teeth, how big to make the incisors, and they need to know where the canines go, where the centrals go. They can’t guess that at all. They need the bite registration. The bite registration is giving that information.

And essentially, when they put the jaw registration on like an articulator, right? So they can actually mimic the, some kind of movements and do up and down. And sometimes they may get ambitious and do side to side, right? What we’re trying to do with any articulator is recreate the patient’s jaw on the tabletop.

That’s exactly it. So there’s a number of things that we’re trying to record when it comes to a complete denture wax jaw registration. And essentially all of it stems that the ultimate aim is how can we essentially give the maxilla and mandible relationship to the technician. So when they have it on their table, how far it’s apart and how big you want the denture, how much you want the OBD on their articulator is the same as on the patient, essentially.

That’s at the crux, that’s what it is. When you get back your upper and lower wax rims, okay, you’ve got to first try it in because the preceding appointments are so important, the primary impression, the secondary impression. If something hasn’t gone quite right in that, you might ...

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The first EVER ‘Prospective’ episode of Protrusive – I interviewed new-grad Dr Triman Ahluwalia in 2023, then again 7 months later in 2024 to see how he gets on with his first year as a real Dentist ????

We uncover what it feels to be a freshly qualified Dentist, the pressures and fears that come with procedures such as endo and surgical extractions, but what we can do as growing clinicians to overcome these hurdles.

https://youtu.be/9NtKCIVfMLsWatch IC052 on YoutubeThis episode is packed with lots of top tips to help you in your journey from the ground up, or as a reminder for those that have been there and done that, that we are forever learning on our journey and there’s always something out there to help us become better Dentists.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:02:02 Introduction to Dr Triman (2023)03:32 Experiences at Dental School07:15 Procedures You Fear + Sectioning Teeth11:25 Thoughts on Social Media in Dentistry15:26 Documenting Work16:30 Future Career Plans18:00 Additional Comments from Triman19:03 Back to the Future: 2024 Triman Update21:50 Dental Photography Progress23:08 Tricky Dental Procedures Update27:46 The Good and the Bad of DFT32:26 Career Path in Dentistry34:49 Triman’s Top Tips37:06 Wrapping Up

Don’t forget to check out the Protrusive App where you can find more awesome tutorials on becoming a more efficient and effective practitioner.

If you liked this episode, you will also like IC029 – Young Dentist Thrival Guide

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on on the Ultimate Eduction Plan, including Premium clinical workthroughs and Masterclasses.

Click below for full episode transcript:Jaz's Introduction: Welcome to the first ever Protrusive Prospective episode. You see, I interviewed Dr. Triman Ahluwalia in his first month of being a real dentist, i. e. newly qualified. I then interviewed him again seven months later to see how he got on.

Jaz’s Introduction:Hello Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every year we make an episode to help those who are in their first year, i. e. they’ve just qualified and they’re entering the big bad world dentistry. And this is a interesting one because I’ve never done a prospective episode whereby I’ve told the guest to wait six, seven months and then we’ll continue the recording.

Just to see if the perspective has changed. I think this is essential listening and watching for those who are literally about to enter the first year of dental school, or maybe you’re returning to work again after some time off, or maybe you just want to gain some insight into the mind of the newly qualified dentist.

Maybe you mentor some dentists, by the way, speaking of mentorships and big things, Intaglio is almost out. For those of you who don’t know, Intaglio is a new platform we’re making to allow one on one mentorship. Look, it doesn’t matter. How much money you paid to these courses doesn’t matter how many continuums or diplomas you’ve done.

When you have that specific case and you need someone to sit down with to discuss that case, step by step for a good hour or even two hours, the course organizes the diploma teachers. They are busy. They don’t have the time to do one on one, which is why we created this platform to allow mentors and mentees to connect and allow fair exchange.

Because you know what when a mentee needs help they really value it and they value that one on one time so Intaglio is coming soon and also a big update number two is I’m in my new studio I’ve now moved from reading to West London quite close to Heathrow it’s like little India it’s called Southall. I’m close now to my parents my in laws we get lots of support for family so that was a big reason I’m still working in Reading. But yeah, it’s been a crazy time with moving.

But now this is my first episode, first intro being recorded in a new studio. Wish us good luck. And now we’ll join the main episode with Dr. Triman, catch you in the outro.

Main Episode:We can say doctor now, Dr. Triman Ahluwalia, I might feel strange to you. How are you doing my friend?

[Triman]Yeah, I’m doing great. Big fan of the podcast. So it’s a great honor to be here and hopefully shed some light on DFT.

[Jaz]Brilliant. Well, welcome to the Protrusive Dental Podcast, my friend. It’s so lovely to have you. And I’m so thankful, thanks so much for agreeing for the nature of what we’re doing today. It’s going to be delayed gratification. I’m going to talk to you now at the very beginning of your DF1 journey.

So those are my international audience. DF1 is basically like your first year out of dental school. It’s kind of like a bridge between dental school and like the real world. We kind of get a bit more support and things are a bit slower to start with, which is good. I definitely learned a lot, enjoy my time, but it’s not about me. It’s about you today, my friend. And so just before we delve further into the questions I have for you, just tell us a little about your journey in dentistry and dental school so far?

[Triman]Yeah, so, my name’s Triman. I’m 23 and I graduated dental school from King’s College, London this year in 2023 And I’m currently undertaking foundation training in part of the North London scheme at Ivy House Dental and I also recently wrote an article that was in the BDJ student just looking at the preparedness of newly graduated students like myself for independent practice, which is very on topic for today’s discussion.

[Jaz]Excellent. Yeah in case everyone’s watching the video on youtube and seeing me just slightly sweaty. Maybe the camera’s hiding it I’ve just had these korean buldak noodles. I don’t know if you ever had these before.

[Triman]No, I’ve not had them before.

[Jaz]There’s something else, my friend. So I’m enjoying that very much. So it might get a bit hot and spicy in the discussion as well. Let’s see if it transfers through. Tell me, what is your biggest worry? Like you have been, in fact, let’s take a step back. Tell me, and I hope you’re comfortable discussing this. Tell me about your experience at dental school, generally speaking. And then also how much did you actually get to do? How much experience did you qualify with bearing in mind that you were probably partially affected by COVID as well?

[Triman]Yeah. So this was sort of like the big question that was plaguing me towards the end of my summer holidays and I was about to enter DFT and I was actually thinking how prepared am I actually for the real world of after dental school and I think, yeah, as you were saying, COVID sort of was a big factor, especially for my year.

I know that’s like the new thing for everyone to say that my year was the worst, but I guess my year I think was the worst. But for me, I started seeing patients sort of regularly from the start of fourth year, I would say, and for reference at King’s, you sort of start seeing patients. Towards the end of second year, which was when COVID hit for us.

So I didn’t really see anybody till fourth year and it was also a big backlog as well. But so it was sort of in our heads from the start anyway, for my cohort, that our clinical experience was going to be significantly more limited compared to sort of our predecessors. And I think the Kings overall, they did a pretty good job of getting us up to speed and the amount of time that we had.

And we saw sort of as many patients as we possibly could. And I think sort of towards the end, I think me, maybe my colleagues, I think we all started developing a bit of a quiet confidence about the most final year dental students have about seeing patients, getting ready to leave and. But I think, actually, when I actually started looking at my numbers when I was about to start DFT, because when you start DFT, you have to do something called an Educational Transitioning Document.

It’s basically just where you write down, sort of, the numbers of procedures that you’ve done, and how confident you feel with them, so you can share them with your educational supervisor going forward. And, for me, I was actually looking at mine, and I was thinking, there’s not actually as much dentistry as I would like.

I mean, for example, like I did about say like 50 plus fillings or so, and that seems okay, but then when you break it down and you see that I’ve only done like two amalgams, it’s not exactly the greatest and the most brimming with confidence. And then of course, there’s also procedures that. just haven’t really touched or just haven’t really got sort of like the full depth of experience. So things like endos, sort of surgical extractions, for example.

[Jaz]And endo wise, have you not obturated before clinically on a patient basically?

[Triman]No, I have. So I’ve done for me anyways, I did three endos. So I did, I’ve done one incisor, canine. I think I did one molar as well. And that was sort of from start to finish, but assisted so I was quite fortunate that I got to at least a mix of sort of like 3 teeth But I think that was sort of the benchmark for most of my cohort as well. I think most people had about that much. I mean, we just had an induction day actually for founda...

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Is this the death of impressions for Dentures?

Are digital dentures predictable? Time saving? Cost saving?

Are all types of dentures suitable for the digital workflow?

Even if you don’t use an intra-oral scanner, your lab may be utilising a digital workflow, so it’s a great time to dive deep into this area.

Impression Club’s Dr Rupert Monkhouse joins us for another removable prosthetics themed episode where we discuss how digital dentistry is changing the way we make partial dentures and complete dentures.

https://youtu.be/P8XBEU5I6kcWatch PDP195 on YoutubeCheck out Impression Club courses

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A and C.

Dentists will be able to:

Understand the key differences between traditional impression techniques and digital workflows in denture creation, including the benefits and limitations of both methods.
Evaluate the accuracy and efficiency of digital dentures compared to traditional methods and implement best practices for integrating digital workflows into their clinical practice.
Effectively collaborate with dental technicians using digital tools, fostering better communication and teamwork to achieve optimal patient outcomes in denture fabrication.

AGD code 670 Removable Prosthodontics (Emerging technology or techniques)

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:03:18 Protrusive Dental Pearl – Understand the Why05:38 Introduction to Dr Rupert Monkhouse8:11 What kind of Dentures can we do Digitally?13:33 What work still requires Impressions?17:05 Which Scanners?19:55 How Accurate?28:24 Should Digital be the Gold Standard?30:55 Immediate Dentures38:55 Cobalt Chromes47:55 Finding great technicians58:08 Impression Club

If you liked this, you will also like GF018 Intra-Oral Scanner

Click below for full episode transcript:Episode Teaser: For the workflows where we scan the lab work or we did the reference denture, eight out of eight preferred- When I've got the macro flash on it and my 4G megapixel camera. Yeah. I can see the difference minorly aesthetically in the teeth and things. Beyond that, there's no real downsides from my perspective. So clinically for me-

Jaz’s Introduction:Is this the end of impressions for dentures? Have we finally reached a time whereby we can scan the tissues and we don’t need any of that mucocompressive nonsense. Is digital dentistry there yet when it comes to dentures? For our clinical steps, the design and the manufacture of our dentures.

Our guest today, Dr. Rupert Monkhouse, back again on the podcast, does a wonderful job of giving us an overview of how digital denture is employed within dentures, not only by us clinicians, but also the lab side and the manufacturer side. But I asked him to truly dive deep and focus onto what we do clinically.

How much of what we do clinically can we now do entirely digitally? And the two workflows we discussed today in really good depth are the complete denture workflow and the Cobalt Chrome partial denture workflows. Get your onions ready because this is a really deep and really awesome episode. I think Rupert does a wonderful job.

You will find out which scenarios we should be actually scanning and ditching the impressions and whether there are any game changing benefits of moving to a digital workflow for dentures. This episode is our highlight episode for removable prosthodontics month. And next month, i. e. September, will be occlusion month.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. I feel like I haven’t connected with you guys for so long. I know you’ve been having an episode every week, but a lot of those episodes actually recorded a while ago. I knew that when the summer would come and my son would be off school, that we would get really busy.

And also we’ve moved from Reading to West London. Not too far from Heathrow actually. Moving is not fun, but we’re finally settled now in my new office space and it’s so great to get in front of the camera again and make protrusive episodes because I learned so much. I had a minimal understanding of digital dentures and I gained from this episode and I know that you will too.

Here at our new family home in West London we celebrated my son’s fifth birthday and I was thinking, oh my goodness, where did those years go? And I actually remember when my son was born and I announced it on the podcast all those years ago. And many ways we have grown. We as a Protrusive community have grown around the world.

Whether you’re watching this on the Protrusive app, YouTube, or listening on Spotify on your commute, however you consume Protrusive, it really means a lot that you tune in. If you aren’t already on our community for the geekiest and nicest dentists in the world, do check out protrusive. app. You can actually access it on your laptop or your web browser or the native iOS or Android app.

If you’re going to download the Android app, by the way, make sure you actually make an account on the website first, which once again is protrusive. app. The big change with all this I want to announce is that we are finally PACE approved for those doctors in North America. When you answer our quizzes for CE, you can actually enter your AGD number and we will take care of the CE for you. The American doctors have been asking me for years about this approval and I’m so pleased that we can now contribute to your CE tally.

Dental PearlEvery PDP episode I give you a Protrusive Dental Pearl. Today’s pearl is related to the field of prosthodontics, whether it’s removable prosth or fixed prosth. There’s often lots of stages when indirect work is involved.

And the pearl is that it’s so, so, so important to understand each and every stage of what you do and why you do it. What benefit is the technician gaining? What challenges are you presenting to the technician? For example, when I was learning complete dentures for many years, I followed the whole checklist in the recipe book for all the things that you check for, for a wax jaw registration.

But sometimes I was guilty of not knowing why we are recording certain. Sometimes I was guilty of not knowing why we were recording that piece of information. What benefit will it actually have to the patient or the technician in recording this extra piece of information? And it’s only when you understand the reason for which you are recording something that you can actually be more judicious about your work and actually understand, actually, I don’t need to record this because the technician doesn’t need it in this scenario.

I’ll give you another example. I remember taking one of my impressions many years ago to my consultant. I was a trainee and I showed him my impression and I thought, hmm, I think I’ve screwed up because there’s an air bubble. I didn’t notice it before, but I see an air bubble in the impression. Does this mean that we can’t proceed with the crown anymore?

And that I need to bring my patient back? But he pointed out to me that yes, there is an air bubble. But where is the location of this air bubble? Is it in a critical location, i. e. at the margin where your seal will be disrupted? Or is it a little bit away from the margin? And actually visualizing what the model, what the cast model will look like.

And what this actually means for your crown. Is it critical or is it not? In that case, my air bubble wasn’t critical. I didn’t have to bring my patient back. And so when you really think what the technician is getting from you and what compromises that you may accept, it can really help you advance your prosthodontics.

Another example is should you do a half mouth scan or a full mouth scan? Imagine you’re doing a single crown in what kind of scenarios is a half mouth scan acceptable? And what kind of scenarios do you actually need to scan the entire dentition? So Protruserati, make it your mission. If there’s any aspect of prosthodontics that’s always confused you in terms of data collection, what you send to the lab, then please post it on our app.

The philosophies and values of protrusive guidance is that we don’t want to be judgmental. There’s no such thing as a silly question and we can all learn and grow together. Hope you enjoyed this episode, I know you will, and I’ll catch you in the outro.

Main Episode:Dr. Rupert Monkhouse, welcome back to the Protrusive Dental Podcast once again, we’ve talked about your journey before, which we absolutely loved because if anyone hasn’t heard it, it’s a wonderful story about how you landed your associate position that you’re in that you’re still there now, actually.

It was just wonderful. I won’t do the spoiler now because I want everyone to go back and listen to that because it was so good. And then you also talk about complete lower dentures, which we all hate, and then you covered that really well. And then now with so much of the digital stuff around, I was like, okay, who better than our own resident denture geek, Dr. Rupert Monkhouse, to talk to us about digital dentures.

Now we were catching up before we hit record, and some people may not have heard of you, very few people, right? You are like the guy associated wi...

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How are periodontal diseases managed in general practice?

Join us for an engaging conversation with Emma Hutchison, our Protrusive student, as we explore Periodontology (Perio) in the real world.

This conversation delves deep into the practical protocols, patient communication strategies, and real-life scenarios every dental student and practicing dentist should be aware of.

https://youtu.be/X5ahZ9bzsc4Watch PS008 on YoutubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:

0:37 Emma’s Dental School Experience: Special Care Dentistry
03:02 Emma’s Denture Adjustment Case
06:11 Periodontics Month
06:54 Communicating with Patients about Gum Disease
10:15 Managing Non-Engaging Patients
15:04 The Psychology of Habits
17:13 Referral Protocols in Dental Practice
20:00 Risk Factors in Periodontal Treatment
25:03 Genetic Factors in Periodontal Disease

Don’t miss the special notes on An Introduction to Periodontal Diseases available exclusively in the Protrusive Guidance app!

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App!

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, be sure to recap PS007 – Basics of Indirection Restorations Part 2 – The Crown Fit

Click below for full episode transcript:Jaz's Introduction: Welcome to another episode of Protrusive Students. We're joined by Emma Hutchison, our Protrusive Student, to talk about Perio. Look, I'm no periodontist. I'm no specialist, but I can share a few pearls of wisdom for treating Perio in the real world.

[Jaz]Emma had some absolutely fantastic questions about protocols, communication, and what to do if you have a non engaging patient. Because let’s face it, that’s what happens in the real world. Our patients don’t floss and they don’t brush how well we want them to. So how do you manage that? Here at Protrusive Students we try and cover the themes just for you guys. And of course, if you’re a dentist watching this, then it’s also relevant to you. We just go back to basics. Let’s get to the main part of the interview and I’ll catch you in the outro.

Main Episode:Emma Hutchison, our Protrusive Student. It’s now perio month, so it’s great to have you back. Just give us an update, basically, in terms of what new things have you learned at dental school? What are the interesting experiences that you’ve had? Any ups or downs that you’d like to share with us?

[Emma]So, I’ve only seen one patient in the last week, because I’ve had a few no shows last week and it was for a denture ease, so it wasn’t anything too tricky, which was fine for me. But, yeah, it was good, just a wee denture ease. The elderly gentleman was very happy, so that made me happy. In terms of lectures, lots of special care dentistry at the moment. We’re very heavy with special care dentistry in our second half of third year at Glasgow.

[Jaz]I know in some countries they don’t have that as a speciality. Can you explain to everyone listening and watching what special care dentistry is?

[Emma]Yeah, so I suppose special care dentistry, a lot of patients that have very complex medical histories. I mean, this week we were doing people with mental health problems, schizophrenia. We’ve been doing cardiology, oncology, patients with very learning disabilities as well. Patients that I suppose you could consider a bit more medically compromised or that can be a bit more trickier to treat. So we’re very heavy on that in our third year at Glasgow.

[Jaz]So if you can treat those medically compromised patients and you can treat anyone, right. It really tests us in terms of what medicines are on, which antibiotics you can and can’t give, what the guidelines are in terms of when it’s safe to treat, when it’s not safe to treat, all those things.

[Emma]Yeah, definitely. And a lot of it is refer to the BNF and all your drug interactions. But no, it’s good. It’s really interesting to learn all about these medically compromised patients. And it’s amazing how much you need to change of your regular dental routine to suit these patients, I suppose, and make accommodations for them as well.

[Jaz]Interesting thing to reflect on based on a couple of things you said is one, the slow pace of dental school in terms of when you have some DNAs, which happens a lot, unfortunately, in dental school, just the nature of the beast. And then how do you fill your time to make sure you’re actually doing something productive?

I felt like a lot of time when I was studying dentistry, patient wouldn’t turn up and then you’re just there doing suctioning for someone else or nothing. You’re having like an impromptu tutorial or something, which is good, but sometimes you kind of be there. Like looking out the window. And so it’s really important to make sure you’re not doing that.

So I’m hoping everyone’s going to have their productive student notes ready, reading them, taking them with them. So if a patient doesn’t show up, they can have that. So this is just the nature of the beast. The other reflection I have is denture ease. What do you think caused this patient to have an area that needed adjustment for this denture?

[Emma]So I had delivered this denture, it was a wee while ago, the patient was, had unfortunately been in hospital for a wee while, so I had planned to see him two weeks after the denture delivery, just as standard protocol to see if there was anything wrong with it. He was in hospital for a month, so it had been a while. And when we fitted that denture, it was perfect. It was like a glove. And then he said, when he went home obviously, it’s a brand new denture, it’s going to take some time to get used to, but when he started eating, that’s when he noticed it was painful and it was really digging into his freedom down there, but it was easy enough to see he had a huge ulcer there, the poor man, and pressure indicating paste, showed me exactly where to adjust it as well.

So it is quite tricky with those things because it can take a wee while for it to almost heal start hurting these new dentures. It’s tricky as well. I’ve seen a patient before who hadn’t been wearing the denture because it was sore. And then it’s a bit more trickier to see where the pain is actually coming from because you’ve not got redness or something like that.

[Jaz] So it’s a couple of lessons to share then based on that. Just so I don’t forget is, always warn your patient that this is normal. Like you should say to your patient. It’s like you said, like a glove. That’s exactly it. It’s like a brand new pair of tight shoes, right? You’re going to get some foot blisters on your feet, right? It’s normal and to adjust it. And when they come in and it’s like the ulcers there, you could use pressure spot indicator paste. But do you guys have Dycal in your clinic?

[Emma]We do have Dycal, but not on our Prosth clinic. I don’t think-

[Jaz]It’s something I was taught by Mark Bishop to use just on the ulcer, just the base, actually, not even the Dycal, just the base on the ulcer and then put the denture on and then see and pick it up. It’s like anything that will just mark because what you’re testing for pressure is where it’s actually too much pressure. But for the ulcer, you just wanted to rub off on exactly where to adjust the denture. So you can actually use anything that marks off onto the denture. So that’s a good thing to use.

We actually had an episode with Mark Bishop, I think it’s episode 28 of the podcast. So anyone who’s new to dentures, check out that episode with Mark Bishop. We talked about the use of pressure spot indicator, the use of the Dycal in that way. And it really talks you through everything. Now, one thing to bear in mind, like your one is obvious because it was like overextended probably in that frenum area.

But number one thing before you do an adjustment on the teeth on the actual chewing surface of teeth themselves is before you adjust anywhere on the inside of the denture, check the occlusion because it could be the fact that the patient bites together, it actually is hitting on an incline and the entire denture is then moving and then the teeth bite together. And so you need to make sure it’s got a nice, clear, easy, repeatable bite. Because if it isn’t, it’s actually the bite that’s the problem, not the fact that it’s overextended anywhere. Do you know about that?

[Emma]Yeah. No, I’ve never actually really thought about it like that to check the occlusion first. Because then I suppose nothing’s going to get much better if you don’t address that.

[Jaz]Because imagine the denture itself is actually perfectly flush to the tissues, but it’s the bite being off and then the pressure gets on that’s causing it. So really good top tip is to check the occlusion first in those areas. But anyway, we digress. It’s Perio Month. Thanks for sharing your experiences with us, always gives us a few things to talk about there. Tell, ask us your student based perio questi...

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It’s your first night on-call and you are bleeped at 3am – there’s a nasty facial laceration waiting for your urgent attention. You have never sutured the face before…”who you gonna call?” – well sometimes even the Ghostbusters will be more helpful than the on-call trainee!

https://youtu.be/3RKZG3yy2sU Watch PDP194 on YoutubeOur good friend Dr Ameer Allybocus joins us again for another episode where he gives us a lowdown of his experience when he was a DCT trainee many years ago. There is a lot to learn in this podcast from Ameer as he dives into the Trials and Tribulations of being an Oral and MaxilloFacial Surgery DCT during the early years of his career.

There are laughs and tears in this one, so hold on to your seats for an emotional podcast that will leave you wanting more.

Highlights of this Episode:

00:00 Introduction

01:37 Protrusive Dental Pearl

03:26 Introduction to Dr Ameer Allybocus

19:40 The MaxFax Beginnings

24:00 MaxFax at UCL

29:37 MaxFax isn’t all bad

36:05 DCT Oral Surgery

42:16 On Call

48:26 Book Recommendations

49:15 Working at the Queen Elizabeth Hospital

54:13 A Life Changing Experience

59:57 MaxFax: Benefits, Tips & Tricks

65:26 Tips from Ameer

66:25 Trauma and Accidents

70:56 MaxFax Puts Dentistry Into Perspective

74:33 Closing Words

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you liked this episode, you will also like: Getting Ahead after Dental School 2023 – IC042 – Protrusive Dental Podcast

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What makes us reject crowns and send them back to the technician? What are the standards/guidelines to consider before accepting and luting indirect restorations?

Join us as we explore the key factors that determine the quality of a crown. From the initial lab communication to the final occlusal checks, we cover it all. This episode is packed with essential tips that are perfect for dental students and professionals alike.

https://youtu.be/ftafglxcBbMWatch PS007 on YoutubeHighlights of the episode:

1:33 Emma Hutchison: Student Life and OSCEs
06:44 Handling Lab Work and Fitting Crowns
14:15 Crown Rejections
18:12 Understanding Occlusal Tolerance
20:09 The Importance of Occlusal Precision
22:24 Building a Strong Dentist-Lab Technician Relationship
24:17 Tips for Dental Students
27:46 Microbiology in Dentistry

Don’t miss the special notes on Microbial Ecology and Infection Transmission available exclusively in the Protrusive Guidance app! (Join the free Students Section)

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App!

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, be sure to recap PS006 – Basics of Indirect Restorations Part 1 – Decision Making

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Clinician Development Tool: https://protrusive.co.uk/cdt

Did you know, there’s a cheaper, quicker and more natural treatment option than using Dental Implants, WITHOUT compromising on longevity? Sounds too good to be true right?

You already know about it. You most likely studied it already at Dental School and just haven’t given it much thought in a clinical scenario.

Meet Dr Lukas Huber who will remind us of the power of Autotransplantation for such cases, which in turn can massively help our patients who have missing or hopeless teeth, all while keeping laboratory costs down and success rates up.

https://youtu.be/CjUdDsuCWQAWatch PDP193 on YoutubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:02:10 Clinician Development Tool
03:34 Introduction – Dr Lukas Huber
07:40 Autotransplantation Procedure
12:45 Example Autotransplantation
18:40 Step by Step Autotransplantation
26:35 Placing the Donor Tooth
30:15 Transplant Restorative Augmentation
35:00 Learn more from Lukas

I thought that Dr Lukas is an inspiration to all the general Dentists and am so grateful he is part of our Protrusive Community – thanks for sharing your entire protocol!

Don’t forget to claim CE Credits on Protrusive Guidance by completing the quiz.

Check out Dr Lukas Huber’s Instagram!

If you liked this episode, you will also like Atraumatic Extractions

Click below for full episode transcript:Jaz's Introduction: You may already be familiar with an auto transplantation. Essentially, it's a scenario whereby, for example, you remove a pre molar from a patient, and on that same patient, you put that pre molar and you re implant that pre molar in to the central incisor socket. So for example, you've got a central incisor of poor prognosis, you remove that, and then you put this recently freshly extracted pre molar in to the central incisor.Jaz’s Introduction:
And essentially you let nature do its thing, you let it heal. And literally you’ve kind of given this patient the best implant there is. You’ve given them a human tooth, their own human tooth. Another common scenario is replacing a premolar, for example, an upper premolar, with an upper wisdom tooth that’s potentially over rupted or non functional.

That’s another common indication. But all these things, we’ve all seen it in like an orthodontic lecture at dental school. And then it lives somewhere at the very far back of our minds. And it’s not really an option that we discuss with our patients very much. Or when we’re treating planning, we kind of have it in our blind spot.

It’s just not something that we see a lot of, which is why I’m very excited to welcome to you, Dr. Lukas Huber, a general dentist, ladies and gents, who has a few of these procedures up his sleeve and is happy to share the full protocol. Look, some of you will go away today and the stage of your career, where you’re at, you will probably be able to offer this treatment to your patients.

And you’ll actually remember that, ah, yes, this is an option. And if I follow the steps, I can get a good result. In fact, Lukas very kindly shared all the evidence space that he uses in his decision making. So I will put that in the Protrusive Vault on Protrusive Guidance app. Now, for the rest of us mere mortals, who may not feel confident despite the full protocol being shared with you on the podcast today, most of us will be like, you know what?

I’m actually just much more educated about this option now. I know what to say to a patient. I now know which kind of cases would be suitable for an auto transplantation and which ones are not suitable. And so now hopefully this option will not be living in the very back in the corners, deep dark areas of our mind somewhere. It’s come a little bit more to the front of our minds. So we can actually consider this as a realistic and actually damn right cool option.

Dental Pearl
Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. And so today’s pearl I’m sharing with you is a really cool tool that you can use online.

It is amazing for that scenario, for that stage of your career, where you’re just not sure what courses you should do next, or where should you start focusing? What are your weaknesses? Which disciplines or facets of dentistry Should you be focusing more time and energy on? It’s a question I get all the time from the Protruserati, which is why when I discovered the clinician development tool, I was really impressed.

This is really well curated by Ripe Global. And yes, it takes about five minutes, some deep thinking to answer this quiz. But I tell you the information and the detail that you get is the best I’ve seen from an online resource like this. It’s a really clever tool that assesses your confidence in the different disciplines and is very mindful of what your goals are and what stage of career you’re at.

And your current income level and your projected income level. And how much time you spend in the clinic and how much time you would like to spend at the clinic. How much restorative you do and how much complex restorative you want to do. And all these really key factors which makes this tool just the best.

I made a little short link for you so you can check it out. Go to protrusive.co.uk/cdt, that’s clinician development tool. So that’s /cdt, just three letters. I’ll put it on YouTube, the show links and Protrusive Guidance. I’ll put it everywhere. It is well worth doing. Even if you’ve got lots of experience behind you, you’ve got 15, 20 years experience behind you. It’s nice to see what this tool suggests is the next step for you. Hope you found that useful and outro.

Main Episode:
Dr. Lukas Huber, welcome to the Protrusive Dental Podcast. I am in awe of the work you do. And I just, before we hit the record button, I asked you, are you a specialist? Are you a general dentist? And you said general dentist and I celebrated, right? I celebrated so hard, right? So please tell us about yourself. Where do you practice and tell us about your career so far?

[Lukas]
Okay, so my name is Lukas Huber, originally I’m from Upper Austria, like a really, really small village. I think we have more cows than we have people. I then went to Vienna to study dentistry there. And afterwards I worked in a quite big insurance company. I recently thought of it because of you the Protrusive app about like burnout in dentistry. And this was quite a crazy time. I had like 20, 25, 30 patients in six hours, then started to looking for something else, you know?

[Jaz]
So can I just say this? So this was like a public funded system or?

[Lukas]
Yes. Yes. So I had like, most of them were just pain patients. Yes. And I decided to look for something else and then got great job offer here in Konstanz. Never been to Konstanz before. I asked my partner, she said, I know you’re crazy. We love Vienna. Why should we go then? We just tried. We said, okay, we will try it for six months. And if it’s good, it’s good. And it was crazy good.

[Jaz]
My geography is poor. How far is Konstanz from Vienna? Like how far is it?

[Lukas]
It’s like 600 kilometers, so it’s like a five hours car ride, which is quite a lot for an Austrian boy.

[Jaz]
Absolutely. And did you get headhunted, or like, how did you find this position?

[Lukas]
Facebook. It was crazy, yes. Yeah, we took a dog and we’re really happy here. We are like in Southern Germany, like the Southern part. We are near a big lake called the Bodensee. So if any Protruserati is ever here in Konstanz, let me know. I am more than happy to show you around.

[Jaz]
Amazing. And then what have you done in the additional, like a master’s degree? I see your work is like, it’s exceptional. Tell us about what led you there. What are the sort of career development steps that you took?

[Lukas]
So we are a general practice here. We are four dentists and we cover like nearly everything in dentistry. So we do aligners, we do ortho, resto, we do surgery. We don’t do like big stuff of surgery, like, I don’t know, external sinus lift, for example.

But we cover, I would say like 90 percent of dentistry and I really enjoy being there. So we are doing really high quality dentistry. My boss is really like letting me buy everything I want, everything I need. He’s always like, if you are happy, I am. And that’s just really, yeah, like a big chance for me to develop. I took a lot of courses in surgery because I’m really interested in this topic. Yes. And here I am.

[Jaz]
That’s amazing. And I love how you have such a supportive principal who is happy to help you get the toys. It’s not about the toys. I mean, it’s about the toys, but it’s also not about the toys. It’s about the mindset, right? It’s about the mindset, really, that I want to help support my associate, be the best they can be. And that kind of mindset goes a long way. Like, I do hear stories whereby associates buy things and they don’t use them. And that’s why some principals, they worry. But if you find the right person and it looks like you found the right team, but credit to you because a lot of people, if they got an offer that was almost too good to refuse, but it was 600 kilometers away. They would be like, you know what? It’s not for me. I’ll wait for something down the road. So, you took a massive action basically to make the create, to find the environment.

[Lukas]
Yeah. But I’m like exactly this person, and also my partner. So it was really, the deal was, okay, we do this for six months. We sub rented our apartment in Vienna, went here also into a sub rent and we were quite sure to leave again. But it was like fantastic. And here we are.

[Jaz]
And how long has it been now you’re in Konstanz?

[Lukas]
Two years.

[Jaz]
Two years. Okay, good. Well, thanks for telling us a little about yourself and the topic of today is auto transplantation. Now, autotransplantation is something that I got exposed to just from the orthodontic lectures. Like I did a diploma in ortho and at dental school. It was like something that was mentioned, but like you’d never ever, like you could pretty much go your entire career without ever seeing it, touching it, smelling it, like just a buzzword that every three years might just pop up.

Oh, that’s interesting. That’s cool. Right. And that’s it. How well you documented and share on Instagram. That really inspired me. Okay. And to know that you’re a general dentist who did that. I am just so, so happy to just learn from you and share with the Protruserati about how do you even get into this? So tell me, how did you even get into this? How much of the autotransplantation cases have you actually done?

[Lukas]
So it’s quite a rare indication. So you don’t do this on a weekly basis.

[Jaz]
Exactly.

[Lukas]
You have like, you don’t have these many cases where, where you can perform that. I got in touch with it at university. So we had a professor who is doing that, like I think one of the most cases in Austria, but even he is doing that, I don’t know, every one or two months, so it’s not something you do really often, but it is underestimated. I think it is not that widespread as is that, but it is a really good and really like it has a lot of advantages for the patients. So I’m more than happy to spread it around.

[Jaz]
Yeah. And it might be something that perhaps should be an option to consider, but because it’s like such a, the back of your mind somewhere, it doesn’t even come to the surface. And then you miss out some of those cases where actually this might be a good case.

And what you prove is that if you’d like a bit of surgery, then you don’t have to be a specialist to do this kind of work, basically. That’s what you’ve proven that. And so tell us about what is the ideal case for an autotransplantation and just for the students maybe listening just from the beginning, what is an autotransplantation?

[Lukas]
So, autotransplantation basically is when you transplant a tooth into another side of the mouth. Basically, you can transplant every tooth into every side you want, but a lot of that doesn’t make sense. So you have like the main indication and also like the beginner case is when you take the wisdom tooth and transplant it into another side where the tooth is totally destroyed and you cannot rescue that tooth anymore.

For example, the first or second molar if that is totally destroyed or if you have a genesis of the second premolar you can also transplant in there. And that’s the best case scenario because it’s so easy to explain to the patient, you tell the patient you have a tooth here that is totally destroyed, we cannot rescue that anymore, and you have your wisdom tooth that has to be extracted anyway.

I love the idea because it’s patient talk a little bit, a lot of patients tends to simplify dentistry, you’re telling them the tooth is probably like five millimeter beneath the gums and they are saying, Oh, just put a pin into it, do a crown over it. And that’s easy. And that’s like the talk you have, both tooth have to be extracted. We just take this one that’s good and put it there. And then patients love the idea and they are more than happy with it.

[Jaz]
So excuse me for diving into a nuance straight away, but really you just mentioned something interesting that’s piqued my interest. Like you just said a genesis of a second premolar, for example. In my mind, autotransplantation was like you remove the tooth. So now you have the socket and then you are able to put a different tooth, like a wisdom tooth, for example, into that socket. What you’re describing is you pretty much has to do an osteotomy, like for implants, right? And then you put the tooth there. Is that correct?

[Lukas]
Yeah, that’s totally correct. So you have two possibilities. So when there’s a disjoint tooth, as you say, you just have to extract it, but you can also have the possibility that there is no tooth anymore, maybe for a year, maybe five years, or anagenesis. And yes, you pretty much do as an implant surgery, you just do a osteotomy, you create space for the transplant. And that’s also a scenario which works as well as if you extract it out into it. So that’s no problem at all.

[Jaz]
Very fascinating. That’s good. That’s good to consider. And then therefore, what is the most common, like which is the most common donor tooth and which is the most common recipient tooth, if you like, which are the teeth that are more commonly restored by auto transplant and which tooth is sacrificing itself to move into different position.

[Lukas]So mostly I will consider to take the wisdom tooth and transplant it into I would say mostly the first molar because everybody knows that that’s a really important tooth and you want to replace that one. That’s the most common thing, but what is also commonly done is you take the first pre molar and put it into the central incisor position.

I think that’s also the case what we learn at universities, which is done a lot. You can take like mandibular incisal if you have a lot of crowding, put it into agenesis of lateral incisor at the maxilla. You can do primary canine, put it into central incisor position in a child. So you have a lot of possibilities, but that are the most common indications.

[Jaz]
Okay, well, let’s go to the scenario whereby we’re considering removing an upper wisdom tooth and we want to put it into the upper first molar. So maybe the upper first molar is failing due to, I don’t know, resorption or a crack. And then therefore, because of a crack, we can’t restore this tooth anymore.

So what is the sort of success rate and predictability? Because really if you’re not going to be doing it, we’re either accepting a gap or maybe considering implants, for example. So let’s forget bridges and stuff. So when there is a toss up between implant and a wisdom tooth, what may sway us more towards an implant? What may sway us more towards an auto transplantation?

[Lukas]
That’s a really good question. Because like when you are performing out to transplantation, it has a lot of advantages by an implant. I mean, as you say, that’s like the most reasonable comparison. So that’s the most reasonable comparison. So when you’re doing implants, I think, what many of us don’t consider or don’t have in mind that the implant is like an ankylose tooth. Everybody knows, but our natural teeth passively erupting a whole life. The alveolar process is like growing a whole life and over 50 percent of the implants are in intraposition after some time, even if we are like over 18.

So that’s the most common age where people start to perform implants and the tooth itself, the PDL. It’s like, osteoinductive, that’s what we all want. We want it osteoinductive sources. So that’s the best thing that can happen to us. When we perform auto transplantation, we have proprioception, so the tooth is still maintaining a healthy alveolar process, a healthy alveolar bone.

We have a really good aesthetic outcome, so it has a lot of advantages. It is really cost effective. You can move this tooth orthodontically afterwards. You don’t have any complications with that. So that are the main advantages. But frankly, if I have a patient who is like 40, 50, 60 years, most often we don’t have the chance to extract a third molar because it is already extracted.

And it really makes sense to put an implant because the implant has really high success rates, but so does the autotransplantation. So we have survival rates over 90 percent even after 10 years, we have really long term data. So we know that it works. We know that it works really predictably. So it has a lot of advantages and therefore, yeah, it should be like more in our minds when educating patients. Yes.

[Jaz]
And hopefully after our chat today, people will consider it as another option. Now in that scenario, we are essentially avulsing you’re like kind of doing an avulsion. You’re doing a trauma, a guided trauma to avulse the wisdom tooth, right?

And then you’re moving it over to the first premolar and I’ll get you to talk through it a bit more scientifically. But sometimes when you experienced an avulsion, sometimes you are committed to perhaps doing a root canal, 10 days, two weeks later, basically, I imagine because of how sterile or how quick everything is. And the cells are still alive that perhaps is root canal always there is? Is it part of the protocol?

[Lukas]
That’s a good question. If the apex is still open so if the apex is like more than one millimeter you don’t have to do root canal treatment at all. Over 95 percent of the cases are showing revascularization, so you have a vital tooth there, but if the apex is already closed, if the root formation is completely finished, root canal treatment has to be performed.

The cases where we have revascularization are really seldomly, it’s like, around 10 percent of the cases. So you should not wait, you should perform root canal treatment if the root formation has already finished and if the apex is already closed. Yes.

[Jaz]
Okay. So, and then what about when trauma cases, the most long term complication we warn our patients about when re implanting an evolved tooth is resorption and ankylosis and that kind of stuff. So, how prevalent is that amongst auto transplantation cases?

[Lukas]
That’s a good question, because that’s like, we always learn from the failures of others, but hopefully not of ourselves, but that are the most common complications. So you can have, as you said, it can have root disruption and you can have encloses, you have that in a round 5 percent of the cases so it’s quite comparable to an implant actually. Because when you are looking at the data of peri implantitis, you have like crazy crazy numbers going from I don’t know 10 percent to 100 percent. That are like a crazy variation of numbers depending on the study. But when you are doing autotransplantation these failures are about 5 percent. But if you have root disruption, what you have left is bone.

So perfect situation for a healthy alveolar process later and a good site for an implant. So that’s actually not a big deal. If you have ankylosis, what you have is basically a tooth implant there. I mean, you can perform the coronation if it’s like an aesthetic issue or not an aesthetic issues.

If it’s like a functional issue there, if you need the bone, if it doesn’t grow, you can perform like surgical extrusion or you just let it be and like perform the restorative in a restorative way and just build it up. So that are the two complications you can have. They are quite certain if you are having a good protocol and we will talk about the protocol. Then we are talking about like three to 5%. Okay. So it’s really, it’s like something which is quite handable.

[Jaz]
And exactly what I was gonna ask you next was about the protocol. And I think to make it more specific and make it tangible for everyone, that case I saw of yours recently on Instagram just beautifully executed.

I really enjoyed watching that. And I’ll put the link for everyone to check it out. Just talk about that specific case and then use that case example to describe the whole thing about getting the 3d printed tooth and everything and the sequence and the protocol of it.

[Lukas]
Okay. So the case was like a 20 year old boy or man, and he had like a fracture around 2mm and beneath the gums at the second premolar, and the tooth was completely destroyed. So we couldn’t rescue that tooth anymore. We talked about orthodontic extrusion, but that would also just be a temporary approach. So we have no chance to rescue that tooth. We talked about implants. I have a genesis of my second premolar as well. So, kind of related with the patient.

[Jaz]
You connected with him.

[Lukas]
I told him that. And I said, you’re 20 years old. We can do an implant. Normally, I will never do implants before the age of 25 in the aesthetic zone here, they’re like a real broad smile, so it was the aesthetic zone for him, and I told him I wouldn’t do implant there, I would never do that, so I started 25 in the aesthetic zone where we do implants.

And I said, what we can do is just take your wisdom tooth, which has no sense there anyway, because at the opposite, there was no tooth at all. So he couldn’t chew with that. That tooth made-

[Jaz]
It was a non functional wisdom.

[Lukas]
It was non functional. It was already extruded. So it had no sense that anyway, it was just a shoe trap. And I said, we can just take the tooth and transplant it into that site. So there was this root which we had to extract anyway, there was this wisdom tooth non functioning and patient said, yes, that’s quite, you can understand that. So sure. We talked about alternatives, but that was for him the best treatment option.

And yeah, so we began, it’s always the most important thing when you’re doing any surgeries like planning. You have to get an idea what what to expect. And the best thing you can do, and we also have a lot of studies about that, is to perform CBCT scan and get a three dimensional expression.

You can just send the CBCT data to your technician. If you can do it yourself, please do that. But we couldn’t do that in our office, so I sent it to my technician. He just deleted the rest. Just extracted that tooth virtually. So the wisdom tooth, the donor tooth, and just made an STL file.

And we know that these STL files are really, really good. They don’t have any deviation to the real truth or like minor, which are not affecting our surgery. And he just-

[Jaz]
Just to make this tangible, what we’re aiming for here is, as well as having a look at the anatomy and making sure there’s no red flags to doing this procedure. What we want to do is, we want to 3D print that wisdom tooth.

[Lukas]
Yes. We come onto cut off that tooth.

[Jaz]
Yes. And the technician help you to delete all the bone, delete all the maxilla, delete everything, and just preserve a nice 3D printed tooth. And then now you’re gonna explain some, a lot of people ah, that’s clever and I got it. And some people thinking, hmm, why do you want a 3D printed tooth? So you’re gonna come onto that in a second.

[Lukas]
Yes, for sure. So you just print that as you said, you can also take biocompatible material. You can just disinfect it into alcohol because you need this one later, then just do anesthesia and then in my case, you extract the hopeless tooth. If there is no tooth at all, you can also make an incision. You have to create some space for the transplant. That’s just implant thinking. Okay. So you have to create space, you have to drill, you do that slowly. You do that with water cooling, you’re handling with bones. So just normal procedure. And it is perfect to take the replica and just check, do I have enough space? So that’s like the perfect condition you can have.

[Jaz]
And we’re talking about space not only in the osteotomy, but we’re also talking space like mesial distal.

[Lukas]
Yes.

[Jaz]
So you might have to do some enamel plasty, right? Mesial distal to allow the tooth to actually engage in, right?

[Lukas]
Yes, yes. And always, you shouldn’t expose the dentine, but you can do like 0.5 millimeters mesially distally of the gap. You can do 0.5.

[Jaz]
Is that the most easiest IPR ever?

[Lukas]
Yes. I loved it. And you can also do it on the transplant tooth and then you have two millimeters, for example, which you can use and that, as you said, you have to create some space for the transplant in the bone. You can just check with your replica, you just move it a little bit mesio-distally. You can check, can I move it a little bit? You just move it a little bit buccal lingually, if you cannot move it, okay, buccal lingual, I have two less space. I have to create some space.

[Jaz]
And what are you aiming for? Like, how do you know when to stop? Because you know, how much primary stability can you even get with an auto transplanted tooth, right? I mean, imagine the socket is too big, then it’s like kind of swimming around. So it’s interesting to know how you handle that scenario. But equally, if it’s too tight, like I imagine, obviously, you can’t start shaving the root tip because you’re getting rid of all the PDL, you have to remove the bone, right? But then what do you do in a scenario, basically, is it a no go, is it a abort mission if the extraction site is just way too wide for your donor tooth?

[Lukas]
No, because the PDL cells can differentiate into osteoblasts. So you really have the most osteoinductive force you can have. And that’s what we always aiming for in implantology. So here you have it. So you really have the most osteoinductive force and you get really a lot of bone growth. Okay. So best case scenario would be like 0. 5 millimeters around the tooth. And you need a bit more apically, like two to three millimeters. But if you have more, it is no problem at all. But as you said, if it doesn’t fit in, you have to create more space and it’s like with an implant, in the upper jaw, when the sinus is there, you can do some osteotomy, you can do bone splitting if you like, but in the best case scenario, you don’t have to do that.

So you create the space and you’re checking and checking and checking with replica, like that’s the most crucial part of it. And why the replica? Because otherwise you would have to take the donor tooth and the donor tooth has a really long extra old time and we know that the PDL cells, you’re going to kill them. Okay. So that’s the sound of the replica. That’s why a replica is so advisable and so good.

[Jaz]
Amazing. And so once you have found the right space, then you extract the wisdom tooth, right? And then you move it across. But one thing I’m interested to know is, do you have to then use particulate bone graft to help secure it, give it some stability or not really?

[Lukas]
No. So you shouldn’t do any like xenograft for example, or allograft. You really don’t need that. And we also know that if you do that, the survival rates are like decreases so you don’t have to do that. And if you have to like augment some bone before then the question starts to rise is it really the best case scenario for the patient because then it’s like yeah, then you can also do an implant.

So yes, and you do like normal extraction of the tooth, as you said, and that’s what we’re doing every day. Oh, that’s not a big deal for us. The only difference to a normal extraction is at least I don’t do that at a normal extraction. You just go with a blade into the sulcus. And going once around that you just do cautious and really like you want to handle it with care.

Yes. You want to do it as, as dramatic as possible. And best case scenario again, is like you have a vertical extraction device, but you can also do normal extraction. Just try to don’t touch the root surface. Try to stay in the crown. And that’s the thrilling part of the surgery, you want to get the tooth out in one piece because that’s all it takes. Yeah. So that’s like-

[Jaz]
The precious PDL layer preserved. And then you move it across and because you’ve already rehearsed with your 3d printed tooth, your path of insertion, and that maybe you need to shave it into proximally because you’ve already practiced that as well. And then you’re going to sink it in, but just tell us a bit about that. But is it just a matter of just sinking it in, in a couple of sutures or tell us about this bit.

[Lukas]
Yes. So as you said, you have your replica and you just know you taking the tooth out, everything is in one piece and you’re just putting it in and it just fits because you always checked before. And as you say, then you have to do some sort of fixture and there are two possibilities. So you should not do some rigid fixtures. So it should allow some micro movement. That’s really important for the PDL cells.

[Jaz]
Like a trauma splint, right?

[Lukas]
Yes, that would be the best case scenario, trauma splint, yes. Or like a really thin wire, like 0.3, 0.4 millimeters. So you have to allow some movement. That’s really important. If you have good primary stability, so if you have like mesially and distally good proximal contact, if you have good primary stability, you can just do X suture. Okay. So you’re just fixating it with a suture. It is important that the tooth is in slight intro position. So you should not have any occlusal contact.

You check that with your replica before you put it in slight intraposition. And then you’re just fixating it, as I said, normally with the trauma splint. But if you have really good primary stability and you can really get that. So in the case I had, I’m pretty sure I know that I could have gone without the trauma splint.

I am deciding for the transplant. I always like to be on the safe side, but it would have worked really well with just an X suture over it. If you have like really wide gums and the gum isn’t fitting on the new tooth, then you can just do some adaptation sutures that you have like a good dental alveolar seat to protect this blood clot in the new socket.

[Jaz]
Do you need antibiotics?

[Lukas]
We know that when you do systemic antibiotics that you have better success rates, so yes, I would do that. Just normal amoxicillin after the procedure for five days, that’s completely enough. You have to have good oral hygiene, so, when you are thinking about contraindications, there are no really major contraindications to the procedure. It’s like with every other surgery. So you have to have good old hygiene. You have to have a compliant patient. We are handling with-

[Jaz]
No active perio, smoking, the smoking mechanism. I wonder if smoke, I mean, who knows because the end numbers of smokers, the studies probably have never been done. It will never happen, but yeah, it makes sense. Impaired wound healing.

[Lukas]
It’s wound healing and as I said, it’s wound healing and it defected. And the odds that you lose this graft, it’s probably high, I guess. But otherwise you don’t really have like contraindications. I mean, we are handling with bone, we have to think about bisphosphonates or like real, I don’t know, real heavy and bad diabetes, which isn’t treated.

But otherwise you can really perform that like in every patient who is willing to do that and who has a missing tooth. She doesn’t need any more. So it’s really good procedure and you really like have a lot of advantages for patients.

[Jaz]
And then thereafter, like when do you review them? And then when do you do the root canal?

[Lukas]
So I always like to keep it simple. I always like to keep it cost efficient. So there are some studies that are suggesting that the sooner you do the root canal treatment, the better, so you can do root canal treatment before even transplanting the tooth. I don’t like to do that at wisdom teeth. So I like to keep it simple, just transplant the tooth.

Two weeks later, I remove the stitches or the wire or the trauma splint. And at that time, I’m doing the root canal treatment before. And as I said, if the apex is still open, when the, if the root formation isn’t done, you’re just controlling, doing the fixation away, but you should not perform any root canal treatment because the chances of revascularization are really, really high.

[Jaz]
Brilliant. And then thereafter, when would you look to do some sort of veneer, crown, restorative augmentation? When would that happen?

[Lukas]
If you take the third molar, if you take the wisdom tooth and really place it like, as we said, second premolar, first or second molar, then in most of the cases you don’t have to do like any restorative augmentation at all, because as I said, you’re doing it in slight interposition.

But the tooth is seeking for its opponent and it’s going to extrude anyway. And mostly it’s imperfect occlusion afterwards. Or you just do the minor occlusion adjustments, like you do after aligners to have like perfect occlusion. Yeah, that’s the way to go. So mostly you don’t need any extra treatment, but otherwise you do it.

Around one or two months after the procedure, two months after the procedure, the tooth is like it was there the whole time. So it is like fully healed. You can do nearly everything with this tooth. If you want to remove it atraumatically, you should wait three months or six months even. That it’s really completely healed before you move it. But we know that there are no higher or no significant higher root resorption when you move it. So you can really, it’s like a normal tooth. It’s like it has been there the whole time.

[Jaz]
Brilliant. Are there any papers you mind Lukas sending over so we can share with the Protruserati, just because you sparked their interest. They’re very geeky. That’d be great to read if you have any.

[Lukas]
I love that. I’m always trying that everything I say is like evidence based because I love not just sharing my opinion, but really like really papers and we have so much evidence out there. We have like a case reports. We have randomized controlled trials, split moth designs, even meta analysis over 30, 40 years. So we also have the long term data.

[Jaz]
I’ve just never looked for the literature because it’s something that you come across and then you never realize because yeah, it’s just something that the back of our minds. But you’ve done a great job in bringing it to the forefront of our mind and really reminding us that this is a really cool option. Yes, it has to be the perfect storm. perfect conditions, but you can really do something a little bit spicier and something that’s probably in the best interest of that patient at that time for their cycle of care. So very, very happy with that. Lukas, anything else you want to mention before I ask about how we can follow you and learn more?

[Lukas]
Not really. I mean, after you’ve performed the procedure, you should check the tooth in a closer interval. So you should check it like one month after it, three months after it, half a year in a year, like with any other trauma case, if you having a hard time extracting the tooth and you imagine that more of the PDL is damaged, then you should just do some kind of healing booster, everyone has a different concept, like hyaluronic acid, you can do Aminogen, you can do platelet rich plasma, you can do doxycycline to prevent root resorption, but you should just boost a little bit that healing, just some failure knowledge to prevent that.

[Jaz]
What’s your poison of choice in that scenario?

[Lukas]
I do doxycycline if I have root resorption. I tended to do Aminogen because I think it’s best for the patient. But nowadays I do more Hyaluronic Acid because it’s just not that expensive.

[Jaz]
It’s the honest answer. And I love it.

[Lukas]
Yes.

[Jaz]
No, excellent. I’m so, so happy we covered this. It really helped to remind me about making this an option. I’m sure everyone’s feeling like, Oh yeah, that’s perfect. Not only is that just cool, but you know what, there might be a time, I think all of us listening and watching right now, there will come a time in our career where we can actually implement this or even suggest this as an option and consider it.

So thanks so much for reminding us about how cool of an option it is and inspiring us as a GDP to consider this. I’m not saying guys go out there based on this podcast and start doing all the autotransplantations, but it’s something to inspire you to want to learn more. And I would definitely check out Lukas’s Instagram, Lukas, tell us more about how you can reach out to you and learn more from you, my friend.

[Lukas]
Just one more thing, because it’s so interesting what you mentioned, because I think that as a GDP, when we’re doing implants, you can really perform this procedure. It’s not that complicated. You’re just dealing with bone. You’re modulating bone. I wouldn’t go out and transplant the first premolar into the central incisal position.

You have to have a multidisciplinary approach there. You have to have a good orthodontist. But the scenario we made today and the scenario also from Instagram where you just transplant a third molar into the another molar position is like perfect scenario case to begin with and to start with.

[Jaz]
Not that I do implants, but I always hear that make your first implant on someone with a low smile line, a second premolar or a molar. It’s the same, similar principle, right? You want to start with the easier cases.

[Lukas]
With the simple cases, sure. Every one of us wants to do that. So how can you follow me? I’m on Instagram. I don’t have a private Instagram account because I was always like, no, I don’t need that. But I’m really happy that I started my professional Instagram account.

It’s just such a big chance to get connected. I mean, I’m sitting here talking to you. That’s like crazy and I’m really happy that I have this account. It’s like Dr. Lukas, or drlukashuber, and yeah, I’m sharing my cases. I’m more than happy to get connected. I love to get feedback on my cases. It’s crazy when you post the picture, you zoom like 20 times in and you see every mistake you’ve made like six months ago.

[Jaz]
I appreciate you, you sharing and also flying the flag for GDPs. And I think it’d be great to a great person to connect to and just get inspiration from and like minded, nice and geeky Protruserati as we like it. So, Lukas. Thanks for giving up some time tonight to talk about this very geeky topic, but I don’t know if anyone else had fun, but I enjoy this chat very much. So thank you so much.

[Lukas]
Thank you so much for having me and love to get connected.

Jaz’s Outro:
Well there we have it guys, Dr. Lukas Huber from Konstanz. Thanks so much for staying and listening all the way to the end. I just love interviewing fellow Protruserati so it was great to see his work on social media which prompted me to message him and say you know what can you share this with our Protruserati colleagues and didn’t he just do a brilliant job.

Look this episode is eligible for CPD so if you are a regular listener please consider joining Protrusive Guidance. We have two plans available on Protrusive Guidance and with both those plans you can collect CPD for every PDP episode even retrospectively as well. So if you’re already doing the hard work of listening then just answer a few questions and get your CPD. Mari, our CPD queen, will send you the certificate.

And she’ll send it again to you in three months, and every quarter, in an annual summary, your little special folder on Google Drive that we make for you, which has got all your certificates. So check out protrusive.App if you’re not already on there, or just download the iOS Android app.

I want to thank my team. We’ve got Mari on the CPD side of things. We’ve got our clinicians, Krissel and Nav. We have our editing team of Erika and Gian. Without my awesome team, none of the podcast would ever be possible. And lastly, thank you, The Protruserati, for clicking on such a niche topic. Like you decided to join us today on a topic of auto transplantation.

That means you are geeky and I love you. So if you satisfy the criteria of being nice and geeky, I would love to see you in our little community on Protrusive Guidance. Thanks so much. I’ll catch you same time, same place next week. Bye for now.

View Details

What is the best bonding agent to use?

Does it actually matter? Spoiler: it does!

How do you get the best bond to dentine and enamel with the adhesive system you are using?

Dr Sam Sherif joins us in this episode, where he discusses bond strength in detail as well as sharing his top tips in achieving long lasting adhesion for our daily adhesive Dentistry. There’s a lot to learn in this one so get ready those onions ready!

https://youtu.be/FICDBVljsGwWatch PDP192 on Youtube Protrusive Dental Pearl: Always read the directions for use – ESPECIALLY for your adhesive systems!

Did you know? Paid members on Protrusive Guidance can access the PDF summary notes as part of the Protrusive Vault. Oh and be sure to answer the quiz for 1 CE credit!

If you liked this episode, you will also like Immediate Dentine Sealing Part 2

View Details

Is Shillingburg’s textbook irrelevant?

What materials are used in the real world?

Is it right that dental students are primarily taught PFM crown preps?

When to Onlay and when to go full crown?

The Direct vs Indirect debate continues, too!

In this two-part journey, we’ll dive into the world of crowns, bridges, and ceramics, exploring their applications, benefits, and the science behind these crucial dental materials.

Join Emma and Jaz as they guide you through the fascinating world of indirect restorations.

https://youtu.be/7J5S2ThC8AIWatch PS006 on YoutubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:

01:46 Welcoming Emma back
02:07 Emma’s Learning Progress
05:57 Crowns: Material Choices and Real-World Applications
09:41 Onlays and Overlays
11:33 Direct vs Indirect Restorations
18:40 Onlays vs Crowns: Decision-Making
22:18 Conclusion and Next Steps

Don’t miss the special notes on Indirect Restorations available exclusively in the Protrusive Guidance app in the ‘Crush Your Exams’ space!

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App!

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, be sure to recap PS005 – Should our Restorations Follow Textbook Anatomy? Tooth Morphology

Click below for full episode transcript:Jaz's Introduction: Welcome to this two part episode on the basics of indirect restorations. If you're wondering why I sound different, or if you're looking around thinking, hmm, this isn't Jaz's usual studio, it's because my studio is a conservatory, and it is absolutely roasting right now.Jaz’s Introduction:
So, to spare you my sweat patches, I am recording in my living room, and I’ve got about three minutes before my wife and kids come home, so let’s crack on.

Look, crowns and bridges, anything indirect is a big steep learning curve when you’re a student. But what I’m hoping to cover today will not only help guide students, but also is like a basic revision of indirect restorative. I remember being taught PFM, porcelain fused to metal crowns, and speaking to Emma, our Protrusive student, she’s also learning porcelain fused to metal.

Let me tell you, in the real world, many of our restorations are all ceramic. So Emma really was interested in learning more about this. So remember, Emma’s our protrusive student, follow her journey through all these episodes. And really, I’m getting Emma to ask all the relevant questions because sometimes you lose touch in the struggles of when you were a beginner.

And that’s why Emma’s really gonna make things tangible for us, break things down. And ask me the right questions so I can cover things that can actually help young dentist students and those who just want some revision of the basics. We cover key themes like direct vs indirect, on lays vs full crowns.

I know we did a full episode on that recently by the way, PDP189, you should totally check that one out. But we kind of talk about it more in the basics foundational student friendly version. Hope you enjoy this episode, and yes, there are Emma’s famous student notes available to download in the student forum and Protrusive Vault section of Protrusive Guidance, our app.

The website for that is protrusive. app or download it on iOS and Android. Remember, if you email student at protrusive. co. uk with proof that you’re a student, you get full access to this area. Enjoy the main episode, I’ll catch you in the outro, and of course, do come back for part two.

Emma Hutchison, the Protrusive Student, and all the students listening and watching, and Dentist, who sometimes like to join us here. Welcome back to another edition for Dentist students. This is June. This is June’s edition. We’re focusing on onlays and crowns and that kind of stuff, which is the theme of the month. But particularly, we’re going to have an opportunity to catch up with you, Emma, and also answer your questions from a student’s perspective.

Main Episode:
So firstly, Emma, How you been? How’s the last week or so? How’s the last month been? Anything new that you’ve learned last time with dentures? Any new experiences that you’ve had?

[Emma]
Yeah, so the last time that we’ve recorded, it’s actually been a quiet one actually. I had a patient in last Friday with a fractured fill in, had to take all that out and patch that back up. Other than that, I’ve not seen any more frost patients or anything like that. So it’s actually been quite quiet. I’ve only seen one patient, but not as-

[Jaz]
Academically? What are all the kind of themes that you’ve been covering academically?

[Emma]
So, recently, I think in Glasgow, towards the end of the semester, because we’ve only got a month or two left. It’s February right now that we’re recording this. They start to pile in more and more of the theory stuff. I don’t know if that’s just how it works out in Glasgow. But you sort of wince down on the clinical time and ramp up a bit more on the theory stuff. So it’s been a lot of consent, ethics, all that sort of thing that we’ve been covering, which would be good to do on here at some point as well. But yeah, just whole range of things, but it’s good just trying to keep on top of it, I suppose.

[Jaz]
I think that our next chat has now been decided on the consent ethics of communication. So there we are. Easy as that. Right. Great. Well, today let’s talk about crowns, right? So I remember being a dental student and you learn all these different types of preps on the phantom head.

And initially you still feel like you’ve got two left hand in five years out of it. And you’re trying really hard not to hit the adjacent tooth and you end up tapering too much. And I found crowns at a very, deep learning curve in terms of getting my hand coordination right. Being able to use the mirror and focus on the reflection and not trying to use a direct vision, trying to switch to indirect vision. Are these the challenges that you’re living and breathing right now?

[Emma]
Yeah, definitely. I mean, I’ve not had any crown or bridge patients so far. Nothing like that. I’ve only had complete crowns down on phantom heads at the moment. And even that without a tongue in the way, cheeks and all the rest of it, it’s really, really challenging.

The only thing that I can think of at the moment, we have been taught sort of two different ways. It might be different in lots of universities about the process you go through and metal ceramic crowns versus all ceramic crowns. And that’s been a lot of my teaching so far, is the differences between those two. Nothing quite like-

[Jaz]
Well, they’ve told you the differences, but I mean, fair enough, but have they given you any indications of what we’re actually doing in the real world? What you should be focusing a bit more on, or when you actually come to treating your patients, what’s the more likely type of crown that you may be doing? Have they sort of covered that?

[Emma]
No, actually, I’m not really sure what type of crowns that we do provide in Glasgow Dental Hospital. I actually don’t know. I really don’t know.

[Jaz]
I mean, I’d be fascinated because back when I was in Sheffield, it was very traditional metal based and PFM, so porcelain infused to metal. I don’t think I did a all ceramic crown as a dental student, to be honest with you. I’m struggling to remember if I did. Maybe one anterior tooth. But things have shifted a long way in the world of ceramics. So I’m hoping, because really PFM is getting phased out. Like there are still a big place of PFM.

We’ll talk about that when I would use PFM, but it’s all the buzz materials are lithium disilicate, which is Emax is a brand name, if you like, by either part of lithium disilicate. Have you covered that ceramic name, lithium disilicate?

[Emma]
Yes. Yeah. Yeah. And that’ll definitely be included in the notes for this month as well.

[Jaz]
Brilliant. Excellent. So yeah, this is a type of glass ceramic. It’s an etchable ceramic. So one of the things I remember learning as a student is etchable and non etchable ceramics. And then zirconia is the other one. Okay. So, it’s being used a lot for it’s a different properties like strength and whatnot, but we always have to balance it out with how abrasive it is to natural tooth, how much tooth height you have and how much reduction you can do. So many different things you consider in the matrix. So where do you want to start, Emma? What’s your top question?

[Emma]
Yeah. So my first top question, I’ve been thinking about this, so as I’ve been saying, what I’ve been taught so far in university is to prep the teeth depending on the material that’s going to be used for, let’s just say, a crown.

Again, quite a broad question that I’ll start off with, does this align with real life dentistry? I don’t know if you’ve seen many of the bits and bobs that I’ve put, that I’ve sent to you for my teaching on this already, but yeah, does that align with real life dentistry? Like, how much does your prep rely on the material that you’re going to use? Does that influence it a huge amount?

[Jaz]
Okay, great question. And really, at the beginning, when you’re new to crown preps, you’re kind of, so much visual stimulus. You’re trying to keep your hands steady. You’re trying not to taper too much. And so, as a newbie dentist, as a dental student, you’re just trying to get the basics right.

And really, your hand skills aren’t there. And so you’re trying to just about get a margin that the technician could read. And so you’re doing all that. And then you kind of just pray that it’s enough and you send it to the technician and hopefully they can make a crown out of it.

And the most common one is you didn’t give enough occlusal clearance. So actually what you’re being taught is a really good way that you should begin with the end in mind. That’s a really, really good thing. So I’m not one to say that. I will look at a tooth and I’ll say for definitely, for sure, it’s going to be this material.

Sometimes it is clear, but a lot of time I will do the following, Emma. So let’s take a tooth that’s carious. It’s an old MOD amalgam. It’s carious. We know that by the time we remove all the amalgam and the caries, there’s not going to be a lot of tooth structure left and it’ll be too ambitious for a composite. Okay. So does that make sense so far? You’ve decided already that you think you’re going to be going indirect. You’re going to do your gold standard caries removal. You’re going to build up a core or a foundation restoration, typically, a bulk kill, dual kill composite, that kind of stuff.

I use something called Paracore. Some people use GIC, which is a bit weak. I tend to stress composite to be honest with you. So we’ve got a core in, but now you need to prep it. Now, when we’re prepping it, before we prep it, we kind of now decide, right? What material am I aiming for? So, aesthetics will come into play here.

Functional demands will come into play here. For example, for an anterior tooth, you’re going to get better aesthetics from, let’s say, a lithium disilicate crown than you would from a PFM, generally speaking. To get the same level of aesthetics from PFM, you’d have to be very aggressive, give a nice meaty shoulder, which is more invasive.

So let’s say you decided that you’re going to do an Emax crown. And so Emax is like the brand name of Ivoclar. So it’s a lithium disilicate and they produce these guidelines, right? So they say, okay, for example, a one millimeter a rounded shoulder, for example, all the way around and a 1. 5 millimeters occlusal clearance.

Okay. Let’s say, okay. And so you have that in your mind and you know that you want to give your technician enough space for aesthetics and also to respect the integrity of the material. So yes, you are going to then prep according to what’s gold standard for that. It all depends on that initial decision you make.

Okay. And once you’ve decided that I’m picking this material for this reason, then yes. Aesthetics and material integrity. So for PFM, like I think I was reading your notes. You said 2. 5 millimeters occlusal reduction, right?

[Emma]
Yeah. Yeah.

[Jaz]
That’s a lot.

[Emma]
Okay. Okay.

[Jaz]
That is a lot. So, and okay. In the real world, we are moving more to this dentistry. I doubt you’ve been taught this yet, and maybe you won’t get taught this, I don’t know, but onlays and overlays made out of ceramic. Is that something that’s been covered yet?

[Emma]
I don’t think so. I’m not sure.

[Jaz]
Do you know what an onlay, overlay is? Do you know what these terms are?

[Emma]
Yeah, I know what inlays onlays are. I think I’ve maybe prepped one onlay in Phantom Head, and that was it, really. That was it.

[Jaz]
Was that a metal one, by any chance?

[Emma]
I couldn’t even tell you, Jaz. I couldn’t even tell you.

[Jaz]
Okay, well, put it this way. Let’s just, for the students, just break it down. Onlay is you’re replacing at least one custom. So you’re replacing one at the one cusp. Overlay is you’re covering all the cusps. For example. Now, you could do an onlay in metal. So let’s say you can use your non-precious metal or gold. Okay. Right. And the way that preparation will differ to a ceramic one is the metal one is allowed to have sharp internal line angles, right?

Because the metal can tolerate it. It’s very well defined and it’s very minimally aggressive. It’s like, 0. 7, sometimes 0. 5 millimeters. of axial reduction and occlusally, it could be a millimeter thin, which is great. So very minimally invasive. If you compare that to a lithium disilicate, it’s much more rounded and slowing.

There is no sharp internal corners allowed because sharp internal corners, it starts to crack glass, glass ceramic, you’re cracking the glass base. So the prep, when you look at a tooth and the prep looks different, it’s more rounded. I’ve actually got good photos to add to this. So while I’m saying this for those who are watching and not listening, I remember the scenario where I was prepping a lower second molar and a lower first molar, right?

On the same patient, same quadrant. And one was for a metal onlay because I wanted to reduce less occlusally. I had limited crown height and I didn’t want to drill so much in the occlusal clearance. So I went for metal and the tooth in front, I had a good amount of enamel. But I had more to play with in terms of occlusal clearance, so I went for ceramic.

And the distinctive features was one was way more well defined than the other one. So the top theme so far is, yes, begin with the end in mind. And the type of material you choose will influence what your prep looks like. And there is a difference whether you’re going for it onlay, or for a full crown. What questions have you got based on that? Cause I know I’m saying 50 million things here, but that’s going to lead to a hundred million different questions.

[Emma]
Yeah, definitely. So I even wondered this when I was working full time as a dental nurse and it’s just, okay, so let’s take a tooth which hasn’t been root canal treated just for easy, I suppose. What criteria do you consider when you’re selecting the most appropriate type of restoration? Like what are the deciding factors between direct and indirect or an onlay versus a whole crown? And I know that’s a huge question but that’s something I just, I don’t think I would be able to judge very well where I am clinically at the moment. I find that very hard to sort of comprehend put that into practice.

[Jaz]
Emma, even qualified dentists mess with me all the time. Even I’m the same. Like I often ponder a lot less now, but as a young dentist, even I used to, I needed more clarity on this. And so I think it’s a great question. And always remember Emma, throughout as we develop our podcasting relationship, you have to remember that you are the advocate for students, right?

So if I’ve said anything that you’re thinking, it doesn’t 100 percent make sense. There’s tons of students out there thinking, well, what the hell did I just say? So remember, you’re the advocate for students, right? So there’s no such thing as a silly question and you must challenge me and you must stop me because the whole reason we’re meeting together is to benefit those damn students, right?

And some dentists who want to just go back to basics, right? So let’s start with direct versus indirect. We did our very first episode about when is potentially a direct restoration of large composite too large and the larger the composite, the less successful was the number one reason the composite to fail if it was too ambitious.

So if you feel like you’re using more than two compules and probably you’re being a bit too ambitious with your composite, right? If you’re trying to get these perfect contact areas, so the tooth in front and behind, and you’re trying to, you’re faffing around, you’re spending an hour and a half to do a big filling.

That’s too long. Okay. You’re better off doing something indirect. You’re going to, the patient will be better serviced and it will last longer to get something stronger and better made from the lab. So there’s a point where the restoration gets too big. The other times you may consider that, hmm, should I go for direct composite or indirect crown onlay is you’ve got loads of cracks in a tooth.

You’ve got loads of cracks in the tooth. You kind of want to hug the tooth. You want to prevent the flex. Composite flexes more than an indirect material. So these are some of the things that you consider and for longevity, like that indirect would be good. Direct can be less invasive, can be less invasive.

So there’s a point where actually it’s a small MO or a small DO, fine, composite. A large MO, large DO, fine. MOD, maybe fine, composite. But then if you look at the patient and the patient’s got broken cusps everywhere, large muscles, high forces, then maybe you’re going to get better longevity by going for the indirect. So there’s no hard and fast rules. You’ve got to really base it on that individual. But if I was to say one thing, the larger the composite, the more you’re going to tend towards indirect.

[Emma]
Okay, that makes sense. And then, so I suppose again, I suppose again, it is one of those things where a common theme is as we’re going through this Jaz and just you get better at it as you go along judging these types of things. Because I could look at it and someone will ask me, would you put a composite on that? Would you do a crown? And I would believe whatever you say. Because I just don’t know. I just don’t know.

[Jaz]
Emma, this stuff still split room. You can have dentists a room who are all 40 years qualified, right? And we show them an MOD cavity with a small crack inside. Half of them will go for a large composite and half of them will go for some sort of crack. You’d be amazed. There really is very few like true indications. Especially nowadays where we’re really pushing the boundaries of our large composites.

We’ve got some nicer matrices, we’ve got some higher quality composites. So really people are pushing the boundaries of composites. So yeah, I wouldn’t expect anyone to be to say definitively, but the more of the factors you have, for example, the crack, the root filled tooth, for sure, if it’s a root filled tooth, it’s weaker, it flexes more, it’s potentially more brittle, quote unquote, and therefore you’re tending more towards an indirect.

But there’s no very few definite cases where it’s like, hmm, you can’t do indirect. Now, when you look at tooth and to actually reconstruct this with a large composite, it’s going to be so technically demanding to actually get a good contact and a good result. Then again, that’s another reason to go indirect.

Now, there are some rules, like if the isthmus is at least a third of the width of the entire buccal to lingual, those again, little guidelines that we use, but they’re not a hundred percent definitive. Once you make that decision that, okay, I feel as though this tooth needs indirect. And you know what? A lot of young dentists are doing large, they have composite day in, day out, where they should be doing indirect because A, they’re not confident with indirect and no. So clinician experience comes into play. I did that for, for a long time. B, the patients don’t wanna pay for it. And that depends a lot on your communication. So this is maybe really farfetched too.

Like you can’t even imagine, like then again, actually you’ve been nursing, so you’ve seen these live conversations and so the conversation goes like this, right? You know in your heart that this tooth would benefit from an indirect, but what you say to the patient is, okay, we can do a big filling, it’s going to be X amount, or we can do a crown, it’s going to be 3X.

And then you let the patient choose, and they’re going to go for X, they’re going to go for the large filling. But if you’ve seen their facial profile and all the cracks and stuff, that’s actually a disservice to the patient. So, what our young dentists will do, really push the boundaries of those large composites.

When you get that confidence and once you can see your dentistry come back and see that actually those large composites start chipping or staining or the contacts aren’t so good and you really come to terms with the fact that, okay, there are certain teeth which need indirect restoration. The next question you then ask is, how do you decide whether to do?

Something like an onlay or something like a full crown. So I think this is the last thing we’ll discuss for today because this is a big topic in itself. Okay. At dental School, I didn’t prep a single onlay, I don’t think. And it really was full crown, full crown, full crown, a lot of PFM stuff, heavy margin and stuff, right?

So a lot of the stuff I had to learn in the real world. What my current philosophy is now is if I can do an onlay, Okay. I will. Because onlay is more conservative of tooth tissue. There will be studies, when you do a full crown, you remove up to 70 percent of the volume of a tooth. But when you’re doing an onlay, you’re removing like something like 40 percent or 35 percent of the volume of a tooth.

So why not? Right. And so the type of onlay I’m doing more often than not, Emma, is a lithium disilicate onlay. We’re trying to bond basically by bonding. We’re again, we’re not having to control extra bits to get retention grooves and stuff. Then last bit here is why would you bond and why would you not bond?

Well, if you’ve got nice enamel all the way around. You got peripheral enamel, then totally, believe in the bond. It’s going to be predictable. Use lithium disilicate. But if you’ve got your dentine everywhere, the quality of your enamel is poor, it’s hyper mineralized, it’s flaky, it’s thin, then really in that case, we’re probably better off going more traditional and doing our crown.

But even then, Emma, what you’re being taught, 1. 5 millimetre buccal margin, right? I will be doing something like, 0. 7 millimetre or, 1 millimetre margin in zirconia. Again, that’s so much more conservative, right? So that’s a quick fire on, onlays versus crown. Please tell me as a student, does that make sense?

[Emma]
It does make sense. I think the best thing for me, even just this short chat that we’ve had is just, there’s not always a solid answer. And sometimes you don’t know until you go in. And you explore further, and I think that sort of ties in with one of the huge challenges I’ve found as a dental student is sort of having your own opinion and build, being able to have your own opinion because you see different clinicians for the same treatment plan every week and sometimes you do have to stick to your guns and they’re asking you, why are you doing this?

Why would you not do this? But they like it when you fight your own corner, and you have a reason as to why you are choosing this treatment plan. So, no, it is good to know there’s just you give ten different dentists one patient and they’ll come up with ten different treatment plans, so. No, that’s, yeah.

[Jaz]
It’s not only is a frustration point in dentistry, it’s also the beauty of dentistry. I used to only see this as the most frustrating thing of dentistry, whereby, oh my goodness, why can’t dentists just agree? Why can’t dentistry be black and white? Why can’t we just all, if this tooth comes in, then we do this. But that will take away the fun and the artistic element of dentistry. So if we start to flip it and see the beauty of it, right, and no one’s dictating you, and you can justify it in either way that you want.

The most important thing, just like you said, when you come into an exam scenario and you’ve made a decision, then you want to be like in a school debate. You want to say, well, this house believes in this. Now, some may argue that you can do this, but the reason I have rationalized it is because A, B, and C.

And this is my clinical reasoning. This is my clinical philosophy and I would encourage everyone to over their years, develop a clinical philosophy and refine that philosophy and be open minded to learn from new evidence based and new people that you encounter that teaches something that really resonates with you.

As long as you do no harm. There are some things that, unfortunately, Emma, I’ve seen before I’ve worked these clinics whereby I’m seeing these small MO restorations, which just need a small MO replacement and they’re being prepped for full crown. I’ve seen that. And I used to work in Singapore.

I saw a lot with one clinician in Singapore and we could talk about the whole ethics and stuff that becomes very difficult thing to discuss. But most dentists, I truly believe have got the patient’s best interest at heart and they will always try to look at the patient as a whole.

Because, Emma, one thing we haven’t mentioned is that tooth, that you look at anything, this tooth needs a crown, but you don’t know how the nerve’s going to go. So you do that large composite and you wait and you see, and you do like a posh core, you do a large foundation because truly you don’t want to put a crown the next week, come back and they need a root canal treatment through the crown for a biting tooth.

So, this is why the tooth is attached to a patient who has their values, who has their individual anatomical considerations, individual budgets, right, and their own baggage. So, we need to take it as a beautiful thing that dentistry is a variable and not be hindered by that.

[Emma]
Yeah, that’s such a different take because that is, something that I do actually worry about in dentistry is having my own opinions and being able to stick to them. So no, that’s a nice way to look at it. I suppose the beauty of it. Yeah.

[Jaz]
I think if you, I used to do this a to focus on the negative point and why are there second and third opinions, but the more clinicians I meet and the more letters I read, the letters start with in my clinical opinion, it is a clinical opinion and the practice of dentistry is the practice of dentistry.

We are practicing. No one’s perfect. And as long as you can really follow some key guidelines, doing no harm, having the patient’s best interest at heart, working within your expertise. I don’t think you can go wrong Emma, you’ll be fine.

[Emma]
Everyone will be fine. No, that’s good to know though, that’s good to know.

[Jaz]
Excellent, brilliant. Well, Emma, enjoy the chat. Next time, let’s talk about, was it consent and ethics and communication, that kind of stuff, right?

[Emma]
Yeah, a big one, yeah.

[Jaz]
What are the notes that you’ll be dropping in the student space for this month?

[Emma]
So, we might pop, and we’ll, everyone’s favorite, DMS. Very important for crowns.

[Jaz]
That’s dental material science for someone who’s tuning in for the first time.

[Emma]
Very heavy on the examinable stuff there, but also my teaching in Glasgow and just the guidelines that I’ve been given forcrown preps and different types of materials that are used. Again, all very examinable stuff, so.

[Jaz]
Amazing, and I’ll try and collate some freely available PDFs that are online and just bring them all in one place. That are like helpful guides, some good videos. I’ve got loads of videos of me doing preps and stuff. So my only worry is, Emma, by uploading these videos is, if in dental school you don’t get taught a lithium disilicate overlay, and all I’ve got is a lot of those videos, and also a different type of crown, which I do as a vertical preparation, but I don’t even want to go into that, right?

And so, the thing to appreciate here, Emma, is the way I’m practicing now, only about five, 10 percent of it, is what I learned in dental school, which is scary, right? You’re there, you’re in the heat, you’re in the cold face. You’re like, okay, I’ve got to learn this, got to learn it really well.

But this guy’s telling you that actually you’re only going to do 5, 10 percent of those things because things evolve, things change, you go on courses and some of the stuff in the real world actually is more current and relevant than what, no offense to dental schools, but they might be teaching.

[Emma]
Yeah, absolutely. I mean, I think we also covered, gold crowns and things like that. And it was practiced, like, you’ll probably never do this, but it’s all still included in there anyway.

[Jaz]
It’s a good skill to have. It’s a good thing to know. Sometimes, on second molars, I will operate in the right patient. I think, it’s good to train your hand eye coordination. So all these preps. Practice them, learn the rationale, always, always think why, what’s the end result, and base it on that. So always begin with the end in mind. And with that, Emma, thank you so much for another student segment, and we’ll catch you next month.

[Emma]
See you later, bye.

Jaz’s Outro:
There we have it guys, nice and sweet one today, but do check out part two. In part two, we actually talk about the actual fitting of the crown. When do you reject lab work? How do you even quality control the crown when it comes back from the lab for example? And the exact stages of fitting the crown.

And I think this will help anyone who’s got their first few crown preps coming up, or maybe even a qualified dentist who’s thinking, hmm, how do others do it? So do check out Indirect Restorations Part 2, coming soon. Thanks so much for listening all the way to the end, and do check out the Protrusive Student Notes, available only on Protrusive Guidance.

Thanks for joining us, and I’ll catch you next time.

View Details

The secret to success with non-vital bleaching is knowing when it’s not going to work.

Dr Jason Smithson shares his decision making in discoloured incisors AND the protocols he uses in their management.

When is a purely restorative approach more appropriate than bleaching?

When is ceramic preferred to composite?

What is the best way to mask a metal post?

https://youtu.be/r59gt8g1niUWatch PDP191 on YoutubeListen/Watch this episode which reveals all! This episode is eligible for 1 CE credit via the Protrusive Guidance platform.

Protrusive Dental Pearl:

To help achieve great shade selection, take pictures sequentially during your assessment and throughout the procedure, then edit the pictures to show as black and white. By analysing the shade match through a black and white process and in steps throughout the treatment, the shade selection will be far more accurate than just attempting this once at the beginning, especially without using the black and white technique, as this will emphasise the value of the shade

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:
01:56 Protrusive Dental Pearl
03:15 Introduction – Dr Jason Smithson
05:30 Biomimetic Dentistry
14:50 Non Vital Bleaching
24:55 Calcific Metamorphosis
28:30 Ceramic or Composite Resin
31:17 Deeper Dive into Ceramic Use
32:55 Composite veneers
40:35 Perfecting Shade
43:40 Jason’s Courses

Access the CPD quiz either on your browser or by downloading our mobile app. For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you liked this episode, you will also like The ‘Anti-Biomimetic Dentist’ – Restorative Lessons from Pasquale Venuti Part 1 – PDP152 – Protrusive Dental Podcast

Click below for full episode transcript:Jaz's Introduction: One of the most common questions we get on Protrusive is how do you manage the discoloured central incisor? Now, we already have episodes on the non vital bleaching technique.Jaz’s Introduction:
In fact, it’s a two part absolute ripper. But sometimes we experience relapse or we find a case where perhaps it’s too risky to try non vital bleaching and we want to manage this restoratively.

So I brought on once again, Dr Jason Smithson you probably already know who this is If you don’t you probably live under a rock somewhere. He’s one of the greatest dentists ever and he’s taught me so much of what I know. I’m constantly learning more and more from him. In fact, even in this episode, he taught me so, so much. I know you’re going to gain so much from this.

Hello, Protruserati. I’m Jaz Gulati, recording at my in law’s place at the moment, in the loft, because it is half term. The kids are off, but I so badly wanted to record this. So my wife has given me a permit to do this podcast with Dr. Jason Smithson. The kind of themes you cover are when do you know not to even attempt non lethal bleaching, and perhaps a restorative technique will be better?

When to veneer versus when we should actually be crowning. I know crown is like a dirty word, but actually, you’ll see that there is still a place for the crown. Revisit the composite versus ceramic debate when it comes to restoring that discolored central incisor. And this entire episode is sponsored by Sprinkled With gems and pearls from Jason.

Denta Pearl:
The Protrusive Dental Pearl I have for you is taken from this episode. Now, you may already be familiar with the protocol of taking a black and white photo of the anterior teeth that you’re restoring because it helps you to appreciate the value, the brightness of the tooth. And sometimes we use the composite button technique. I.e we put a small little button of composite on the facial of an incisor to see which button of composite, different shades of composite best matches the shade of your tooth.

Now, if you listen to the end of the episode, Jason will share the common mistake dentists make all the time that he sees on social media when we’re doing the button shade test for composite. But when it comes to the pearl, the pearl is the whole beauty of the black and white photo and not just using it at the beginning.

But actually using it intraoperatively or perioperatively. What I mean by this is when you’re actually painting on the different layers of composite, let’s say using an opaque layer first, instead of just proceeding and looking at the end, why don’t you take a black and white photo, or get your assistant to take a photo, even on their iPhone.

Take a photo, quickly convert it into black and white, and have a look. Has that shade of composite that you just placed given enough value? Do you perhaps need to add a little bit more? It’s valuable real time data that you can get by the use of the black and white photo. So I’ve been guilty of using this technique at the start, but not using it as I’m building my layers up.

Especially if you’re trying to mask a discoloured tooth. So next time you’re in this scenario and you’re using like an opaque type of composite, use this technique of sequential black and white photos to help you decide if you’ve got enough thickness of composite.

This episode will be eligible for 50 minutes of CPD by answering the CE quiz at the end. Let’s now join Dr. Jason Smithson. And we actually start off with Jason’s biggest bugbears. We talk about his views on biomimetic dentistry and posts. So please do enjoy that. But if you’re particularly waiting for that content on purely discolored teeth, then you may wish to skip the next 8 to 10 minutes.

Main Episode:
Please do introduce yourself to those who, few people haven’t heard of you.

[Jason]
Yeah, so my name’s Jason Smithson. I am a general dentist. I’m based in a practice called Revitalise, which is in Cornwall, just outside Truro, in the extreme southwest of England. So, if you’re not based in the UK, if you think of the UK as a triangle, and at the top of the triangle would be Scotland, and at the bottom right would be London, and then on the bottom left, just below Wales, and just sort of below Ireland, is Cornwall where I live, so it’s kind of closest to the US.

And in the practice, I’m technically a general dentist, but I just really do restorative dentistry, crown and bridge work, adhesive bridge work, implant restoration, I don’t place implants, but I restore, perio surgery, and something which I’m mainly known for is composite bonding, which I’ve been doing for 25 years now, which is quite a long time, but there we go.

So that’s kind of me and that’s what I do. I also have a very small medico legal practice. I do mainly defense of dentists and the odd personal injuries case. Not a huge amount of my workload. And a larger part of my workload is teaching, and I teach roughly 100 days a year, give or take. So, and have been doing for 15 years, so that’s kind of me. So there we go.

[Jaz]
Amazing. I mean, I’ve been to many of your courses and I’ve learned so much from you. Either through some recorded content that I might have seen online or your live courses. So I can highly recommend if you haven’t learned from Jason for whether you’re on stateside UK, around the world, Jason does post up his photos of his shoes up against the train station a fair bit.

So I know he travels around. So if you ever get a chance to see Jason teach, please do take that up. Interesting thing off script, off script, Jason. You mentioned about your affinity towards adhesive dentistry. Would you identify yourself as a quote unquote biomimetic dentist? What are your thoughts on this terminology?

[Jason]
That could be on script if you like, I don’t mind. Well-

[Jaz]
We’re definitely airing this. It’s just that it’s something I didn’t prepare for.

[Jason]
Okay, so I don’t mind biomimetics as a term, actually. I think it’s kind of okay. But really, all we’re doing with biomimetic dentistry is really using operative dentistry techniques, preparation techniques really, and the materials we have at our disposal currently.

Glass ionomer, composite resin, ceramic, pretty much. Silver amalgams dying out. To the best of our abilities, to restore teeth so that they A. Look good. B. Function well. And, really importantly, last for a decent amount of time. And keep the patient’s tooth in their head which is really what our job is. And if you want to call that biomimetic, then-

[Jaz]
Jason, how does one make the distinction between Adhesive Dentistry and Biomimetic? For me, when I interpret it, I think when I read everything about biomimetic dentistry, it is pretty much adhesive dentistry.

[Jason]
It’s a buzzword, really. It’s a kind of cool and trendy thing to call it, but really it’s just good quality operative dentistry. The original term was coined in so much as there was a kind of a move towards trying to replicate enamel with ceramic and composite resin with dentine because the properties of ceramic are perhaps a little bit more like enamel and the properties of composite are perhaps a little bit more like dentine, but I don’t really buy into that.

That’s just BS really, because if you think about composite resin, it isn’t remotely like dentine, firstly, it’s not vital and it doesn’t have collagen fibrils, et cetera, et cetera. And then we’ve had the whole. And please don’t take this as I’m anti fibers in dentistry, because I’m really not. But then we’ve had the whole thing about, oh, we can use fibers and make it more like collagen.

I’m like, really? I think it’s okay as a general term, because if you talk about biomimetic dentistry, I think most dentists know what you’re talking about. So it’s a descriptive word. So as a descriptive word, it works very well. Because it communicates. But from a scientific point of view, I think it’s a little bit invalid.

I also think that some of the things we do in biomimetic dentistry actually, actually overcomplicate the procedures. And as a result of overcomplicating the procedures, make it more likely that you’ll make an error in one of the steps, and therefore make it more likely that the restoration will fail earlier, which is not our primary function.

A good example of that, for example, would be using fiber technology in a smaller class 1 lesion, smaller class 1 cavity. So there’s a big move now toward placing fibers in the base of a smaller class 1 cavity, and the reasoning for that is it reduces, well, oftentimes you see it, promoted as reduces C factor, that’s not the case at all.

It reduces the impact of C factor, which is quite different. Reduces the impact of C factor in laboratory studies. And is that clinically relevant? I don’t know. Nobody’s really done the studies. And yet it’s really, really heavily promoted. Now I’m not saying it’s a bad thing to do if you do all the steps really well.

But what I am saying is for the average dentist, and we have to accept that in terms of ability, there’s a bell curve. The vast majority of us are average. I’m certainly average when it comes to endo and things like that. Making it more complicated is actually a bad idea because you make more mistakes, it’s going to take you longer for starters, so it’s going to be more expensive for the patient, so it delivers less care to fewer patients, which is no good.

And also, you’re more likely to get a poorer longterm outcome. So actually I don’t see that as a strong move forward. You might consider using fibers in larger cavities and there might be valid reasons for that. But I think some aspects of it are really over act. So there we go. I mean, the other one, which drives me, here we go.

There’s a rant, the other one that drives me a little bit. Nuts is when a patient comes with a, well it’s kind of relevant to the discolored central, a discolored central, maybe endo treated and maybe it’s got a class 5 and maybe it’s got a class 3 and maybe it’s got an endo access and we get bits of composite added and then a ceramic veneer.

Why don’t you just do a crown? And then there’s the whole, and in that same scenario, it’s like, oh, you mustn’t, you would be arrested. Call the police if you put a post in the tooth. Because that will cause the tooth to fail. Well, really? I have objections to cutting a prep to put post in. When I first qualified in the early nineties, we used to stick and this is no disrespect to the brand because I still use the brand nowadays, but you stick a parapost bur down an upper central incisor and cut a nice parallel siding prep and then cut, you probably don’t remember this, but then we also used to cut a lock into the coronal aspect.

I wouldn’t do that anymore. But to use your existing endo access and to put a post in there, what’s the downside of that? You haven’t done any more prep and you’ve got something that is pre polymerized, if you’re using fiber post, or doesn’t need polymerizing if you’re using a metal post, and you’ve bonded it, or there’s a modified glassonomer in situ, it’s taken up the space and obviously it’s got a mechanical advantage to the tooth.

And nowadays you see people putting lots of fibers down and I’m like, why would you do that? That looks really difficult. And from an engineering point of view, just doesn’t work. And like, I’m being told that post fracture teeth. Well, I’ve been in the same practice with the same patients in the same small town since 1997.

And yeah, I get teeth fractured with posts in situ, but not very commonly. If you’ve got adequate ferrule. So, getting right back to the original question, I think biomimetics is a good term in summary. Because it helps people understand what we’re talking about. But I think we’re using it to do quite weird non evidence based things.

Which have now really, really scarily become mainstream. And the reason why they’ve become mainstream is really social media, because this is another one of my bug bears. If something gets a lot of likes on, for example, Instagram, and again, I’m not picking on Instagram. Could be TikTok, could be Facebook.

If something gets a lot of likes on Instagram, it’s instantly accepted as being a valid approach. Well, that’s not how science works. If something is valid, then really it should be evidence based and have proper prospective trial. Well, it should have lab trials first and then proper prospective trials on patients.

And we’ve moved away from that. Indeed, an example of that would be I gave a presentation, I won’t say where it was, but in Europe three months ago. And I presented something and somebody put their hand up in the audience and said that’s not true. And I said, okay, fine. This is cool. This is really good.

We can have a discussion about why this ever so slightly contentious issue may or may not be valid. And I said, so here’s my evidence. I’ve already presented it in the slides. These are the lab studies. These are the clinical studies. This is my experience, which I’ve been doing this technique for 12 years.

And these are my failures. And I admit my failures. What is your counter argument? And it was like, well, this guy on Instagram, who’s got 200, 000 followers says to do it this way. And I’m like, yeah, that’s okay. He might understand the science. Probably does. And he probably understands it better than I do.

And he’s probably got follow ups, but that’s just not science. And that’s the way we’re going. And not to pick on biomimetic dentistry, but it does seem to be seriously biased towards biomimetic dentistry. So there we are.

[Jaz]
I guess if you only listen this far, then you can call this episode Jason Smith’s bug bears and so far I’ve enjoyed every one of them because I think you speak the truth and you’re very much direct. And I think that’s good. I think it’s a nice reminder. That there’s a lot out there, and to be critical of everything you see and you read, and always rely back on, okay, where is the science behind this.

[Jason]
Yeah, I think, I think on the flip, we can be over reliant on science. Like, I’ve also been in fairly academic meetings where I can remember one on perio, a while back I was in, and a guy presented his 40 year retrospective.

In other words, what happened to his case is using this technique over 40 years and somebody counter argued it with a scientific approach, a prospective trial, but the prospective trial is only of 12 patients. So, like, there’s this double blind prospective trial which is actually the pinnacle of scientific evidence.

But with only 12 subjects. Versus this guy’s really anecdotal opinion. He hadn’t done very much other than audit it. But it was literally thousands, if not tens of thousands of patients. Which is actually, anecdote is the bottom end of scientific evidence. Which one is the most valid there? Now, I’d upend it and think, well okay.

I’m more inclined to believe this guy. Although it’s skewed a little bit, again, because he’s got really good hands and people who have really good hands can do things that are often not quite correct and get away with it, so, there’s a lot to think about in science. Really, if you think really critically.

[Jaz]
And then let’s apply this to the theme that I want to cover today, which is the discolored central incisor and I’ve specifically given you this scenario in this task because I have covered before on the podcast about non vital bleaching and particularly I want to just get like a couple of minutes on your take on non vital bleaching because there are some clinicians that I know who are not big fans of it because they’ve done it and then they’ve seen the recourse come back and they’ve been disappointed with relapse.

So, do you think there’s still a place for non vital bleaching or have you found that to mitigate the risk of relapse if you skip the non vital bleaching and just mask the discoloration with a restorative material, therefore negating the risk of relapse? What are the circumstances which you may or may not consider that kind of an approach?

[Jason]
Yeah, so it really depends on the literature you look at, but when you look at the literature, the relapse rate is probably hovering around 50 percent. But which is for a medical procedure not that great. But if you actually read the papers and I actually have because I’m a bit nerdy like that. You will see that the patients were just selected on the basis of having a discoloured tooth and there are lots of diagnoses of discoloured teeth, if the patient’s had an amalgam in the palatal surface to fill, the access cavity is discoloured.

Sometimes it discolours as a result of blood in the dentinal tubules at the time of trauma, et cetera, et cetera. One of the causes of discoloration is something called CM or calcific metamorphosis. And what that means is when the tooth is traumatized. The pulp reacts by laying down dentine, it’s a healing response.

And what you see on that patient is typically either a yellow or sometimes a brown discoloration. And that’s as a result of having less pulp and more dentine. So that’s one part of the diagnosis. The other aspect of the diagnosis is when you take a radiograph, particularly for like an upper central or upper laterals, you will see the pulp chamber of the affected tooth is significantly smaller, or nonexistent in comparison to the pulp chamber of the non affected tooth.

And sometimes these teeth are vital. So let’s pretend it’s got calcific metamorphosis and is non vital. I’ve heard people say other things, but anecdotally, going back to my own anecdotal evidence, and my data is off the top of my head the last time I checked, which was Christmas time ish.

I’ve done something like about 800 cases over the last 15 years. My outcomes for calcific metamorphosis were quite poor. And got relapsed fairly rapidly, usually in the first one to three months. So going back to the original papers, they didn’t take the calcific metamorphosis cases out.

Because it’s not written up in the methodology of the papers. So what they were doing, what most papers do, is look at discoloration, internal widening of discoloration, including calcific metamorphosis cases. So quite clearly their outcomes, based on my own anecdotal experience, will be poorer. So, I realized this when I was looking at this, gosh, seven years ago or so, six or seven years ago, and what I started to do was to not treat the calcific metamorphosis cases with internal whitening using the diagnosis of orange yellow discoloration or diagnostic features of orange yellow discoloration and smaller pulp chamber on radiograph.

And what I found was my success rates went up, and my success rates are low 90 percent now. So, and that is a long winded answer, but in answer to your original question, I would probably not go for internal widening on an adult, on an older adult patient with calcific metamorphosis, I would probably go straight for the veneer or the crown or the composite resin bonding.

The time I might have a pulp even though in my hands the success rates are 50 percent or perhaps even less, or maybe a child or maybe a younger adult, or maybe you put this to the patient and say, look, you’ve got a 50/50 chance of it working, but the trade off is if it does work, we don’t have to drill your tooth and you’ve got a fairly intact tooth. In that case, I might have a go at it as well, with the understanding of the patient that it might fail. So it’s nuanced, basically.

[Jaz]
I feel like I read this in a Facebook comment that you might have wrote years ago because there are a lot of dentists like me who like to, read what you write. The cases that you post are brilliant. Once, remember, you wrote, and it all makes sense now based on what you’re saying here, but you once wrote that, the black discoloured teeth respond better to internal bleaching than the orange yellow hue teeth.

[Jason]
Exactly. So, that’s where you can be the hero or not. Somebody comes along with a black tooth and because we’re a referral practice, oftentimes they’re referred for a crown or a veneer. And I say to them, well, okay, we can do some internal whitening and actually it will, there’s less drilling. It’s quicker, actually, because you can get it done in three days, two to three days and you’ve got more tooth left.

And you look great when somebody comes with a black tooth and suddenly it’s give or take the correct shade with an orange tooth where somebody come often quite a picky patient. They’ve got a very mild orange discoloration of a tooth which to the average person is barely perceptible. But for them is an issue. Not to say they’re a bad person, they’re just more perceptive.

They’re the ones that are actually more tricky, which is not ideal for us. But they’re the ones you could really be careful with. Because again, also matching the shade with resin or ceramic is also tricky as well. So yeah.

[Jaz]
So is it fair to say that the patients that come in with a necrotic tooth, so the diagnosis is not calcific metamorphosis, it’s a necrotic tooth. And we have a black tooth on our hands due to the discoloration from the bleeding of the pulpal bleeding products, basically, the iron, I believe, in the blood may be responsible for this. Is that the kind of case where you’re going to be bleaching every time? Or do you think there’s a merit in sometimes restoratively masking in such, such a scenario?

[Jason]
So, if the tooth was relatively intact and it might have, for example, a small class four. Which they do, because obviously they’ve been traumatized. Or maybe just an endo access. Then 100 percent I’m going to bleach that without question. If the patient comes with endo access and the tooth has, for example, a class 5 and a mesial and distal class 3, I’m probably just going to put a crown on that tooth. Alright? Because it’s already pretty compromised.

[Jaz]
And skip the whitening, right?

[Jason]
Skip the whitening. Yeah, I’m going to do a crown with a probably a post but no prep of the post space and they’re the two extremes. So you’ve got the really minimally damaged tooth and you’ve got the maximally damaged tooth.

The nuance comes when it’s somewhere in between and then you have to take on board factors such as the age of the patient. You have to have a conversation with the patient and look at their attitude to risk. And maybe look at the other teeth around it. How strategic is that tooth, et cetera, et cetera, et cetera.

Because the patient’s also going to understand if we just stick a crown on the tooth. They’ve got a fairly guaranteed outcome with a good ceramist and with a good dentist. But, we’ve pushed them down that restorative cascade so they’re pushing closer to implant and they’re pushing closer to tooth loss.

And they need to understand that. Now that may not be an issue for them if it’s a 70 year old patient and you’re saying to them, well, you’ll probably get 15 years out of this is quite a different scenario from a 22 year old patient. So a lot of little subtleties to think about.

I think as dentists, we often want this kind of recipe, do this, do this and do this, nuance is it’s human nature, but we as dentists, because we’re kind of technically orientated because of that’s the way we work. We want to kind of do this, then do this and do this, but it isn’t that it’s kind of think of multiple factors and then nuance it with a patient.

[Jaz]
This is what makes our profession an art. I used to really get frustrated by this aspect of dentistry, the fact that if I ask you, you’re giving this great advice, which I really resonate with, but then there are a hundred other different opinions and protocols out there and therefore, for the young dentist who’s learning, trying to find their feet, trying to make their own philosophies and way of practicing, it can become a very confusing field.

So once you start to appreciate that actually this is the beautiful side dentistry, that you can do it so many ways and you start to just flip the way that you see this area. I think a lot of young dentists can get more fulfillment from their profession from being actually there are other ways to it. This one resonates with me.

Listen to everyone and do what feels right to you, but also to do your due diligence and actually look at the studies and look at the method, materials and methods to come up with what’s best for your patient at that particular time of your career.

[Jason]
Yeah, I think I’m certainly not sitting here and saying that. The way I do it is the only way to do it and it’s the right way. It’s just one way that’s worked for me. And as a result of that, it’s made me, in my practice, attract a certain type of patient. Now that type of patient may not be for everybody. So, I mean, there are huge outliers, like some people would just say, oh, take it out and put Implant in now.

That’s quite clearly wrong. But most of the balanced views that differ have validity. And what happens is the dentist kind of plays to their strengths and they attract a certain type of patient, and that’s where we’re at. For the good, actually. Well, I would say if we had a scenario where, everything was like stepwise you do this do this do this it would kind of be like in a factory and then it would be less fun, I think-

[Jaz]
A hundred percent. Yeah. I like that. And so I’m glad we mentioned that I think a lot of dentists, I do repeat this theme a lot about seeing the beauty of it and the artistic side of it. And I think it’s, people message me saying that, you know what we need, we constantly need to hear it to remind us. ’cause it’s a tricky, being a general dentist is no easy business.

So it’s nice to be reminded of that. Let’s talk about this particular type of patient, Jason. You mentioned, you beautifully described this patient with a yellow tooth calcific metamorphosis. You take a PA and there’s pretty much no pulp. I see this now and again as well, and I’ve treated a few of these.

And I really want to know about how you approach the case because there are so many difficulties in this scenario, A the fact that this patient is bothered by a slightly off yellow tooth. So we already have because I know some people who have a black tooth. And they don’t want to do anything about it.

You’ve got a black central incisor. And so that’s the opposite end of they don’t give a damn. And then you’ve got someone with like a slightly off yellow tooth. And so they’re now presenting to you. So you know the expectations exactly. And so this patient now, high expectations. And what we’re trying to do is try to match a central incisor with now restorative materials.

So my one school of thought that I’ve been exposed to through social media, and I’m just being honest here, I saw this on social media from a very, very respectful dentist, and what they did is that they prepped this tooth, this calcific metamorphosis, and one of the points they made is like, we want to get into the dentine.

Because it’s the dentine that’s discolored. Now, by getting in there, you give your restorative material more space. And I think this was composite that was used at that time, basically. You give direct composite. So you give your composite more space and you get to the source of the discoloration.

Because it’s not the enamel that this discoloration is coming from. So, your views on generally the different ways that you might approach such a case to get the restorative success. And B, what do you think about this approach of this particular dentist?

[Jason]
Well, I can kind of see his argument, but I don’t, I see the argument, but I don’t see the logic in so much as yes, the discolouration is localized to the dentine, but by cutting more tooth away. What you’re going to do is make the tooth more flexible, more bendy in function, because if you take the enamel off, the enamel’s a stiff bit of the tooth that makes it more rigid. If you make it more bendy, it’s going to do one of two things. Either it’s going to fracture, or as it bends, the tooth bends in one way, and the restorative material, be it ceramic or composite resin, bends in another way.

And the failure will be at the bond between the two, and it will usually delaminate. So, my thoughts are to restore that tooth as conservatively as possible. In other words, don’t drill the hell out of it. On the flip, you have got room to drill the hell out of it if you wanted to do a crown, because the pulp’s quite small.

So there’s that. My approach would be to restore that tooth in as conservative manner as possible. Now, if a veneer is indicated, You’ve got the option of composite resin or ceramic. And if a crown is indicated, you’ve obviously got the option of ceramic. Let’s put the crown to one side for now because that’s less debatable. The only thing I would say-

[Jaz]
I think let’s focus on veneer. You’ve already said that whitening in your hands in this day and age is not what you’d go for. So we’re going for the restorative option. And so really it’s a toss up. And one of the side questions is, when do you go ceramic?

When do you compsite? And then I also want to know about prepping and also about the different opaquing techniques, because I’ve seen some of your cases have been amazed in the use of different opaquers. And so try and find out your experiences and different recipes that you might tried.

[Jason]
So if you’re going down, we’re going to come into tons of nuance here, and is based on skillset of both yourself and your technician, give or take, and your access to certain composite resin materials. So the bottom line is, if you’ve got a superb technician, and if you have really good hands, probably the most conservative approach will be ceramic.

Why? Because ceramic has better masking abilities than composite resin irrespective of what anybody tells you. I’m a composite resin guy. I teach composite resin. It’s really in my favour to tell people composite resin is the panacea for everything. But actually, in this case, if you’ve got a very, very good technician, ceramic is going to be your best option.

Now, the only problem with the ceramic is you’ve got a prep appointment and you’ve got a fit appointment. Now, if it’s a single central, even my ceramist Paul Luke, who’s based in Cornwall, is a superb ceramist. But, single central with Paul, and even with the patient seeing Paul for the shade, and oftentimes the veneer or crown being customized by Paul, chair side, might take us two or three goes to get it dot on.

Particularly for a very fussy patient. So what we’re talking about is three or four visits probably for a patient and you’ve got an A, bill for that which means the cost rise a lot in comparison to a regular single crown or single veneer. B, the patient’s got to have the time to do that. So all things being equal and if the patient’s got the financing, you’ve got the hands and the technician’s got the hands.

And the patient’s got the time, then probably I’m going to go down the ceramic route. Now, most normal dentists who work a normal practice, who do ortho, endo, composite resin, exams, blah, blah, blah. They, they’re not using that level of lab. So probably their outcome with the lab is not going to be as good. So that may skew them down the composite resin route, maybe. So there we are. It’s really related to timeframe, budget and skill of lab technician.

[Jaz]
So I like that approach in terms of assessing one’s ability and which environment you’re working in to decide between composite and ceramic. And more dentists than not who are listening to this, general dentists around the world will be at a position more than likely that they’re going to say, okay, I want to tackle this with composite, right?

So before we now go down the composite pathway, the geeky questions I have about the ceramic is, how thin or how thick is this? Obviously, we’re talking about an aligned teeth. So we’re not dealing with a retrocline incisor that we can bring out. We’re talking about an aligned tooth.

How much prep are we doing, i. e. how thick will the veneer be? And, in your experience, is it a particular ingot of lithium disilicate or is it feldspathic? What do you found as the restoration ceramic of choice in such nuanced cases?

[Jason]
Yeah, so it very much depends on how discoloured the tooth is, nuance again. But you’re probably realistically looking at somewhere between 0. 7 of a millimetre reduction, which is quite chunky, particularly at the cervical. Particularly if it’s endodontically treated.

[Jaz]
So we’re going to be into dentine in the cervical, but the enamel is more in the coronal.

[Jason]
If you look at Shillingburg and Grace, that’s the research on the thickness of enamel at the cervical, it’s 0. 3. There’s just no way you’re going to mask in 0. 3, even with a world class technician is just not going to happen, which again might be another reason why I might go down the crown route rather than a veneer route because I’m prepping quite a chunk off the facial and the ingot. I would probably be using something like for most of the cases, and again, because I’ve got a talented ceramist.

We use the MO ingot, the medium opacity ingot, and that’s something you need to specify because most labs will use the LT ingot, low translucency, and the reason why they use that is it’s easier to handle for the lab in terms of layering and stain and glazing, but we occasionally will use the HO ingot, which is high opacity, but to be on it for veneer, but to be honest, if we’re doing that much prep and the tooth is that dark, oftentimes we’ll be doing a crown anyway, So then we can go back up back one and we may even go down the zirconia route if we’re doing a crown. That’s probably a lecture in itself.

[Jaz]
Okay, brilliant. So that really helps with the ceramic nuances. Now let’s go down the final segment of the podcast then. For a composite then, how much prep are you doing and how does that differ? How does the prep of the composite, direct composite veneer, differ from the prep that you’re sending to your technician for a ceramic veneer?

[Jason]
It’s broadly the same. So you need to prep subgingival. You need to prep somewhere between 0. 3 and sometimes even 0. 5 if you’ve got the room, into the sulcus, otherwise you’ll get grey. You’ve got to prep into the contact points, otherwise when a patient turns to the side you can see a line. And you’ve got to prep some off the facial, perhaps again 0. 7 to 1mm. Now you can get away with it a little bit more with composite resin at the cervical.

By using a lot of flowable opaquer, the only downside with it, so you could do less prep and use more flowable opaquer. The only downside, and if you look at mine, I’m guilty of this myself, they look a bit dead in the gingival third.

Because there’s not so much regular composite resin and there’s a lot of flowable opaquer. And the reason why I’ve done that is to mask it and to get value or brightness and to lose chroma, lose color. But the trade off is it looks a bit dead. And if a patient has a low lip line, you can kind of get away with that.

[Jaz]
And so, you say that it looks dead, but yeah, just to emphasize to everyone, the reason you’ve done that and it’s an informed decision from you is because you want to prep less. You want to be conservative as possible in that area, which makes total sense. And so there’s a trade off that you make.

So I’ve seen Pink Opaque by Cosmodent and there are, I’ve used Ivoclar’s White Opaque in the past as well. Do you have a preference in terms of which flowable opaquer that works well in certain scenarios?

[Jason]
Yeah, I mean, a lot of companies make good ones. Tokuyama make good one. Kulzer make a good one. I kind of like the Cosmedent ones. And the reason why I like the Cosmodent ones is because it’s one of the few companies that actually make the opaquer in a vita shade. Most companies have the opaquer, which is usually kind of white. And if you’re not careful, what you can do is you can end up losing chroma, losing color, and increasing value, increasing brightness on a discolored tooth.

And starting off with a tooth that’s dark and low value but ending up with a restoration that’s too high value so the restoration will really stand out be too bright if you’re not careful whereas with the Cosmodent ones they have the A, B, C shades so if you have for example the surrounding teeth of for example A2 you would use Cosmedent’s A2, A2. 5 opaquer.

And then the base shade, once you’d have picked out the discoloration, would be A2, which makes it a lot more simple, rather than it being a bright white. The pink, which you alluded to, is actually to get rid of grey. So that’s quite useful over the top of, for example, posts. Or, if you’ve got, less common now, but a fractured PFM bridge, where you’re trying to restore the composite, and get away, and hide away the metal.

It works very well, but again, pink on its own, is often too bright. So if I’ve got a grey discoloured tooth and I’m going down the direct resin route what I might do is use a small amount of pink opaquer but maybe add in some of the what we call chromatic opaquer so say the teeth were A2 and the tooth was grey, I’d use maybe one part of pink to maybe three or four parts of A2, A2. 5, mix them together and then I get the brightness of the pink to get rid of the grey you see?

But I also get the chroma, the color of the A2 to match the surrounding teeth. So that’s a lot of people just pile the pink on in one hit and that’s a bit of a mistake. Another option to make it a little easier is to put the pink opaque on in a couple of layers and then put the A2, A2. 5 over the top of that. That works as well.

[Jaz]
It’s a good little tip to think about this different stages of doing it and mixing two different types of products where they’re different qualities. And even just to mix them together. That’s pretty cool. I like that. And recently what I did, and I don’t know if you approve of this, Jason, but bringing back in the series, am I naughty if?

So, here’s something I did recently on my principal. He had a discoloured central incisor and I got a good result. Actually. I’ll put the photos up now in the podcast. So we’ve got a good result in the end. But what I did is I got some composite. This was like Estelite Asteria. I think this was like NA1B, but his adjacent teeth he’d been whitening were just a higher value.

So what I did is I got my composite and then I got some white tint liquid and I rubbed my composite into the white tint. So I let the composite absorb. The white tint, if you like, it wasn’t like pools of it, just like a few drops. And that worked well to lift up the value. And then I used it and then I covered it with some enamel.

It worked out well, but I don’t know. I feel a little bit uneasy about doing this because I don’t know how much it will affect the physical properties. Is this something that is known or is this something that’s a bit frowned upon?

[Jason]
I’ve heard it before, but you’ve got basically two dissimilar materials mixed up and they won’t really mix, what you’ll get is pools of the tint within the resin. One of the things, and again this, I have the luxury of working with a lot of companies and they send me free stuff, so I’ve got tons of composite to play with. I appreciate most people don’t have that option. The Tokuyama product you were talking about is a great product. It handles really well, it polishes superbly, and I love it as a product.

The only downside with the Tokiyama product is it’s designed in Japan, and it tends and I think I’ve been, I think I was the first person to notice this, and I think I’ve been saying it for quite a while, but it tends toward the low value. It tends toward the grayer. And the reason for that is the demographic they’ve tested that resin on people from the far East tend to have lower value teeth.

People from the Far East tend to have more triangular teeth, slightly lower value, and something I really like, which is really cool, is a really strong blue gray opalescence and sometimes even orange effects in the incisal edge. And if you look at a lot of really good, a good example would be a guy called John Chu, who’s a really talented guy from Taiwan.

He does composite resins and they have like really cool blue effects on the incisal edge. And I love that and I wish I could do that on my patients because I just love the artistry of that. But I don’t have the demographic in my slightly boring northern European patient base, and he does in his Taiwanese patient base.

But the flip of that is that Southeast Asian patient base also have low value teeth, and the Tokiyama has been designed for that. So if you take a northern European guy, I’m presuming of principle, who has bleached, Tokuyama wouldn’t be your first choice. You would be wanting to use a composite resin that’s perhaps been developed, perhaps in Germany, because that might be more relevant for that case.

And then you wouldn’t have had to mix the white in. So you probably would have been better off with a bleed shade from, let’s say, Kulzer or Ivoclar or something like that, rather than the Tokuyama. It’s just a thought.

[Jaz]
Very good. I mean, I’ve never heard that before. And so that’s amazing insight in terms of your vast, competent knowledge in different products. So that’s amazing. Well, John already knows this. John, my principal already knows this, but that tint may or may not have been a little bit expired, but anyway, we’ll skip over that. We managed to get a good result on the end. So, but it’s good to know that it’s good to know that there are other ways to it using if you’re not getting enough value, perhaps don’t mix it with tint, perhaps use a different brand.

And so that’s a takeaway there. I know we’ve got a time limit. We’ve got two minutes left. So can you spend a minute, Jason, just telling us about because you talked about the level of prep needed, how there’s a different flowable opaquers, then really the result that dentists get. I mean, aside from the polishing and making sure you get the anatomy right, and I highly recommend they go on some of your courses for that kind of hands on training.

But where the dentist could go wrong now is exactly where I’ve just described that scenario that using the wrong type of composite for the case, they’re not using the right shade for that case. So can you spend just a minute talking about top tips for for dentists starting out and maybe they’re doing this kind of work in terms of how to utilize the concept that they have in terms of shade testing or trying to get as close shade as possible to the case they’re working on.

[Jason]
Yeah, so the main factor is the value of the brightness, and the way to assess that is in black and white, ideally by a photograph. So, once you’ve put your opaquer on the tooth, You need to work out whether you’ve put enough opaquer on, because if you haven’t put enough on, it’s going to end up still being grey.

So what you need to do is to take a photograph of that, import that into your computer, convert that to black and white, and then look at it and compare it with the adjacent teeth, and they should be the same brightness or value. Now obviously in a busy practice, including mine, that’s a huge faff. So what we do is, and most of us have nursing staff who are a bit younger and probably a bit better with IT than we are, I get my nurse just to take an iPhone photo.

So I’ll put a couple of three layers of opaquer on, and then she’ll take an iPhone photo, instantly convert that into black and white, which takes literally seconds, and she’ll say to me, she’ll look at it and go yes or no. And if it’s a no, I put another layer on. Bang. No. Another layer. Bang. Yes. That’s about right.

When she says yes, I’ll have a look at it and just check it. So this is a level of trust and then we move on to layering the chromatic enamel and the effect shade and it’s a much, I mean, I think let’s be clear here from a GDPR point of view, obviously we use a separate iPhone that’s dedicated to this. But yeah, that’s a really good efficient way of doing it.

[Jaz]
Brilliant. So there we have it guys. Next time you’re thinking, hmm, have you got enough a flowable opaquer on or doing the composite button test at the beginning to use a black and white photo, just check out the value there or thereabouts, a good kit. Yeah.

[Jason]
Before we leave, a little take home about the composite buttons. The vast majority I see on Instagram and Facebook are way too thick. They’re composite balls, right? Well, if you think about it, the resin you’re layering is going to be in quarter millimeter layers or less. Right, so if you put a ball of a millimetre or two millimetres of composite resin on the facial of the tooth, that will give you no idea of what’s going on. You need to put a very thin splodge of composite resin, not a big ball, because otherwise it increases, if you put it really thick, it increases the volume of the writer.

[Jaz]Yeah, and I see this a lot as I’ve done it in the past, but I realised, yeah, very on, I tried to more of a smear now. Rather than a ball or a button. That’s a great tip there. Jason, just so you end the recording. I just love to, I mean, I always put your links and everything, your courses, and they do a bit in Glasgow and around the world and all over UK. Tell us about some up and coming course that you’re getting, that you have the moment, perhaps plan this summer or beyond that, what I think you’re doing, is he doing a diploma, restorative diploma?

[Jason]
Nope, but I have got a course with Kuraray. Which is the first one I’ve done in London for quite some time since pre Covid. And that’s actually at Heathrow Airport, the Radisson at Heathrow Airport. It’s the first weekend in July. And that’s a composite resin course with Kuraray. And then I’ve got some courses.

It’s sold out now, but I’ve got a course next week in Derry with Corsa. And then in Glasgow, we’ve got two courses coming up. One in September. I forget the dates. I should have looked at this in September, which is a-

[Jaz]
I’ll put the links on. Don’t worry. I’ll be sure to put the links in-

[Jason]
September and one in November one’s an advanced composite course and one’s an advanced ceramic course. The cool thing about those courses is they’re three days. And they’re entirely HandsOn because all of the lectures are given to you via a webinar.

So you hit the ground running and you start at nine o’clock on the first day with hands-on, and we finish at five o’clock the last day with hands-on, and there’s no lecture at all. And you can watch the, you can watch the lectures as many times as you like. So that’s where we are on that.

[Jaz]
That’s been a big hit with the community. So, the Protrusive Community, on the app, when we’re chatting and stuff, we often mention you and your courses and that’s been a big hit with those of my cohort, my colleagues who’ve been on your course, and they love the fact that they do the theory webinar wise, and you’re there to help them.

They watch it again and then do the hands on. That’s been a big hit. So guys do check that out. I will put the links there. Jason, thanks so much for covering even right to the end, pointing out little things that we can do to improve the way that we practice our composites and our ceramic work. You’re always a welcome guest on Protrusive, and I just want to say thank you so much for giving your time.

[Jason]
Thanks for the opportunity. Have a really good weekend.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. This episode is eligible for CPD. For example, one of the questions in our CE quiz is, what is one of the main diagnoses that we discussed in this episode that causes a yellow tooth?

Is it A, a necrotic tooth? Is it B, aging? Is it C, calcific metamorphosis, or is it D, molar incisor hypomineralization? I actually had so many more questions for Jason, like there’s so many from the community in Protrusive Guidance, but unfortunately we had a bit of a time limit. But even this topic of discolored central incisors could be a whole day, because It’s a big enough problem.

It’s a real world problem, but I’m hoping what Jason presented to us today, the gems that he gave away, will allow you to be one percent better. Maybe you’re going to start taking more black and white photos, even perioperatively. Maybe you’re going to think about the brand of composite that you’re using and whether it has naturally higher value, because a B1 from a European brand may be different to a B1 from an Asian brand.

Or maybe you’re going to start looking at these flowable opaque composites and have a better understanding of when to use something like a pink opaque, which is better suited to those grayer teeth or masking metal. I would actually love to know what you took away from this episode and any other questions you have, because I know Jason will come back on Protrusive again, he’s always a very welcome guest.

So if you have any questions or themes that you want Jason to cover next time, please do comment below if you’re on YouTube, or in Protrusive Guidance, then please add to the already number of questions that you’ve provided already that we didn’t get to cover today, but we want a bank of questions.

We’re just like a ask Jason series. So we’d love for you to partake in that if you’re on Protrusive Guidance If you don’t know what Protrusive Guidance is, this is our network This is our own social network of the nicest and geekiest dentists in the world. It’s got all of the good stuff of Protrusive on there including our infographics. But more importantly, it’s got you guys, it’s got the Protruserati on there, and it’s just been amazing being part of this community for four months now, before we were on the Protrusive app, which we massively upgraded to Protrusive Guidance, and I’m absolutely loving the search function, the chat function, and engaging with you all, discussing cases with you all, without annoying Facebook ads and that kind of stuff.

So head over to www. protrusive. app if you’re not already on Protrusive Guidance, and I look forward to having a DM from you on there to say hello. Thanks for listening once again, I’ll catch you same time, same place next week. Bye for now.

View Details

When restoring molars, should we ALWAYS try to recreate textbook anatomy? (spoiler: NO WAY!)

What preventive measures can we use for toothwear?

Tooth Morphology in the Real world!

In this episode, Emma Hutchison and I explored the nuances of practical tooth morphology. Textbooks provide us with idealized versions of dental structures, but how do these perfect images translate into real-life practice? Can and should we aim to replicate these diagrams exactly in our dental work?

https://youtu.be/OcdQRTV7jpYWatch PS005 on YoutubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

1:38 Introducing Emma Hutchison
01:53 First Denture Experience – What is an Overdenture?
03:13 The Importance of Complete Dentures in Aesthetic Dentistry
8:26 Understanding Tooth Morphology in Practice
11:25 Changing the Morphology of the Tooth
15:56 Difference Between Morphology of Premolars
20:31 Preserving Natural Tooth Morphology
27:26 Real-World Application of Tooth Anatomy

Don’t miss the special notes on tooth morphology available exclusively in the Protrusive Guidance app!

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App!

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, be sure to recap PS004 – Learning Can Be Stressful!

Click below for full episode transcript:Jaz's Introduction: One of the most common questions I get, and also I used to think of, is when we're doing a composite, let's say you're doing it under rubber dam, posterior composite, are you supposed to make the anatomy look like what that tooth is supposed to look like in a textbook? I. e. are you supposed to basically recreate the textbook in the patient's mouth?*Jaz’s Introduction:*
Well, do you know what happens when you do that? Well, this is what happens. The patient bites together and you have to rub it all away. You have to adjust all that hard work away and now it looks like a flat white version of amalgam. So what’s happening there? How can we be smarter? How can we use the textbook as inspiration but also just not end up making all our restorations flat?

It’s a real fundamental and basic question in a way but I think it is so real world. So we are covering today tooth morphology with our protrusive student Emma Hutchison. This is PS005. Remember there’s a series we’re making with Emma throughout the year to cover themes which are relevant to young dentist students and those who are perhaps re engaging back into dentistry.

And also for all dentists who just want to dip into the basics again. I think there’s a real beauty in seeing how far you’ve come and how much you’ve progressed by going through the basics one more time. We were going to talk about orthodontics and stuff but really as a student I thought I wanted to make it more applicable to the real world.

So we deviate more towards tooth morphology and I hope that you can apply some of these tips in practice. Or on the mannequins if you’re still a student. Remember, if you’re a student, you get access to a few secret areas in Protrusive Guidance. All you have to do is send your proof to student@protrusive.co.uk and of course, download Protrusive Guidance app. And then we will link you up to the right space so you get access to a few special features. Let’s catch the main episode. I’ll catch you in the outro.

Main Episode:
Welcome back everyone to May’s episode. Emma, how is it going? You told me that you just fit your first denture.

[Emma]
Yeah, so last week I had an elderly gentleman and we needed a new lower over denture. So I’ve spent the last however many appointments going through all the processes.

[Jaz]
Emma, for those students who may be a little bit more junior to you, Even though the term over denture might be like a new one and that’s strange actually how it’s your first denture because we at the dental school, it was complete dentures that we did. So tell us what is an over denture and is that standard for you guys to make an over denture as your first denture?

[Emma]
I don’t think it’s pretty standard. So basically my wee patient all of them. He’s so nice. He had incisor two on the lower, which we had I had a previous student that had decoronated and we kept the roots in there to sort of give you a bit more bone support and a bit more just support for the denture and that’s proved to be really good for him.

So you make the denture fit in over these roots and that alveolar bone that you still got a good amount of and that’s just made it so much more stable for him. So it really, really worked, worked in his favor.

[Jaz]
Good. And so this is an acrylic denture, yeah? Acrylic partial denture, and is it just replacing incisors, or are there any molars being replaced as well?

[Emma]
No, so he had no teeth on the bottom apart from those roots from 2 to 2, yeah.

[Jaz]
Oh, so it was almost a lower complete denture except just maintaining the four roots. Okay, understood. Now those roots, are they left exposed or have they got like a GIC on them or copings on them?

[Emma]
They’ve got a bit of GIC on them, yeah.

[Jaz]
Okay, fine. I remember doing this in dental school, we did like a metal coping to give the seal basically and that’s something that can be done as well. Okay, very interesting. You know with complete dentures, a message for students and for you as well, Emma, is If anyone wants to go into the smile kind of stuff, aesthetic dentistry, cosmetic dentistry, call it what you want.

The place to learn it is complete dentures. Because with the teeth and the wax, you can literally set the teeth wherever you want in time and space, right? You can make someone into Bugs Bunny. You can give them a severe overjet. You can give them a deep bite. You just design it how you want. And what you learn from experimenting, okay, what happens when I make my upper and my central sides go higher, further forward, further back? You learn so much about tooth display when they’re smiling. So, great place to start learning cosmetic dentistry is actually with complete dentures. Did you know that?

[Emma]
No, I’d never really thought about it like that, to be fair. No, I haven’t really thought about that, but it makes sense. Yeah, definitely.

[Jaz]
It’s an interesting one. I remember going to a lecture, like one or two years qualified, and someone said the percentage of the population that will be needing, like one of those health surveys, like percentage of population that will be needing complete dentures because they’ll be fully a edentulous will be something like less than 5%.

So the kind of joke he made was, I wouldn’t want to specialize in complete dentures. Yet I see like an increase, thanks to social media and people like Rupert and stuff and young dentists get a lot of satisfaction from doing dentures and complete dentures. I think if you gain those removable prosthetic skills.

Then I think it’s going to make you very employable in the future by any principal, because it’s a huge demand and something that not all dentists are keen on. So it’s great that you got that first one under your belt. What’s the top thing that you learned or a challenge or any reflection that you have in on your experience of delivering this denture?

[Emma]
In terms of going through the process as a student, I would say, you’re making your first denture, you’re not going to be able to do it all yourself. I know for the Bite Ridge, I did next to nothing, really, because the clinician had to be there, basically, walked me through it. But what I would say is, don’t be prepared to go in and do all of it yourself, because you won’t be able to.

But know the reasons behind what they’re doing, if that makes sense. So make sure you’ve watched the lectures and make sure you know what they’re doing, but you don’t necessarily know how to do it just yet, if that makes sense.

[Jaz]
That’s right. You have to observe it a lot of times first before you actually internalize it. And sometimes when you read it on a lecture in a book, when you see it in the real life, it’s a whole different type of learning. And it’s like a disconnect there. And then that part of the brain lights up where it all joins together. That’s a great tip. Don’t beat yourself up that you’ll need someone else to do it for you for the first few times.

As long as you’re making visual notes and actually thinking, okay, I’m going to do this and I’m paying attention and always keep asking why. So I love that you said that. And then something to extend to when you get qualified, and you’re not sure, hmm, what record do I need to send to my lab?

If ever you find yourself in a scenario where you’re like, hmm, what do I need to send to my lab? Always think what information, if the lab get this case, what information would they need to recreate the person, recreate the patient, basically. So, of course, the bite registration is that the lab know where to put the teeth so that when they bite together, there’s not too proud, not too shy. So in your case, what was on this gentleman’s upper teeth? Was he a natural dentition or a denture?

[Emma]
No, he had a full upper acrylic already, which was fine. So we just replaced the lure.

[Jaz]
So essentially you had the lower wax block, the wax rim, and you melted enough of it to the desired vertical dimension, how we figured out. And as long as lots of teeth were touching at once, when you bit together, basically that’s essentially what you went for, I imagine.

[Emma]
Yeah.

[Jaz]
How did you transfer the upper denture to the lab?

[Emma]
So we had taken an alginate impression of that denture. So we sent that to the lab as well. And then once we had the records block on the lower all ready to go, cut some notches in it and used some impression paste got them to fight together so that it could be fit back over to that, the cast of the upper, if that makes sense.

[Jaz]
So yeah, absolutely. So as long as the lab have the upper denture or the upper teeth, basically, and then they can work with that to create the lower teeth. But anyway, we’re digressing. We can always say that for a removable prostho talk in the future, because today’s episode and the notes that you’ll be releasing for May.

Now May for my dentist group on the actual Protrusive Guidance App is orthodontics month. It’s May the force with you. But I feel as though to make orthodontics relevant for students and connecting the real world is, was very, very tricky. And I thought since the first year of the student scholarship, something connected is tooth morphology and like when else will we cover that?

So I think tooth morphology is a great one to cover. You’ve got some great notes for it. So this month we’ll be accessing Emma’s notes on tooth morphology, and so they’ll be able to download them on the usual place on the app, Protrusive Guidance. So go ahead and check it out, and all the other notes that you’ve added, and keep adding them in every month, and you’ll have a nice little library of Emma’s notes, which are absolutely brilliant, by the way, Emma. So, what questions did you have in terms of for me and for Protruserati, in terms of connecting this theme of tooth morphology to the real world.

[Emma]
Yeah. So my first sort of question, it might be a bit vague. So it’s great knowing your tooth morphology and building up for us that are anatomically correct, left, right and center, but how does understanding tooth morphology contribute to you in practice? And diagnosing and the treatment of certain dental conditions as it was putting it all together.

[Jaz]
Do you mean like certain like rarer conditions whereby you know if there’s certain conditions where they get like tulip shaped teeth and that kind of stuff and like certain rare genetic disorders do you mean like that or do you mean like more bread and butter stuff?

[Emma]
Yeah more bread and butter really than anything yeah.

[Jaz]
The first thing that comes to my mind Emma is some people generally have got very bulbous teeth, bulbous molars. And because they have very bulbous molars, underneath those molars, there’s these huge, like, undercut spaces. Right?

[Emma]
Okay.

[Jaz]
That is a real challenge, restoratively. Because when you’re trying to, when they think it caries and you lose a marginal ridge, the matrix bands that we have to recreate that extreme curve can be quite challenging. So sometimes anticipating that, okay, this patient’s got very bulbous teeth and therefore I might need to just slow down a bit and try and recreate my contact here.

And that’s the most common one I’ve seen whereby patients, the kind of matrices that we have, we can’t accept them for what they are. We have to kind of mold them and reshape them to try and fit that exact patient. So that’s the first thing I had. The other one I can think of is a certain population, certain countries, they have anterior teeth whereby they’re really curled up.

What I mean is upper incisors, do you recall that they’ve got three planes? They’ve got that gingival plane, the middle plane, and that incisal plane. Imagine that incisal plane being not really flat but quite curled up. And you might notice this on certain teeth, they kind of curl in. And this can be an issue because If you do a class four composite, so a front to tooth filling, and you’re trying to recreate this on this patient, but then that filling keeps chipping, but actually you realize it’s because it curls in, it’s now in the chewing space.

And that lower front tooth, for example, the opposing tooth is kind of sticky outy. Then there’s a whole mismatch basically, because prostodontically driven teeth. What we’re trying to do with prostodontically driven teeth is try and reduce that failure. And so sometimes you might choose to deviate away from the patient’s more extreme anatomy to make sure that you don’t get that interference in chewing.

So if you imagine if someone’s got this sticky innie tooth and it keeps bumping in while you’re chewing, it’s not going to be ideal. Maybe that’s why some people will chip and wear their teeth away. So those are the first two things I had. I’ll ask that question again so I can think of another example. It’s an interesting one.

[Emma]
Yeah, I was also going to ask you, like, if there was any certain situations where you would change the morphology of the tooth restoratively. Again, maybe quite a vague one, but-

[Jaz]
No, no, I can think of a few scenarios here as well. Okay, so you know that upper incisors have got cingulums, right? Now, this might be a bit more complex to get your head around as a student, but sometimes you’ve got severe wear, you’ve worn a lot of tooth structure away through parafunction, through grinding, through acid erosion, and usually a mix of that, right? So now you’ve got less tooth material. Now, to restore this individual, you need space, you need space to actually put your ceramic, your composite. And so sometimes a technique that we use in restorative dentistry is opening the vertical dimension. Like, like what you do with a denture patient, you open them up, right?

[Emma]
Yeah.

[Jaz]
If you did that on a dentate patient and you open up the bite and then you’re recreating the new shape of the upper incisors for example, if you go with natural anatomy then it’s sometimes very difficult to get coupling of the anteriors.

So what I mean by coupling of the anterior is how do we ensure that lower front tooth, lower incisor, actually touches and contacts the upper tooth, so then you can do the whole anterior guidance and that kind of stuff. So prosthetically, when we’re treating tooth wear, sometimes we may choose to give the patient a bit more pronounced cingulums that are going to be a little bit flat or machined in a way to basically get that lower tooth to hit it basically. Because without this more pronounced cingulum, you’re going to struggle to get the coupling of the front teeth. Does that make sense? Right.

[Emma]
Yeah, yeah, that makes sense. So, that’s one situation where you would deviate from the norm and make that cingulum just that wee bit bigger.

[Jaz]
Absolutely. Because to keep the teeth in occlusion at the front, the downside of that is, and why tooth anatomy matters, is imagine you have a wax up and some tooth wear that you’re treating, and then you do some treatment for a patient, but then the patient comes back and their S sound, they’re struggling, they keep lisping.

For example, lisping is a sign that perhaps you’ve encroached that space because when you make the sss sound, the lower front teeth get into very, very close contact to the upper teeth. Now, some people make S sounds whereby the edges of their teeth come together, so they go edge to edge of their teeth.

Other people, it’s like lower front tooth, lower incisal edge to cingulum. And now, if you’ve done that technique I’ve described, some people will start lisping the S sounds. And so, in that patient, you put the articulating paper in, you get them to count, 60, 61, 62, 63. And you see that mark, and you kind of just adjust it away, and you give them some time to re adapt.

[Emma]
Okay.

[Jaz]
And so that’s why, one time in that, actually, the tooth morphology which you may do for a certain reason can impact speech. The other one I can think of is, have you heard of something called canine rises?

[Emma]
No.

[Jaz]
Have you heard of canine guidance?

[Emma]
Yeah.

[Jaz]
So canine guidance is, when you get the patient to grind left and right, the only teeth touching will be the lower canine and the upper canine. It’s a very convenient thing. Now, if you tell a technician, can you please design all these crowns, so that upper left canine, upper left premolar, upper left second premolar and the molar, everything is touching at once. Okay, so it’s very technically difficult for a technician to do that and for you to fit all these crowns and to be exactly like that.

It’s much more convenient to say, can you just make sure there’s one tooth touching the whole way along? Right? So we have all these things about canine guidance. I don’t want to get too much into the philosophy of occlusion stuff, but sometimes it’s very convenient to have canine guidance.

There’s lots of whole other factors as well. Now, if you lost canine guidance and when you grind to the left, right, you’re now in group function and you’ve decided that for one individual patient where you’re going to maybe increase the vertical dimension, do lots of complex sensory, that you want to give them canine guidance.

Again, if you just give them a normal shaped canine, it may not be enough. And so sometimes you need to augment that canine palatally and that’s called like a canine riser. You’ve kind of given it more material so that. It is steep enough, the angle is steep enough so that when the patient grinds, it starts hitting on the canine and that takes over the guidance. So this is when we basically design and deviate away from nature to try and give us a specific outcome that we design. In this case, an example I just gave you is a canine riser.

[Emma]
Okay. Well, so yeah, there is a few different examples there of where you would sort of deviate from the norm or what they may be with its pads when that tooth first came through. So that’s interesting, that’s interesting. My next sort of question, just more one that I’ve always thought myself, I don’t know if anyone else has, maybe my own notes from first year has helped me with this, but how do you tell the difference between a first and second premolar when someone’s had ortho, they’ve had a tooth taken out and the space is closed. I find that really difficult and I’ve had that in a patient. You just feel a wee bit silly when a clinician comes over and changes your chart and all the rest of that stuff.

[Jaz]
Okay, good question. For the lowers, by the way, it’s super easy, right? Do you know why it’s easy for the lowers?

[Emma]
No.

[Jaz]
Okay, from what I’ve seen in patients mouths over the years, tooth morphology is like a distant memory for me, like studying this. But one thing that always I remember is because when we’re crowning lower first premolars, it’s a challenge because the buccal cusp height is a normal position, but the lingual cusp of the lower first premolar is really lower down.

[Emma]
Yeah, yeah.

[Jaz]
The reason why that can be an issue is if imagine you’re going to do 1.5 millimetres occlusal clearance and then you’re removing 1.5 millimetres lingual cusp, you really have lost a lot of tooth structure in terms of percentage of height of that tooth basically. So if you’re looking at a lower premolar and thinking, hmm, is it a first premolar or a second premolar?

You just got to look at, is there a huge difference between the buccal cusp height and the lingual cusp height? If there’s a huge difference, easy, it’s a lower first premolar. If it’s less of a difference, they’re relatively even, it’s a lower second degree premolar. So that’s the one I got. Even I struggle, Emma, with upper first and second degree molars.

You know, if you look at a lot of the way the text has been written, it’s like, when you compare the two side by side, you’ll notice this. When you compare the two features, you’ll notice this, but when you just have one premolar, it can be difficult. So I would ask someone what difference will it make and why is it important that we identify this as a first or second premolar in that individual?

[Emma]
So, no. Is that a trick question? Does it matter?

[Jaz]
You hit the nail on the head, Emma. I don’t think it matters. Right? Because, you’re here now. One premolar was removed and so even I’m like first premolar or second. So, I would suggest that it’s not very clinically relevant in terms of which one’s missing.

The only time, the only one I could think of is, why it would be relevant is forensic dentistry, right? Unfortunately, someone has some sort of a funky way of leaving this earth and they need to now look at the tooth identification marks and whatnot and they’re not sure if it’s three different people and then they all had a premolar removed and then they’re saying, okay, well, this person had a first premolar it’s the only time I can think of it really.

Whereas actually in the real world, even having that knowledge of it’s a first premolar or second premolar, it’s not going to change anything that you do. But I know that the first premodels of the upper have got sharper anatomy. Like what I mean is that they’re more distinct, the difference in the buccal and the palatal once again, whereas the second premolar are a bit more similar.

But I couldn’t tell you more on that. I’d have to hit the same books that you got basically to help me identify it. So for your exams, guys, check out Emma’s notes so that you can nail it on the exam. But in the real world, trust me, you’re not going to blink an eye whether it’s an upper first premolar or a second premolar, whichever’s gone, good riddance.

[Emma]
Yeah. Yeah. And I think especially in your first year, if you have OSCEs in your first year, a lot of the time they’ll just give you a tooth that’s out of a head. I think it would be pretty cruel for them to maybe go for premolars, but you never know. You never know what they’re going to do.

[Jaz]
A common one, a common one I remember from an OSCE years ago, right, is an orthodontic OSCE is. They will tell you to chant the dentition of someone who’s like nine or ten years old or maybe someone with a retained deciduous second molar. Let me say again retained deciduous second molar because that baby second molar especially lower, it looks a lot like the first molar, and so sometimes you might confuse it as the first molar and then you might incorrectly identify the second molar in the wrong way. So that’s a common one, identifying the deciduous second molar and the first molar of adult dentition and making sure you get that right.

[Emma]
Yeah, definitely. That’s a good tip there. I think they love a good morphology in first year especially, so no, that’s a good one. I wouldn’t be surprised if I had something like that this year in third year though. Because we’ve done a lot of piece this year.

[Jaz]
That would be I think a very classic one actually. I think the top tip as soon as you know that’s a quite a common one I’ve seen in exams in general is and then that’s a skill they want to have not to confuse a baby tooth for an adult tooth and so which baby tooth looks very similar to an adult tooth is exactly that scenario.

[Emma]
Yeah or sometimes they’ll throw a hypodontia in there or something as well which is definitely a good skill that that you need to have been able to spot that. Yeah, lots of wee good tips and tricks there, but another question that I had, which the answer again might not be, oh, it’s not that important, but are there preventive measures or interventions, I suppose, that can address issues that relate to TQM and preserving natural tooth morphology? Like, is that something that’s important, I suppose?

[Jaz]
It’s a really, really interesting question, actually. So I mean, the angle that you’re coming from is how can we prevent where? Specifically, in relation to tooth morphology. So that’s interesting. So firstly, the first thing I thought of when you asked that question is generally prevention of tooth surface loss over time.

What can we do? And if you look at different materials and how they behave with each other, for example, the differential wear rates, so for example, if you take cobalt chrome and we take enamel, what if enamel is opposing cobalt chrome? How well do they interact with each other? Does the chrome absolutely destroy the enamel?

Or does the enamel destroy the chrome? Actually, polished cobalt chrome and enamel have very similar wear rates. They will really be good over time. However, if you have a chrome opposing composite, the composite will lose in a big way. So as they chew and grind and whatnot, the composite takes an absolute beating and will wear down, whereas the chrome will not.

So how is that relevant to your question? Well, enamel to enamel, it’s very similar. It’s the same material, right? So, actually, pure attrition, let’s say pure tooth grinding, clenching, tooth to tooth rubbing, if it’s pure attrition, it’s not going to be so damaging, right? Over time, yes, the teeth shape, the shapes will be very sharp and defined, and you see those wear facets, but it may not even go into dentine over someone’s lifetime if it’s just purely attrition.

The issue is we very rarely see pure attrition because of the abundance of extrinsic acid, so our diet, and intrinsic acid, so the single things like reflux and stuff. And so when you put a drop of lemon in the equation, that attrition really accelerates. Then you’re going to get into dentine and all sorts.

So the way to think about it is what’s your biggest cause of wear throughout life? It’s a combination of erosion and attrition. Of course, there’s toothbrush erosion as well, but that typically happens on the sort of gingival areas, not so much on the occlusal, right? So having said that now, what can we do to prevent it?

Diet advice. And for those, now we’re getting into some more occlusal philosophy is, if you set up someone’s bite right and in a minimally stressed dentition, when they grind left and right and stuff, everything’s in harmony, and therefore they’re not going to wear through so much. But, a simple thing is, people who wear retainers due to orthodontics, and they wear those plastic retainers, we know that their teeth will not change very much, right?

Because any grinding that’s going to happen, it’s going to be absorbed by that plastic and not by their teeth. And there’s these great dentists, like for example, a really famous dentist called Didier Dietschi, who shows 30 year follow ups of some of his composites at the front, which is crazy, right?

And then they look brilliant, but he actually says, okay, the reason why they look good, the reason they haven’t worn, It’s because my patient wore her night guard every single night for 30 years. Right? And so there’s a lot to be said about that. Finally, to answer that last point of question, which is the most important distinction, which is, okay, how does tooth morphology come into it?

If you have very delicate anatomy or very, let’s say, boisterous, voluptuous anatomy, I guess the best way to say it is Mamelons, right? If you’ve got mamelons, right, on your incisors, how often do you see people, right, beyond the age of, let’s say eight or nine with mamelons? You don’t, right?

[Emma]
No, no, not really.

[Jaz]
You don’t have mamelons, I don’t have mamelons, because it’s a very delicate, sticky, it’s a bit like, when you go to school, you get a brand new eraser, a brand new rubber, and then you start using it to rub some pencil marks away. You look at it and, oh my god, I’ve lost a huge chunk of my rubber already, right?

But then that rubber will last you until the entire primary school. You won’t get through it because the surface area of rubbing is so much now, right? So mamelons are kind of like that tip of the eraser. They’ll wear away like within a month, right? They’ll go from acid erosion, a bit of wear, basically they’ll go away.

But then the meat of the tooth will take some time. So how do we translate that into your question? Well, when we are rebuilding someone’s dentition, So you’ve got, let’s say you’ve got tooth wear. And then you’re going to open up their vertical dimension. Technically, we are now fully in control of the future anatomy.

We can wax it up any way we want. We can make the teeth look any way we want. Are we going to copy nature exactly? Probably not. Because having those delicate cuspal slopes, having those mamelons, having those very sharp canine tips, they’re just going to get worn away. So sometimes we go for like a age appropriate, right?

We get age appropriate. And we veer away from things that was going to just rub away or fracture basically. And so that’s a long way about saying is, yes, sometimes when you’re waxing cases up and it’s restorative, we’re going to not give someone a 10 year old’s incisor. We’re going to actually focus more on, okay, once that’s been worn away, what’s the main primary anatomy?

So I’m getting to, so maybe you won’t give the whole tertiary and the delicacies, You focus really on the primary anatomy. So if you guys can really focus, for the exams, yeah, learn everything. But for the real world, if you nail your primary anatomy, and then secondary anatomy, the most important one being line angles. Do you know what I mean by line angles?

[Emma]
Yes, I think.

[Jaz]
Emma, what you’ll learn is that if you ever say yes, then you have to tell me what it is.

[Emma]
So is this when, like, once you’ve cut a cavity?

[Jaz]
Okay. I see where you’re coming from. No, not in this context I’m coming from.

[Emma]
Okay, then no.

[Jaz]
That’s okay, and I want you to keep trying because line angles, I don’t think, is something that was in the textbooks, you know. Line angle is something I learned in a composite course and but it is actually tooth anatomy. Okay, so lateral incisors, right? If you look at them carefully, there’s a point where the labial sharply turns into the distal and the labial sharply turns into mesial. And if you follow that along from gingival to incisal, it makes like these two lines.

So these two line angles, these transition lines, basically. If you are doing anterior dentistry, so the next time you do a composite in the front tooth and you are the first one that you do, for example, I’ll say you, we should really brush up. And again, that line angle. In the right position, because if you don’t have that line angle.

Teeth look like tic tacs. Teeth look like flat blobs. It’s having those line angles which gives your incisors character and anatomy. So being really good at line angles when you start doing anterior dentistry is really important. And that’s something that is part of primary and secondary anatomy.

The whole tertiary anatomy stuff, no one ever shows it, it’s for Instagram. And definitely I wouldn’t go around making mamelons and stuff. And things that are, from an engineering perspective, if you’re treating a tooth wear case, you want to build it up for success and longevity. And although, yes, nature is beautiful, sometimes nature has elements where you don’t actually want to copy because it can be too fragile.

[Emma]
Yeah. And that did actually sort of tie in with my final question that I was written down, which was about if you have a patient coming to you, and they’ve seen your work on Instagram, but you’ve decided, this is a heavily worn tooth, you’re not going to rebuild it, like at natural morphology, is that a conversation you’d have with the patient?

Like, is that something that would be built into a consent form? Like, how do you communicate that? If they’ve got this expectation of walking away with a tooth that looks brand new, is as soon as it erupted, and they’re not going to walk away with that because it’s just not, it just wouldn’t be right.

[Jaz]
Emma, I’m really proud of you for picking that question. I think it’s a very intelligent question, okay? I’ll tell you why. It took me years to realize that when I’m removing an amalgam, right, which is invariably was a flat amalgam, right? I removed that flat amalgam, got my rubber dam on, I spent ages trying to think of the textbook and trying to work my beautiful anatomy.

And then I take my rubber dam off and I’m there for 10 minutes drilling it out of the biting end because it was too proud, right? And then it ends up looking like the initial flattened amalgam, right? And it took me years to kind of figure out what was going on. And so the mistake I was making there is I was trying to give this individual a tooth that was not compatible with the opposing tooth.

Because if you start with something flat. Then you’ve got to look at the opposing, and actually, unless you change the opposing as well, and then eventually, okay, you’ve got to look at the hole around the mouth, basically, if you’re trying to conform and keep the person’s bite roughly the same as it was before, then we can actually end up running late and embarrassing ourselves and losing control of the occlusion if we start to build all those natural cusps.

So, what I believe is, and it ties in well with the question, is we need to use the books and posterior tooth morphology as inspiration. Use that as inspiration. But what we give the patient will depend more on A, what the tooth looked like at the beginning before we started. B, what the opposing tooth looks like.

That’s going to actually slot into it and then how they mate together, how they fit together. And then that’s going to take precedence. You can still use like the outlines and the way you shape the angle. So it roughly looks like the kind of tooth, for example, when I’m doing a lower molar, I would kind of give it three buccal cusps and two lingual cusps.

I would do it basically. But they’re not going to be as voluptuous and as proud. It’ll be kind of, like, sometimes they can be quite curvy because sometimes they kind of be like chicken scratches that you put in with the probe, right? Because there’s no way that you can give that tooth anatomy and it still fit in that patient’s bite.

If you give a 60 year old, who’s got 250 years worth of tooth wear, and we’ll talk about that in a moment right here. So if you have a six year old who’s got significant tooth wear, a 12 year old’s tooth, it’s just not going to work on the bite. So, I think we should use the textbook as inspiration. So your question in terms of what do we actually tell the patient, if you have a patient who tells you that they want their lower molar to look like anything, run away. Run a million miles away from that patient. This is a red flag patient, okay?

[Emma]
Yeah.

[Jaz]
Usually, if it’s tooth color restoration, okay, and then they move their cheek out of the way and they have a look, they’re going to be over the moon, right? Okay. So, thankfully, we won’t have to worry about that story. Now, I have had a patient before, Emma, who came to me and she drew on a piece of paper what she wanted her contact points to look like between one premolar and the other premolar.

Like, I was doing her class two composite, and she drew for me what she wanted her contact points to look like, okay? This woman was nuts. All right? So, I’m not saying, you will get the odd funky patient, okay, and then maybe at that point you got to take photos, intraoral camera photos, like, look, I’m going to give you the best I can that’s going to fit into your mouth.

But I can’t make you look like Julia Roberts if you’re whatever, yeah, it’s my position basically. So your point is valid. But thankfully, that’s the posterior teeth, you know what, the patients are going to be okay, as long as it’s tooth colored, and they’re usually blown away by it, basically, in my experience.

But remember that the textbook for inspiration, but actually, what takes precedence over that is how it’s going to fit in that individual’s actual occlusion, which invariably means flatter teeth, less sexier teeth, and uploading it to Instagram when the rubber dam is still on. If you take the rubber dam off and do an adjustment, it’s not going to make it to Instagram, unfortunately.

[Emma]
Yeah, yeah, that’s the real world, that’s as far as you know.

[Jaz]
It’s the real world.

[Emma]
It’s not that good to know because you strive so hard to, in the second year I was carved an amalgams and polishing amalgams on the phantom heads and things and it’s just you go in the clinic with real patients and it’s just not how it is and that can be frustrating because you’ve learned all this perfect anatomy and you want to be able to replicate that but sometimes it’s just not applicable.

[Jaz]
What I don’t want to say is, I don’t want to sort of suggest for this episode that actually tooth quality anatomy is irrelevant because you’ve got to go with the patient’s own anatomy. I think it’s great for inspiration, and to get your restorations will look so much better.

If you get those three primary cusps buccally, tooth lingually, rather than just splodging something completely flat there, okay? To give some sort of anatomy is good. To have cusp tips and fossi does improve masticatory efficiency, so please do strive for it and it’s good, but you got to take a pragmatic approach and when we’re doing more like worn teeth and we’re rebuilding everything up, like you’re doing more of a full mouth kind of job, right?

At that point, you get to design it how you want. And so you want to design it with more natural anatomy, taking inspiration from the textbook, but you still want to design it in a way that if you don’t want to have too steep a cuspal angle, steep a cuspal angle.

Because a too steep a cuspal angle means that cusps will crash into each other. It puts more torsional stress down those cusps and whatnot. So it kind of needs to be minimally stressed at the same time. But the more you learn, if you want to improve your composites, if you want to improve how they look on posteriorly, if you spend some time to really study what tooth anatomy looks like, your composites will look absolutely beautiful just by positioning exactly where a cusp begins and where it finishes. Even though it’s a flatter one to match it, your composites will still look beautiful.

[Emma]
Yeah, no, that’s good. So take your books as your inspiration and go from there and see what sets in your patience. So no, that’s good.

[Jaz]
Absolutely. Brilliant. And what I would say is when you’re in the clinic, top, top tip is always check the occlusion before you start. I think we talked about it last time. Get a thin articulating paper. Don’t get the big fat blue wad because what’s going to happen is a patient might get the entire tooth goes blue. And you think, well, hang on a minute, where are the bite marks? If you’ve got a thin occlusal paper, you see a couple of few three or four dots, basically. And you’re roughly trying to copy that into your restoration. That will save you a lot of time and some adjusting away at the end, basically.

[Emma]
Yeah, yeah, no, that is a good tip. And it’s something, I did a tiny, tiny wee composite on lower central last week. But I did that before I checked the occlusion beforehand. It was an old one that had popped off or something, but no, that helps me because after, the patient’s occlusion was actually quite, like, almost edge to edge, and then the clinician came over and was asking about articulating paper and stuff, and you’ve got to grind that down, and I was like, oh, I checked it beforehand. And they were really happy with that, so I got a wee gold star there.

[Jaz]
Really good Emma, I’m glad our chats are paying off there which is great, and I think hopefully we can pass that on to everyone as well, which is great. Basic thing, but even dentists getting a bit in the real world, you’ve only got like half an hour or something to do a restoration, you’re like, okay, LA, quick notes, okay, let’s go in, let’s remove the caries, let’s do the filling, basically, but it makes so much, it will save you so much heartache, and basically it helps you take pride in your work, try and work with a degree of precision.

For to get it happy in the bite and to appreciate sometimes a tooth is not even in the bite. And then if you didn’t know that and you try and build it into the bite, but it was never in the bite in the first place, and there’s no real need to do in certain cases, that kind of stuff. That’s going to save you time as well.

So glad you emphasize that. In terms of next month, I’m just having a look with, oh, it’s crowns and onlays month. Okay. So Emma, I want you to think about some questions for crowns and onlays. I think we can actually make something really juicy here. I mean, there’s so many different ways we can go. And I will let you, as a protrusive, mains protrusive student, to suggest which notes would be good for the students and what clinical questions you want to ask me so that we can actually connect the students in the real world together, basically.

[Emma]
Yeah, good. I’ve not done, I’m not giving anyone a credit or anything yet, so.

[Jaz]
Have you covered the theory of it? Have you done it on phantom heads?

[Emma]
Yeah, yeah, we’ve done it on fansubhead and things, so I’ll cook up some good questions for that one, next one.

[Jaz]
Good, and we look forward to checking out your notes as well. So thanks so much guys, and I’ll just catch you in the outro. Thank you Emma.

[Emma]
Thank you.

Jaz’s Outro:
There we have it guys. Thank you so much for listening all the way to the end. Remember, we have the student forum section on Protrusive Guidance, which is something you can access on the laptop. protrusive.app or download the Protrusive Guidance app.

It’s on iOS and Android. And like I said, if you email student@protrusive.co.Uk with your proof of being a student, we will give you access to a little secret area, which is usually a paid for area, but just for students as a way of giving back, we’re going to make this happen for you. I look forward to growing this segment of the podcast with you guys, and thanks so much for all your comments and engagement on YouTube, as well as Spotify and of course, our Protrusive Guidance app.

Catch you same time, same place next week. Bye for now.

View Details

Air Particle Abrasion!

Images of Sandblasted teeth look cool but does it ACTUALLY improve clinical outcomes?

What are the indications? When is it genuinely critical to use?

More pragmatically, are there any decent alternatives eg. roughening with a bur?

Air particle abrasion, a technique used to prepare tooth surfaces for bonding, has sparked considerable debate among professionals. This episode discussed its effectiveness, implications, and best practices with Dr. Veronica Pereira de Lima.

https://youtu.be/oTGQBTyuY-kWatch PDP190 on YoutubeProtrusive Dental Pearl:

Two advantages of slicing off a corner of the rubber dam are:

Anterior Dam Stabilization: By flossing the cut piece through the front teeth, it acts as a makeshift wedge, securely fastening the dam in place without the need for traditional wedjet.
Simplified Orientation: This technique aids in aligning the rubber dam properly, streamlining the entire setup process for more efficient dental work.

Check out ‘Quick and Slick Rubber Dam’ online course (on-demand) only available via the Ultimate Education Plan on Protrusive Guidance

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

00:44 Protrusive Dental Pearl
04:16 Dr. Verônica Pereira de Lima Introduction
07:07 Journey of Dentistry in Brazil
08:34 Academia vs Clinical Practice
09:20 Journey about PhD and Work Surrounding Air Particle Abrasion
11:12 Importance of Air Particle Abrasion to Clinical Dentistry
15:57 Health Concerns Regarding Air Abrasion Particles
18:10 Air Abrasion Contraindication
20:13 Size of the Microns – Clinical Guidelines
22:25 Pragmatic Approaches in Clinical Practice
24:28 Cojet as an Air Abrasion Particle
27:37 Improper Use of Air Abrasion
30:07 Air Abrasion Guidelines Regarding Different Ceramics
31:40 Alternatives to Air Abrasion
33:29 Dr. Veronica’s Personal Guidelines – Air Abrasion Protocol and Unit
40:27 Learning with Dr. Veronica

If you love this episode, be sure to watch Immediate Dentine Sealing Tutorial Part 1 – PDP173

Click below for full episode transcript:Jaz's Introduction: Air particle abrasion for the restorative dentist. How important is it? Hello, Protruserati. I'm Jaz Gulati and welcome back to the Protrusive Dental Podcast. In this episode, I'm joined by Dr. Veronica Pereira de Lima.Jaz’s Introduction:
She was the lead author and a systematic review in 2020 that looked into air particle abrasion and the significance for improving dentine bonding. Some of the key questions that we cover in this episode are how important actually is it? What micron of sand and which sand should we be using? Is there any benefit of CoJet? CoJet is like this sand with silica embedded into it.

Does that really make a difference? And ultimately at the end of the podcast, we will answer the question. If you don’t have it at the moment, are you really missing out? And the answer actually might surprise you.

Dental Pearl
Every PDP main episode, I give you a Protrusive Dental Pearl. Today’s pearl, very fitting with air particle abrasion, because when do we use air particle abrasion? Well, we use it a lot when it comes to adhesive dentistry. And for adhesive dentistry, rubber dam isolation is often favourable. Now, I’m no rubber dam police, but I’m an avid user of rubber dam. And the tip I want to pass on to you today is, are you using things like Wedjet? You know, those stretchy silicon type strings that you use to anchor your rubber dam?

And the terminal tooth for example, you’re using a clamp on the molar and then all the way to an incisor, maybe you’re using like a Wedjet or something to secure your rubber dam. Well, instead of using two clamps or a clamp and a Wedjet, I like to use a clamp. And my favorite clamp is a soft clamp.

Why? Because it’s softer. It’s kinder. I don’t need to give a lingual anesthesia. As you guys know, I’m a huge fan of buccal, articain infiltrations, even for lower molars. But that’s a whole other episode. In fact, we’ve done that episode already. Do check out PDP 143 if you’re interested in that. But back to rubber dam.

So rubber dam, what I will do, instead of using a Wedjet, I will cut a corner of the rubber dam. Okay, now this serves two purposes. One is, once I’ve put the rubber dam on, I’ve got a clamp on one side, and I’ve got the little cut piece, that little triangle of dam that I cut away from the rubber dam.

Well, that I can now floss through the anterior contacts, for example, if I’m doing a quadrant, and now the rubber dam is secured by a clamp on one side and by this makeshift Wedjet, using the dam basically to secure it. And it’s super simple. It saves the environment so we don’t have to buy an additional product to secure the rubber dam anteriorly.

And sometimes the contacts are tight enough that you don’t need anything. You just have to floss it through and it stays. But if you want that extra security, you floss through, you stretch and you floss through this piece, this little corner, this triangle of rubber dam. Now, the second benefit here is you try and cut the corner which represents the quadrant.

So, for example, if I’m isolating the lower left quadrant, then when I punch my holes on the lower left quadrant, let’s say I’m doing the second molar, first molar, pre molars, canine, and lateral incisor, for example, right? On the lower left side is where I’m going to cut my triangles. Why? Because you know when you sometimes put your clamp on, and then you put your dam on, and by the time you’ve got the dam through some of the contacts, and then your nurse is helping you, and you get the frame on, and then you’re thinking, hmm, which corner of the dam goes on which part of the frame?

Sometimes it happens, and sometimes what ends up happening is you end up confusing it, and you’ve kind of got this like twisty, funky rubber dam thing going on. Now, because you have the cut corner on the lower left, you know that the cut area of dam is the lower left, and you just put that on to the lower left corner of the frame. Now, you’re much less likely to make this funky rubber dam mistake because it’s aided you in orientation.

So two benefits of cutting the corner of the rubber dam. One is that you can floss it through to secure your dam anteriorly instead of Wedjets. And two is it helps with your orientation. It just makes the process slicker. And talking of slicker, if you’d like to improve in rubber dam, check out the quick and slick rubber dam webinar that I did.

It’s available on Protrusive Guidance platform. That’s www.protrusive.app. And then there’s 30 plus clinical videos. These range from like two minutes all the way to 15 minutes of tricky cases, loads of different quadrants, anterior, upper left, upper right. All the mouth, basically the entire mouth uncut videos of rubber dam, which so many of you messaged to say it’s really elevated your rubber dam game. So those who are interested, check out quick and slick rubber dam available on Protrusive Guidance. Now let’s join the main episode and I’ll catch you in the outro.

Main Episode:
Dr. Veronica Pereira de Lima, welcome to the Protrusive Dental Podcast. How are you?

[Veronica]
Hi, Jaz. Thanks for having me. Yeah, I’m doing great.

[Jaz]
You are in the Netherlands, but you are from Brazil. And I want to unpack a little bit about that. Actually, I want to unpack your story. I always like to learn our guest story and like why you went into academia, how much clinical you do, what is your future research interests? I have so many questions in my mind already before you can just unpack the air particle abrasion.

But I just want to point out that you’re the first of a guest that I sought out on LinkedIn. I read your paper. I read some study that you were involved in with to do with air particle abrasion. I found that you’re doing a PhD and I thought, okay, I must reach out to you to have this geeky discussion that we’re going to have today.

So thank you for accepting my spam message on LinkedIn that led to a chain of events to book out time in your super busy diary to record today for the benefit of dentists. So Veronica, tell us about your journey from South America to Europe.

[Veronica]
Yeah, it’s a quite a journey. So yeah, I’m actually from a city called Manaus, which is a capital of Amazonas, which is way in the north of Brazil. Think of Amazon. So there is where I did my bachelor and master studies and where also started developing my interest for research, of course. With some limitations, like resources and stuff. And that’s why there was also no PhD in dentistry in my city back then. And then I decided, okay, I would like to go for a PhD and then I had to move out of Manaus and went way, all the way to the South of Brazil to a city called Pelotas.

And then that’s where I started my PhD. It was not specifically in restorative dentistry, but it was a bit more like in dental materials, more broad area. And during this time, of course, I was really mainly focused on research, not so much in the clinical practice, because of my PhD there, because of the partnership that was between the universities of Pelotas and in Nijmegen in the Netherlands.

I came up here this for a period of a year, stayed 14 months and then decided later after I finished my PhD to stay here. And now it’s-

[Jaz]
Amazing.

[Veronica]
Yeah. Yeah. Quite a journey when you think about it. And then, after I finished my PhD two years ago, here in the Netherlands, I decided to, okay, I want to go back to the practice. So then I had to learn Dutch. And do the whole validation recognizing of my diploma here, which was quite another particular journey, but which I’m happy to, I might happen to have finished it. And so now I am also licensed as a dentist in the Netherlands and I’m practicing part time and working at the university on teaching and research at the University of Amsterdam.

[Jaz]
What a nice balance. What a nice balance you have there in terms of practice and academia. I have this perception of a Brazilian dentist that generally, like, I see a lot of literature from Brazil. So I feel as though that dentistry in Brazil has a strong culture of academia. Is that perception correct, you think?

[Veronica]
No, I think so. I think we just, we’re a big country. We have a lot of universities each state has a few universities and usually research is mainly done in public universities. So yeah, if you think about it and that’s why maybe you can see so much of our publication of research there. And I think it’s just growing in the last couple of years. Yes.

[Jaz]
It’s definitely something I’ve seen in when I’ve been looking for literature that a lot of from Brazil pops up. And I also have this perception that lots of South American dentists in general like to go to the States and to do like further study, PhD, that kind of stuff. Whereas you went transatlantic. Did you consider the USA as well as when you were looking at options?

[Veronica]
I was honestly, when I went for my PhD, I was quite open to anywhere. I just wanted to also experience some international opportunities and see other how dentistry is done in other places and research in other places.

But I think when the opportunity came for the Netherlands, the topic was also very interesting. It was in the tooth wear, but also with the restorative aspect of it. Not that I’ve done any restorative procedures, but more like following up results of the patients which are treated for tooth wear and yeah, it was just like, that’s a nice thing. I would like to go and it’s a very interesting topic. So it was pretty much what happened and the opportunities that came my way.

[Jaz]Good. And now that you are like doing two roles, the clinical practice and academia, do you have a favorite child in that regard? Do you favor one more than the other?

[Veronica]
Oh, it’s really hard to tell. I can say during the time that I was not back at academia, so after my PhD and I was only at the practice, although I was not fully as a dentist, I was kind of under supervision. So it’s a different story. I really miss academia. I really miss parts of just writing and doing research. And also, yeah, what’s new for me, it’s more also a teaching role. So yeah, I can say that now I’m quite satisfied with the balance.

[Jaz]
Good. Well, I’m glad you’ve achieved this balance. I think it’s a nice thing to have. And I’m just happy that I found someone to discuss a geeky topic of air particle abrasion. So tell me about your PhD and how you got into work surrounding air particle abrasion.

[Veronica]
Yeah. It’s also like sometimes, research ideas, they don’t come when you want it. They just show up to you. And of course, when you’re doing a PhD, sometimes that can come from you or from your supervisor. In this case, it was an idea from my supervisor.

We came, yeah, I was thinking about this topic. What do you think? We could make like a systematic review. And see what’s there. And of course, initially we wanted to do something like with clinical studies, but that was not possible. And then we decided to say, okay, let’s do it with in-vitro studies, with the laboratory study.

So not with patients, but in the lab, and that was not another level of challenge because then you have a variety of studies, but yeah, it was really at the beginning of my PhD. So my second year, I was not with the idea, clear idea of what I wanted to do for my thesis yet, but I said, okay. Sounds interesting.

Let’s do it. I also did that with two bachelor students at the time. We were working together on this. So it was quite an immersive topic back then, which it’s funny because even though the paper was published in 2021. The research, the search, was done in 2018, 2019, so it’s quite some time ago already. But yeah, so-

[Jaz]
But it’s still a very much a hot topic. I see air particle abrasion questions from our community all the time. So some of those things I want to pick apart. So for example, the first broad question I want to ask is, from what you’ve read and the research that you’ve done and also in clinical practice, how important do you think it is for a restorative dentist now, 2024 we’re recording, is it really, I mean, clinically, I would say my clinical experience that I don’t want to practice without it.

I love air abrasion. I love the biofilm removal. I love the confidence it gives me my bonding, but I want to know is that perhaps false confidence? What does the literature say about the importance of air particle abrasion when it comes to clinical dentistry?

[Veronica]
Yeah, that’s very, very interesting question. So I was surprised to see that even though a few years have passed since the research was done, but it’s still quite relevant. I could not find, at least on my last search, any other meta analysis related to it, because unfortunately, there is also a lack of primary studies on that. So you don’t have clinical studies really focusing on that.

It’s more of like a side outcome that is still relevant. And there are quite some things I have the impression the same as you. Some things are a bit like a feeling of the dentist, of the clinicians. Yeah, it feels good to work with it. And I also worked with it. So yeah, I can, I understand the feeling, but in terms of evidence, there’s no like a strong clinical evidence that says, oh yeah, we doubt it.

Your adhesion is not going to be good. Or with it, your addition is going to be amazing. So it’s something that so far we can say it doesn’t improve a lot, but also it doesn’t harm your addition. So I think I would say in that case, when you have something like this. And it just like, if you know, that’s an extra step, but if you’re good about it and then you, yeah, it gives you confidence and say go for it.

So how important it is. It definitely can be an additional step for several procedures related to adhesion, either direct or indirect procedures. Definitely. For example, if you go for immediate dentine sealing that you can definitely use also air abrasion at the later stage, but yeah, just knowing that.

If for some reason you cannot have that or don’t have access to it. Yeah. I don’t think that’s going to be the difference to make your procedures, your adhesion or any worse than someone that does.

[Jaz]
Certainly Veronica. I mean, I speak to lots of dentists who don’t use it and they say, look, my composites aren’t falling off. My composites are still in there and I don’t use their abrasion. And that’s the argument they said. My most compelling argument I found was when I first learned, probably 2013, 2014, I saw this lecture series from Dr. David Clark as part of the biofilm, and he talked about when you start plaque disclosing teeth, and you look at the plaque, and no matter what you use, if you use an ultrasonic scaler, if you use just the brush and the prophy paste, when you disclose again, you will always find plaque.

The only way he found that the biofilm was removed fully and there was no plaque being disclosed any longer was from air abrasion. Sometimes we’ll never be able to find evidence per se about how much difference it makes. But if you go back to the foundations of what we’re trying to do, the foundations of adhesive dentistry is having a clean substrate.

So that’s why the main conference I get just having clean substrate so that you get the best substrate to bond to and also the least likelihood of getting staining around the margins as well. What are your thoughts on that?

[Veronica]
Yeah, definitely. I mean, if you have ever have done it clinically, you can clearly see, for example, if you have your matrix, everything placed, and you’re going to do air abrasion afterwards, and then you can see clearly.

So, for example, if there is any contamination. That’s also much more clear as well. So for example, yeah, I don’t know, saliva, blood, whatever. You can clearly see after you do that step of air abrasion. So that gives you more also, yeah, let’s say control of your field. But I definitely think that is a two things that are related that because air abrasion is going to promote like this mechanical cleaning, as you said, the removal of any contaminations or incontaminants that are the surface that you’re going to make the adhesion.

But also, of course, the mechanical roughness that it produces that also helps increasing the adhesion area, surface area for the adhesion. So definitely, although, yeah, as you said, not because something is not, yet based on if this doesn’t mean that we have to discard it, it’s just, yeah, maybe after in some years we’ll have that, but I definitely recognize the same benefits that you mentioned. Yes.

[Jaz]
Okay. Well, in that realm, some other applications that we have for air abrasion, obviously, like for example, if you’re bonding zirconia, the APC protocol, the A stands for air particle abrasion. It’s part of the APC protocol bonding to zirconia. That’s another reason to have it in your toolkit. The other reason is when a crown comes off, and it’s loose and it’s still in a condition to bond it.

To get rid of the cement on the intaglio surface, my favorite word in dentistry, intaglio, to get rid of the cement in the inside surface, air abrasion, I found just brilliant to do that. The downside, I mean, exactly. When you’re using like a bur, you might be gouging out the internal surface of the ceramic.

When you’re using ultrasonic scaler, it’s a very slow process. And so there are other benefits that we have. The downside of that is perhaps some health concerns. I know I’m jumping the gun here, but that particle. You see it in the air. My beard is always filled with air particle abrasion, because I’m using it so much.

So did you find any data or have you come across any data about the health concerns about the use of aluminum oxide, for example, which is one of the most common particles used for air particle abrasion? Should we be worried about it?

[Veronica]
Yeah, I did check about it. I could not find any like recent evidence about some paper from 2003 and 1999. Yeah, if you think of the air abrasion used chair side, so just for intraoral use with proper suction device and proper individual protection like as mask and this kind of stuff, it seems to be below safety thresholds. It’s just so tiny, so very little that yeah, it’s not believed to really to be a cause of concern.

I do think that, for example, if you’re going to use outside of the mouth, for example, in a crown or something like that, that you want to clean up, then I know that it can be really messy and can create a lot of particles. Especially because, in that case, I don’t know, maybe you can ask someone to use the suction device, but I think it’s a bit tricky.

So I would say for that purpose would be better to use. There is a type of special air abrasion device, that maybe something that the labs would use as well. It comes in a little box so you can put your hands inside it and then you’ll have a little bit more of controlled environment and then the particles are not going to come off of your face. So then I would definitely suggest that. But again, in that sense, there is no specific studies only about the simulating, the chair sides exposure in that case. Yeah. It seems to be. It’s still safe, let’s say.

[Jaz]
Well, good point regarding the suction. Also, a lot of times we use it under rubber dam isolation, which will help to some degree. Now, I am going to confess that I also use it without rubber dam, in the mouth, okay? And so, things get very gritty, and so I say to my patient, okay, it’s going to feel like a car wash in the mouth, let me go away, wash it away. And so, it’s a very messy stuff. Are there any concerns that you have, as in part of the experience or research, about using air abrasion in the mouth without rubber dam isolation. I’m not condoning it, but I’m just being very real world with you that me and some clinicians do use it like that. Is there a massive contraindication?

[Veronica]
No, although of course, in that case, you really need to be more, I think, cautious and aware of not directing it to soft issues. I’ve seen happening once with a colleague that a little bit. I think went on the size of the cheeks of the patient, huh? On the inside and it got a little bit of a reaction which it was nothing crazy, but there’s not about much about it in the literature but I would definitely say even without a rubber dam you can make a proper control of it with suction. So I think definitely and really be aware of not directing it to soft tissues.

[Jaz]
It’s careful judicious use of it obviously. With that, just a clinical tip for those listening. When we’re using air abrasion in the mouth and when you wash it, there’s still always some particles of sand exactly at the margin and inside the cavity still. So what I always do is I go around with the ultrasonic scaler and that’s when I get the clean surface because I’m using the magnification.

That’s just a little thing that I found to be very important. So every adhesive procedure, I always have air abrasion, but I also have the ultrasonic scaler set up so that I can scale around. Otherwise you do, if you don’t use magnification, you’re not realizing there’s a little particles of aluminum oxide still there. So just a little tip there for everyone.

[Veronica]
And definitely is also, that’s just adding up to it. That’s actually also important for the adhesion itself. Okay. Often people do also the etching afterwards. I mean, there’s some variations in there. There’s a jumping a little bit of a head, there’s no like fixed protocol about it, but it’s very important also to remove the residual of the oxide afterwards. Because otherwise that can also be a little bit against what we wanted, which is improve the adhesion. If there’s a layer of particles of it on steel on the surface. Yeah, for sure.

[Jaz]
That’s right. So getting rid of all the debris. Now, speaking of the debris and the size of particles, is there much, I mean, I think you’ve said conclusively, we don’t have enough data because I see some papers that are pro air abrasion and also some papers that actually no difference and that kind of stuff.

So overall your systematic review, show that, okay, overall, we don’t know if it really is a massive plus point, but are there any variations within 27 microns and 50 microns, which is commonly the two most common particles use? I’ve also seen 90 micron on the market. Any clinical guidelines you can suggest in terms of when is it right to use each particle size?

[Veronica]
Yeah, no, there is unfortunately no answer to that question. No direct answer on the literature about that. Most of the studies that we included in the review. They were using particles that were equal or higher of greater than 30 microns, micrometers. But also for the little bit below that, overall, you don’t find the big difference in the effect of these particles, except for certain comparisons.

And also they were not in the long term. Because when you think of adhesion, it’s not that you, if you reach a high adhesion at the same, like today. It does, you really need to look at in the long term. So after aging and stuff, what’s going to represent and that information we don’t have yet. So I would say if you stick to this most, let’s say commercial, yeah. Frequently used, like for example, 27 to maximum 50, I think you are in the safe side.

[Jaz]
Lots of dentists actually say, lecturers say that they like 27 microns for cavity because it’s not too abrasive. So if you’re close to the pulp and whatnot, so, it will do the biofilm removal It may be make a nicer surface under the scanning electron microscope. It looks prettier, but maybe it doesn’t achieve the better bond strength. But it’s certainly they like what they see under the microscope or under the scanning electron microscope and then for 50 microns for actual like the intaglio surface of crowns and resin bond bridges which makes sense. Pragmatically though what I do, and this is just pragmatically and some other conditions, I’m just not in the enjoyment phase of switching sands.

I don’t like, oh, now is this I have to switch it. It’s a step too much. So I use 50. And that way with the 50, I can use it aggressively on restorations and metal and stuff and removing cement where I need to. But when I’m doing it on teeth, I’m favoring this like, soft sandblasting. So being a little bit further distance away from the cavity and being very careful to aim the sort of the beam, if you like, of the sand to exactly where I want to go and just being careful about that. In your clinical experience or what you’ve seen colleagues do, what you’ve read, is there a good pragmatic approach in practice that you think?

[Veronica]
I think what you’re saying that you kind of try to compensate a little bit of size of the particle, for example, with the distance. And I think that’s also a good idea in case you either don’t want to, or don’t have the conditions of changing the particles. I think definitely we need to be more mindful about when we are doing it in the mouth on a tooth substrate, because it does cut a lot and it cuts even more when it’s hard tissue. So for example, you already finish your, usually, you finish your bur preparation. So you remove the carious dentine or whatever that you’re working on. And you’re almost reaching that stage that is that hard dentine that’s healthy. So that you don’t want to remove more than you should. So then you have to be, yeah, you cannot be too enthusiastic with the air abrasion because in that case you can really remove more than what’s needed.

So I think it’s definitely good that you take these measures and yeah, it’s really like, so you have some factors that can influence the air abrasion effect. So we have particle size, you have pressure, you have distance, you have angle, and you have time just to mention a few, okay? So all of these, they going to play a role of course, but we don’t know what’s the effect of them because some of the studies, they are so different. They use so many things.

[Jaz]
It’s difficult to study all these grammaticals.

[Veronica]
It’s really different, difficult to compare them. So we can, because we need to first be able to compare so we can say which is better or not. But I think you’re definitely on the good direction that you’re balancing it a little bit with the particle size and stuff.

[Jaz]
And with the use of air abrasion, some other clinical protocols I’ve seen is when you’re trying to bond to existing composite, virtually all the clinical expertise that I’ve seen says that, okay, a good step to activate, reactivate the composite. It’s ready to silanate and then re bond a new composite to old composite. But air particle abrasion is used a lot. And then in particular, I’ve read some research about the use of cojet, a particular type of sand. Have you studied or looked into CoJet?

[Veronica]
Yes. So it’s one of the particles used. So you have just maybe people that are not familiar with it, but the difference with the CoJet is that it’s first of all, it’s a branded name, huh? From, it’s a 3M-

[Jaz]
I think, it’s a 3M product.

[Veronica]
Yeah, it’s 3M. And then you have not only the oxide, the alumina oxide, but you also have silicon and that’s especially the silica. It’s what helps with if you’re going to use, for example, a repair, if you want to use a sealant, then you can improve the bonding to the sealant because of the silica.

So in case of repairs. Because there is already some evidence that for repairs, it’s nice to use a sealant. And then if you use something that’s going to improve the bone into sealant, then you have an extra. So either you can do something to roughen that surface. For example, it doesn’t need to necessarily be air abrasion.

You could also do that with a bur, for example. But then you have, with only air abrasion, without being CoJet, you’re going to still going to have the benefit of the roughening of the surface. So you’re going to improve the quality of that surface for adhesion. But then if you use the CoJet, you also have the benefit of the silica and then you have better adhesion to the better bonding to the ceiling for repairs or for like if you’re bonding to metal or yeah, also zirconium also on the other types of materials that are not only composites that can be a benefit too.

[Jaz]
And to use CoJet, and this is, excuse my English, I’ve never used it. Is it just a matter of just buying the powder or do you have to buy the whole kit for the air abrasion unit as well? I’m not sure.

[Veronica]
Yeah, good question. I also, I’m also not sure about it. I know that in a lot of studies when they use CoJet, they combine it with a special type of hand piece or something. So I’m not sure if it’s compatible with any type of what with system. So yeah. Yeah, we need to check that.

[Jaz]
It’ll be good to look into it. And as part of the research, I’ll look into it for this podcast before we release it. It’ll be good to know because if it is showing promising data for when you are bonding to old composite. And that’s a lot of what we do in modern dentistry, trying to be conservative, minimally invasive, refreshing, old composite is part of what we do. And also with aging populations, we’re probably doing it more and more in the future. Therefore, if this really is the magic sand, if you like, then maybe we should just be stocking it and buying it.

But however, if there’s cost concerns that you need to get a brand new unit, then that might tip the balance. So I will look into that. It’d be interesting to know more about a CoJet, but I’ve definitely seen that it’s a quite encouraging data. What I’ve seen. Any times that you’ve come across in your findings about when we should avoid it? Are there any scenarios that we could be doing harm by using air abrasion or perhaps the improper use of air abrasion?

[Veronica]
Yeah. It’s really difficult to tell, but I could think of a few. So for example, you can use airbrasion if you have just that superficial enamel caries. That’s like, imagine some type of situation where you just use sealant, you not go for the full restoration.

And in those cases, it can be useful to use a little bit of abrasion. Fine. But you cannot use it, for example, if you want to, yeah, diagnose caries. I don’t know why would you do someone used that, but I’m just saying that I found an example.

[Jaz]
People used to, I mean, Veronica, we know that people used to use a fissure bur. They’d be like, hmm, let me see if it’s carious. It’s back in the day. They’d stick a fissure bur in and open it up and then see, ah, is it carries or not?

[Veronica]
So, yeah. So yeah, so there is a good example. So I could not think like, why would someone do that? But maybe people think, yeah, because I’m going to dry it and then I can see, I don’t know, but that would not be a good case for using air abrasion. Other than that also, as I said, you need to be aware that with air abrasion you’re not going to be able to have that tactile feeling of the cavity of the tissue, so you need to be aware of that, avoid it if you really think maybe that you’re already like really it can also be because you’re in a deep and you don’t want to expose, there’s a risk there, so you should avoid it in that case.

Also, if you cannot have proper isolation or protection in, of your field. And I’m not talking necessarily of rubber dam, because sometimes you can also have it like with other ways. So, if you cannot have that, you should also avoid the air abrasion. And another thing that I found very interesting, I think is also a good point.

You should not replace the etching, for example, with air abrasion. So skip a step and only use the air abrasion because of what we said before of this mirror layer. And the debris. So that’s not the way to go. So you can add it as an additional step, but should not replace that. It doesn’t replace that. No, no.

[Jaz]
Absolutely. And I think the other one I could think of is just be careful if anyone’s doing zirconia bonding. Air particle abrasion is a reasonable thing as part of the protocol for the APC protocol. But. if you’re doing it too aggressively, are you causing micro cracks in that zirconia, for example, that’s a concern.

So a term I’ve seen is soft sandblasting being used and the other one would be lithium disilicate. For example, I know plenty of colleagues who air abrade lithium disilicate. Any stance you have on that? Because last time I read the Ivoclar guidelines, Emax, for example, it’s a glass ceramic. They specifically say, do not air abrade, but I know some clinics who do and they don’t seem to have any fractures of the ceramic.

It’s just that because I read it in Ivoclar. Anything that I have that’s Emax, I don’t do it because I feel as I’m trying to follow the instructions for that. Any guidelines on different ceramics and air abrasion?

[Veronica]
Yeah, I don’t know. I’m not familiar with this recommendation from Ivoclar, but I can tell that yeah. With lithium disilicate you have not a great problem with bonding because you can just condition it and without having the risk of creating of any-

[Jaz]
Surface irregularities and microcaps.

[Veronica]
That’s damage to your, ceramic, with zirconia is definitely needed because then you do have a problem. So you do need to have to do something to increase your possibilities with adhesion. So, that’s a very interesting example. What I know is for the glass ceramics, yeah, it’s just not needed. You can just do the proper conditioning with the fluoridic acid and then, you can reach a good bone strength.

[Jaz]
Well, lots of colleagues don’t have air abrasion and I feel the number one question I get from the Protruserati community is, I don’t have air abrasion. Can I just use my Prophy Jet instead, like the polishing powders, very much softer stuff. Now, based on what you’ve said so far, because the data doesn’t strongly support the use of air particle abrasion, then really maybe they could just be using for the biofilm removal aspect, just be using the softer powders that are more for the biofilm.

Is there anything that you know about in terms of alternatives to air abrasion that people use and they can consider?

[Veronica]
Yeah. I think if you think of only the biofilm, I even go further with the pumice. So just know some like polishing with the pumice, that’s not going to leave any residue behind. But also if you think of the micromechanical effect of roughening the surface, then I would just go for like, for example, for roughening with the burr. Yeah, that too should also work. So for example, if you have like an old composite and you’re going to make a repair or something like that, you want to reactivate, remove that externally, and then have like a new layer on under it.

So I’ll definitely go also with the bur. And even if you don’t have air abrasion, for example, if it’s not a composite, if it’s like a sclerotic dentine that’s very hard and dentine, you can also activate a little bit the surface with the bur. But again, that’s an alternative. Even though, for example, in the paper we saw that when there was a difference favoring the Arab region, it was for some particles and for some pressure, yes.

It was usually when it was compared to either to hand excavators or with burs. So sometimes actually in those case, and I’m not saying I’m not going to generalize it, but some of my, let’s say sub comparisons, we found the difference than the air abrasion was better than those mediums. But yeah, if you don’t have it.

That’s what I was saying. If you don’t have it, you’re going to use what you have and not think that because you don’t have it, you’re going to have a too bad of an addiction. It’s not like that. I think it’s if you take care of other important details and steps on your clinical procedure, you can still reach a good, effective adhesion.

[Jaz]
If someone’s listened to this episode and they’re now feeling like they’re a little bit more knowledgeable about the guidelines for air particle abrasion. And just like a lot of research, we don’t have the answers. What was your personal reflection guideline in terms of if someone’s sitting on the fence, and they’re thinking, should I spend this equipment budget on an air particle abrasion unit?

It’s a two part question here. One, do you think they should do it? Or maybe because the evidence says it doesn’t significantly improve bond strengths that much, maybe just to skip it and continue to use the bur. That’s part one. And part two is any data on the more fancier units like, Aquacare, the crystal marks, any comment on those? So part one, if someone’s not using air particle abrasion at all, is it time that they invest or maybe should they save their money and buy another gizmo instead?

[Veronica]
Yeah, it’s a good question. I would say, air abrasion is definitely another tool in the dentist toolkit. So, the same thing, for example, yeah, can you be a dentist without magnification? Or, is it really something that the people that use it there’s a lot of benefits, but if you don’t have it, doesn’t mean that you cannot do dentistry, not necessarily, because we all kind of start without it. So it’s a bit-

[Jaz]
I like that. I actually love that. Because I love that Veronica, because I don’t trust any dentist that doesn’t use loops. That’s just my fact. Okay. I don’t trust if you don’t use magnification, I would not let you near anywhere near my mouth or my family’s mouth. And actually, if I was going to have an adhesive procedure or my family member was having adhesive procedure. And if I started working in a new clinic, my requirements are always the same.

I need air particle abrasion, I need rubber dam. If I don’t have these two things, I refuse to work in this clinic and that has worked well every time I go to a clinic and they always supply those things. So that’s my personal stance. Again, the literature doesn’t support it, but I like the comparison.

Okay. Literature maybe can’t support that a dentist who uses magnification crowns will last longer than a dentist who doesn’t use magnification, for example, right? So maybe the literature won’t support it, but in terms of how we perceive it and what do we feel in the absence of literature, because literature is one third of evidence based dentistry, right? It’s patient experience, patient values, and we have to consider that as well. Yes.

[Veronica]
Yes. Very much. It might get there. We might get there. And yeah, no, I’m out about getting heavy answers, but of course, sometimes you have questions that are more urgent to be answered. So there is also that, but yeah, it’s just to give it, I thought, yeah, just now if it’s a good example, so I would say if you have the means to do it, I think you might really like it, enjoy it and see the benefits and the quality of work and also, yeah, a bit of pleasure and fun that you have using it. That’s about the part one then. So yeah.

[Jaz]
And part two the fancier ones. The Aqua Care. The crystal marks. They had the water jet with them.

[Veronica]
That’s the thing. I had the opportunity of also working with Aqua Care and it was fine to me as well, but I don’t know any comparison terms of brands of devices of that. I just felt that okay, it was good, but I was also used. Let’s say in one room in the practice they have Aquacare in the other room they have another type and I was just used to the one that was in my room and I was happy with it. So I could not see from the clinical perspective, like personal perspective, I could not see like a huge difference, honestly. So, yeah.

[Jaz]
I think that the fans of Aquacare and Crystal Marks, these systems with the water, and there are some cheaper systems out there as well with water, I think twofold. One is that they’re less messy. It’s less messy, it’s easier to clean up because of the whole water with it as well. There seems to be, virtually none, I’m told, in the air and they feel better about the whole safety aspect, right?

So that makes sense. And, but there is also the, is it called Sylc maybe?, the bioactive glass, maybe the bioactive beads that come with a particular AquaCare that seems to have some promising soft tissue responses. That I’ve seen some lectures talk about and maybe there’s something in that, but yeah, I’ve never had any compelling evidence research, but it’s one of those things that I’m going to say that just like you said, if you have the means, right, if you have the means and if you can buy the best loops, the highest magnification you can afford, great. But if you only got the brand that you can afford and that will do good for now, I think that’s a good way to go. But to use something is better than using nothing in my opinion.

[Veronica]
Yes, yes. Yeah, I know that there was some studies that used also the glass beams in the review, but it was just not much. It was just, in that time, it was just a minority of the studies, huh? So as I said, science and evidence, they also need time. So maybe in a few years, we’re going to have more studies that’s used to test those equipments and those other particles so that they can maybe have a different, yeah, interesting, more new information.

[Jaz]
Veronica, you’re a true academic in the sense that we’ve ended the podcast with the usual sentence that you read at the end of every dental paper ever, which is we need more time, we need more papers, we need high quality studies, but it’s so true.

[Veronica]
Yeah, unfortunately, yeah, sometimes like, I mean-

[Jaz]
It’s the same conclusion every time, but this is the reality of it. We don’t have the clinical trials.

[Veronica]
Exactly. I mean, I’m not even saying clinical trials because honestly, not everything, like imagine clinical trials really need to be like a major important question. Some things are perfectly fine to be also evaluated in the lab. If you wanna compare, for example, different materials, like different composites, different these waves, yeah.

You don’t need to necessarily do it in the patient because some concepts are the same, but you wanna, so just see like a tiny details of differences in the bone strengths of that’s perfectly suitable to be tested in the lab. So, I think that’s the case also for air abrasion, but yeah, more studies are needed.

[Jaz]
Watch this space. More studies are needed. Oh, Veronica. Well, thanks so much for having this geeky discussion. It’s something that the community has asked for a long time in terms of more, just a geeky one about air particle abrasion. My personal stance, as I’ve said, is I’m very pro it, but I just want to, and I’m happy to have you say in this podcast that, look, we need more data.

It’s not as nice as you’re saying, Jaz, and I appreciate that. And that’s what the study said, and we can’t argue with the studies, but let’s see what time tells. Personally, the clinical satisfaction I get outweighs any of that. And I know that it’s not doing any harm, but the whole biofilm removal, but when I didn’t have the air abrasion, I was using Pumice, right. And I got by fine as well. So there are some considerations for that as well.

[Veronica]
Yeah. And even though we don’t have that big fat, yes or positive or go ahead, but we definitely also don’t have it yet, a big fat no. So I think, that’s why like sometimes you also need to balance it a little bit. Are there many risks?

Are there many harms that might be overcoming like positive effects? We don’t see that very much so far in a regarding to air abrasion. So I’ll say In this case, it’s okay to go with your feeling, because we might have some more definite definitive answers in the future. But just for now, we also don’t have many major red flags.

[Jaz]
So good. And are you happy for me to share your systematic review with the community in the download section in the show notes?

[Veronica]
No problem.

[Jaz]
Amazing. I will do that. And just tell us what are you working on next? Like what’s what’s next on the horizon academically for you? What are you researching next?

[Veronica]
Yeah, right now I’m at the Department of Cariology at the ACTA at Tech, from a University of Ment Amsterdam. So, yeah, right now it’s a little bit still very early stages, a bit of qualifications needed and yeah, still developing some work on the tool for, but in terms of research is still open for possibilities. And I will come soon.

[Jaz]
Good, good. Well, as a community, we wish you all the best. Thanks for giving the time. If anyone wants to send some love your way and a thank you, and maybe a geeky question, how would you accept that? How would you welcome that?

[Veronica]
Yeah, no, yeah. I’ll be happy to receive that. And I’m always quite active on my research gate page. So yeah, people will sometimes reach out for publications. I do my best to respond really quite fast to send the papers and stuff. And also, yeah, as you could see, also linked in. So yeah.

[Jaz]
I’ll link them to the research gate and honestly wishing you all the best with the future research endeavors and your new life in the Netherlands.

[Veronica]
Thank you. Same to you.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end. I’d like to thank our guest once again, Veronica Pereira de Lima, for being geeky and being kind enough to accept my invitation. Protrusive is all about the geeky and kind dentist. That’s you.

Now, if you want to find the home of the geekiest and kindest dentist in the world, you want to head to Protrusive Guidance. There, under this episode, you can answer some questions in the quiz to get some CPD. You’ve done the hard work of listening to this episode already, so why not get 40 minutes of CPD for this?

One of the five questions for this episode is this. Which of these factors determine the cutting efficiency of air particle abrasion? So which of these factors determine the cutting efficiency of air particle abrasion? Is it A, the particle size? Is it B, the pressure? Is it C, the distance away from the substrate? Is it D, the time of air abrasion? How long are you actually air abrading for? Or is it E, all of the above?

Now that was an easy one, I know. There’s a few others there. If you can answer those, you’ve got yourself a certificate which Mari, our CPD queen, will email to you. In fact, Mari will send you quarterly certificates and an annual review of all your activity within Protrusive.

I want to thank Team Protrusive, so Erika the Producer, Mari the CPD Queen, Krissel, Rakesh, Nav, Emma, who will help with the premium notes, and Gian for his video wizardry. Do me a favor before you go, whatever platform you’re listening on, consider giving it a like, a thumbs up, a subscribe, whatever button you can click on, please click on it.

It really helps the podcast grow, so I can continue to bring cool and geeky content to benefit us all. Thanks so much once again, I’ll catch you same time, same place, next week. Bye for now.

View Details

Paying through the nose for your indemnity? You may get better protection with insurance AND it has saved Dentists £1000s – get a quote today from PDI / AllMedPro and get an additional £100 off (this is a promotional link that will save you money)

Associate contracts are actually a HUGE deal that we do not give enough attention to…

How long can your principal keep your retention for?

Is it really true you cannot work within a certain radius?

How principals and associates may be getting screwed over by the poor contract!

Finding the right principal/associate is very exciting, so much so that we sometimes forget how important it is to read through the small print of our contract.

This can prove very costly in the future in our industry where mistakes do happen, so it is extremely important to be aware of what we are signing up for.

https://youtu.be/lC_POxlmL_UWatch IC051 on YoutubeJoin us today with Neel Jaiswal and Sarah Buxton for a breakdown of how to negotiate the right contract for you, the power of being an Associate in this day and age, and the importance of Insurance. There’s a lot more in this episode so don’t miss out…’Court is in session!’

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:02:08 Sarah Buxton and Dr Neel Jaiswal
08:40 Associate Contracts
11:15 Who Checks the Contract?
13:50 Contract Bias towards Principals?
18:50 Getting Contracts Checked
21:28 Retention of Fees
30:48 Annual Leave
35:00 Exclusion Zones
43:04 Vicarious Liability
52:18 How to get in touch

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. This includes Vertipreps for Plonkers and clinical videos demonstrating Onlay Preps.

If you liked this episode, you will also like GF019 – Indemnity vs Insurance

Click below for full episode transcript:Jaz's Introduction: If you're an associate, when you joined the practice, did you read and did you understand your contract? And if you're a principal, do you actually understand the contract that you're giving to your associate?Jaz’s Introduction:
Look, something I make very clear in this episode is that I’m a man of trust. I’m not the biggest fan of forms and contracts.

I don’t really think any of us are, right? My biggest currency is trust. However, in this day and age, unfortunately Protruserati, trust is not enough. We need everything backed by writing and unfortunately a huge takeaway of this podcast will be that contracts are super super important to the letter. So it is my duty to make contracts tangible.

In this episode joined by Sarah Buxton and Dr. Neel Jaiswal. Sarah is representing the legal side and Neil’s representing the medical legal side. So together we’re going to make dental contracts tangible for you. Everything from what is a fair retention fee to withhold from an associate after they stop working to who should be paying to get a contract checked.

This one actually might surprise you actually. So who should be paying? Should your contracts be checked? The answer is yes, they should be, believe it or not. Who should be paying for it? What about the retention fee? What about vicarious liability? What if an associate messes up? And now the practice is responsible.

How do you cover that in a contract? What about the clause that you can’t work X number of miles away when you leave a practice? Is that actually enforceable? Is it actually worth the paper it’s written on? And so with all these themes, this I promise you will be the most to the point, concise and actionable piece of education on dental contracts you’ll ever listen to.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to an Interference Cast, which is an arm of Protrusive Dental Podcast, where we discuss non clinical but important topics. This particular episode is eligible for one hour of CPD. You just have to answer some questions under the Protrusive Guidance Network, which is on the website.

You can like access on the laptop my entire network. It’s got all my educational content and the forum on there as well. That’s www. protrusive. app and the native iOS or Android app, which is Protrusive Guidance. The best way to do it is that you make the account on the web and then use that login on your native app. So if you love protrusive, you want the full experience, do check us out on there. But without further ado, let’s demystify these contracts.

Main Episode:
Sarah Buxton, welcome to the Protrusive Dental Podcast and our guests. Once again, Neel Jaiswal, Dr. Neel Jaiswal. Great to have you here, sir. Really, really super important.

Like this is kind of the topic that I’m so in love with clinical dentistry. And when we talk about contracts and stuff, like it is for me, it’s a snore fest. However, the difference today is that we’re going to cover the super important, the key things that actually we’re all talking about on all the dental forums.

Sarah, I think you get bombarded with these contract questions that we’re covering today. So I’m actually really excited to actually get some answers, get to the bottom, all these nitty gritty little details before we continue. Sarah, please introduce yourself. How did you get in to the dental space.

[Sarah]
Thank you. Well, I must be a bit like you because I get really excited about contract law. So we can be sad together, but yeah, thank you for having me. Yeah. I’m Sarah Buxton. I’m one of the directors and owners of Buxton Coates Solicitors. We are a niche firm that advises dental practice managers, associates, buyers, sellers, all aspects of buying and selling and running a dental practice.

And my specialism is employment and HR law. I didn’t wake up one morning and think, oh, it’d be really, really good to act within the dental industry. I fell into it by having one dental client and I thought, oh, it’s quite interesting, did a good job and then it grew from there and actually it is quite an interesting area of law for an employment solicitor, especially especially when it comes to self employed associates and workers and employee status.

So over 15 years experience. So I always say to our clients, look, you don’t have to explain to me what a UDA is. I understand, I know the acronyms. So yeah, always, always happy to have a chat with people. And yeah, I really do enjoy this topic that we’re going to speak about today.

[Jaz]
Good. I’m glad someone’s passionate about it, but we know we want answers. We definitely want answers. And that’s why we’re going to be picking your brains today. It’s a bit of a minefield. I feel there’s a lot going on, especially the last few years, then talking about the whole self employed and employed, and there’s a lot of confusion regarding that. So seeking some clarity, Neel, my friend, you are here as someone who’s representing the medical legal challenges that can sometimes come between.

So there’s been a nice interplay here between us. Sometimes we seek help from our indemnities, right? When it comes to these issues and is that in a rightly or wrongly and also we’ll talk about vicarious liability, right? This new, not new things been around for a while, but it’s a very much a hot topic as well.

And so I think that’s where you’re going to come into a lot. We’re looking to get a borrow your expertise and your experiences, but Neel, for anyone who has not listened to our previous episodes, we’ve done loads of medical, legal ones, including a really big one that got a lot of positivity. A lot of love was insurance versus indemnity.

What are the differences? So if anyone has not listened to that, please, please, please do yourself a massive favor, save yourself thousands and listen to that episode, but Neel, just introduce yourself, my friend, for those who haven’t listened to that episode.

[Neel]
Well, thank you again, just for having me today. Always a pleasure. And nice to see Sarah again. Yeah. I’m a director of professional dental indemnity, and I’ve been doing that for about five years now. So it’s been a learning curve for me. I was like, you’re a dentist. We don’t really know about contracts. We don’t really know about GDC. We try to stay away from all these things.

And then I kind of, a bit like Sarah, fell into it and started to help people. And so PDI has been going for five years, but I’ve still got my clinical practice and my practice here in Hertfordshire. So I’m always happy to help. And I don’t know if you remember, Jaz, how this topic came up. I think it was like 11 o’clock at night and I texted Jaz, can you talk?

I know it’s late. I know you’ve got a young family. Same here. And I just had a call from a client. It’s a PDI client. And it was so unfair. I think her principal was basically keeping six months of gross for the renewal fee. And she was newly qualified, she was in tears. And I’ve heard it a couple of times before now, this thing where principals are taking the retention-

[Jaz]
Can I stop you there, Neel? By renewal fee, do you mean the retention fee?

[Neel]
Retention fee, sorry. I’ve just come from the gym, as I was saying to Sarah. So I’m a bit light headed.

[Jaz]
That’s fine. So retention fee, for those who are not familiar with it, this is where you’re leaving your place of work where you’re an associate, but then they keep some money aside so that in case there are any failures or the whole point of it is in case any failures, any remedial work that needs to be done, there’s a pot of money that they can use.

And after a certain amount of time, it’s going to be six months, 12 months, Sarah, I’ll ask you later. What’s a reasonable amount of time. We’ll talk about that. But then that should be ideally returned to the associate. Have I got that right? Any amendments to what I’ve just said?

[Neel]
Yeah, that was the case. And in this case, we’d see this unfair amount and older principal, younger dentist, happened to a few of her associate colleagues. And I’d also been it before, seen it before where they’ve gone to court over it. And then the principal reacts by sending notes off to the GDC. And it becomes a whole tit for tat.

And you have a lot of this blue on blue stuff, which is a total waste of time for the GDC and our money. So really for the viewers and listeners out there, it’s really important to understand the contracts, but you will find yourself in deep doo doo if you get that wrong. So it’s really important. I think it’s a must have in terms of, you know, pretty even at the graduate level that we should understand the contracts. So it’s great to have Sarah here.

[Jaz]
Well, let’s make it a mission for this, this time we have together right now of next 20 minutes, half an hour, 40 minutes, wherever it ends up being to really make sure that anyone who listens to this is going to feel really confident.

Okay. What is the purpose of the contract? What’s fair? What’s unfair? All those really important things, including we’ll talk about the retention fee as well. Look, I’ll be honest with you. My view on contracts has always been this. Okay. I’m old fashioned this sense, in the sense that a contract for me is something you sign, right?

But the day that you need to look at it, something has gone wrong. Like there has been a disagreement. Like for me, the time I have to pick up a contract is bad news and I’m probably leaving the place. So that’s how I see it. And I I’m very much a trusting soul. I’m very much my principal. I’m hoping he’s not listening to this, but I didn’t read.

Okay. I mean, okay. I’ll admit I didn’t read the contract fully though. The one that I signed the practice. Okay. I’m just being super real. And Sarah, I guarantee you most associates are in my position. They see it. Okay. It’s the BDA one, whatever they’ll sign it. And I, cause I trust the guys I work for.

However, all the issues I see on the Facebook groups, on the protrusive guidance community, the common answer is, well, depends on what’s in your contract. Have a look at your contracts. What does your contract say? So actually we need to give it more a gravitas, right? So the question naturally I want to ask you is the first question is, I think Neel’s already answered his perspective is how essential our contracts in this day and age.

[Sarah]
Yes. So essential. And I agree with you. I would say this to most of our clients that actually what the contract is, is a document that we want to refer to when something’s gone wrong, but ultimately we want to be able to have a good relationship between practice owner, associates, or self employed hygienist, therapist, whoever the relationship is, and hopefully we can get by by doing things by agreement.

However, when things do go wrong, or you want an answer to understand your obligation or their obligation, the first place where we will always go to is the contract. So it’s really essential if you’re ever in a dispute and the first thing the judge in any case will look at is let me see the contract, what’s in the contract? So it’s essential that you do understand those causes in there and in my experience, like you say, many associates do not get their contracts checked and understand it.

[Jaz]
I’m not proud of it. Listen, I’m not proud of it, but it’s an honest admission of my nature of just being very, I go by trust. I looked him in the eye, like, do I like this guy? Do I trust this guy or girl? And that’s why I go by it. But you’re right. That’s not good enough for this.

[Sarah]
Absolutely not, because it’s okay until something goes wrong and nobody trusts anybody anymore. And then you end up paying the legal fees for being too trustworthy. And that’s what we don’t want. We don’t want to be in disputes.

It’s stressful. It is time consuming. It is incredibly expensive being in a dispute. So if we can set out the obligations and understand the obligations in the first instance, that is something that will hopefully prevent a dispute from happening. And that’s why I would always recommend for contracts to be checked.

But I must say, it’s not just associates who don’t understand associate agreements or what’s contained in them. Quite often practice owners don’t as well, and they will have downloaded a contract, a template contract, try to fill it in themselves, given it to the associate, and they don’t understand the terms either. And so it’s both parties. So associates, if you don’t understand them, don’t feel bad because quite often practice owners don’t as well.

[Jaz]
In which case then my next question is, if you are joining a new position as an associate or you’re hiring someone as a principal to be an associate or a self employed associate or otherwise in your practice or hygienist or nurse, whoever, do you think the standard of play now, nowadays is that any contract should be checked and then like we allude to, but therefore my next question is, who checks it?

Should it be someone in your space? Should it be any solicitor? Should it be the BDA? Should it be your indemnity? Who can help us to check these? Because it sounds like we should be getting checked.

[Sarah]
Well, for me, it’s the day job and there will be solicitors out there. I would say, make sure that they understand the dental profession because it is unique. And I’m sure we’re going to come on to why associate agreements are so unique. And I think that’s really important. Whoever checks them, they not only need to have the knowledge. But you also need to have a good working relationship with them. I think that’s really important. It’s an important document.

You need to be open with them about what you’re wanting from the relationship with your practice owner. And they need to support you with the negotiation, the compromises, explaining what’s to be included, what’s normal, what’s reasonable, so there’s a lot to it. But I think one of the important things is when you’re looking for somebody to provide you with advice, trust is the key. So just make sure that you trust the individual who you’re taking the advice from.

[Jaz]
You know, maybe I’m simple minded, but I would just love like, let’s say the contract’s eight pages. I would love a half page summary of key points, right? That should, I think that should be made like a standard thing that it should be.

Cause we recently made a will and like, there’s like a plain English, like summary kind of thing. I think all contracts should have this including associate principal ones, but I have never seen that before myself. Is that something that you see?

[Sarah]
I mean, the difficulty with it is, is that each and every associate agreement is different. So quite often in the dental industry, we talk about templates and, oh, it’s this template, or I’ve downloaded this, but you’d be surprised how many people will play around with those templates include clauses within the template, so they no longer become standard. And I say that because I don’t believe they are.

And for a practice owner, you will not have the same associate agreement as the competitor down the street, because the relationship you have with that associate will be different. So I think, yes, there will always be key terms that we can speak about and come on to so that people understand those key terms, like Neel said, the retention clause, but generally speaking, how that retention clause works will differ from practice to practice.

[Jaz]
I have a million questions, but the most pertinent one now then is, in your opinion, having seen thousands of contracts, and usually by the fact that it’s the practice and the principal that issues the contract, like, it wouldn’t be like the associate coming, here’s my contract for me to work for you.

It’s the principle giving it, right? So therefore, do you, in your opinion, are contracts bias and favour towards the principal both financially, both in terms of terms, and therefore the owners and the associate to be like, hang on a second, let’s just step back here and just amend this. Would you agree with that?

[Sarah]
To some extent. I mean, when we’re drafting contracts and especially in this day and age, because when we’re speaking about it, it’s not easy to engage good associates at the moment. So if you want to get an associate in your practice, it’s important that the terms are attractive. And if you are putting unfair terms-

[Jaz]
What does that mean? Sorry.

[Sarah]
In terms of not sneaking things in. Having a license fee that’s acceptable. Having a retention clause that’s acceptable. Because if the associate does take advice or reads the agreement and understands it, if they’re not happy with an unfair term, they’ll probably just go, I’ll see you later because there’ll be another practice down the street that actually will engage them on some fair and reasonable terms.

So we don’t see that often that practice owners are going out to be unfair or sneak a term in to make it unjust for the associate, but there will be financial considerations and there are some practices out there who will maybe that they’re doing the right thing by including clauses that are heavily in their favor, and they hope that the associate never goes and gets it checked.

And Neel already gave the example, didn’t he, of the retention fee, which was six months gross fees. And obviously that is somebody taking advantage of probably the associate’s good nature or naivety, that they are not going to get the contract checked or actually read the contract and understand it.

[Jaz]
Very good point. Now, before I talk about retention fees, yeah, Neel, I was gonna say anything you want to add to that?

[Neel]
Just a cheeky question, Sarah. If the contract is, if you employ a solicitor and a principal, there’ll be a principal bias. I know you were saying we should try and make it fair, and I understand that. It’s also, it’s in the associate’s benefit to have a contract that favors them. Should the contract cost be split down the middle and the associate work, and the lawyer works for both parties, or is that something you can do?

[Sarah]
No, so lawyers are not able to do that because lawyers act in the best interests of their client and they cannot get themselves into a conflict and for example If you have a practice owner saying I want this clause in and you have the associates saying I don’t that will be a conflict. So we wouldn’t be able to act so we would only act in one of those party’s best interests and we’re heavily regulated just like you, just like the dental industry and that comes from our regulator.

And so yes, lawyers do act for one party or the other. Now, what I would say about the cost of that, the practice owner usually bears the cost because it’s for the benefit of their business and they provide, as Jaz has already said the agreement. They’re the starting point from the agreement.

There were some instances where the associate may bear the cost of having an associate agreement drafted. And that is usually when the associate decides that they are going to run their business through a limited company. So it usually only happens in private practice because of issues to do with the NHS and superannuation and whether you can take part in it.

So it’s usually only private associates where this will happen. And the only reason why the associate will want to run their business through a limited company is for tax reasons, for the tax advantages. So it’s wholly for the associates benefit to do that. And sometimes the practice owner and the associate will come to an arrangement where they’ll say, okay, we’ll do this. We’ll pay your limited company. We’ll engage you as a limited company, but you bear the legal costs. And that’s often happens, but we will still only act for one party. We can’t act for both.

[Neel]
It also comes back to a previous conversation about our associates employed or self employed. And that’s a whole different rabbit hole.

[Jaz]
Yeah. I mean, we could easily fill a whole episode on that. So let’s be careful where that goes, but based on what you said, Sarah, it sounds like when you have the contract, you may be also, as well as seeking legal advice from someone like yourself, you also need like a relationship counsellor to go through your contract and make sure that both parties are satisfied in a way.

That’s one thing that came to my mind there. So this concept of the principal paying, I’m all for it as an associate. Listen, yeah, I’m all for it. But having that conversation, hang on a minute. Like surely, Neel, I don’t know about you, mate, but surely it’s associates who are paying. Like if an associate gets a contract, I don’t know any associates who are ballsy.

And I was like, hey, your contract, listen, I want you to pay Sarah to make sure that this is all above board. Right. So I just thought the associate just takes it as a hit and gets it checked and then comes back, like just maybe gets it checked on the slide, not even the slide, but like just gets it checked for their own own benefit. So how do you even have that conversation with the principal that hang on a minute before I even think about signing this, I want you to pay for me to get this check.

[Sarah]
Well, I think associates are in a strong position at the moment. Because of the market, I come back to the point that actually practices are struggling to engage good associates. And actually the legal fees to get a contract check is, I don’t mean this in the way it’s going to sound, but it’s peanuts to get somebody in, in terms of that right person. And actually it’s in the practice owner’s benefit that they have sought advice and understand the agreement because again, what we’re trying to do is stop a dispute from happening.

And actually for some of the causes to stand up in court, it’s better if both parties have taken legal advice, such as restrictions. So there’s one of the causes where if you’ve taken legal advice, they’re more likely to be enforceable. And when I talk about restrictions, I mean, restrictions that happen post termination in terms of where you can work, non poaching of staff, non poaching of patients, non dealing, so those type of causes.

So, again, I think associates are in a strong position to negotiate. And to ask practice owners the things which ordinarily they wouldn’t have done, and I appreciate that that’s quite difficult. Especially if you’re fairly new to the profession and you’ve just got your first associateship and you are respectful to the practice owner, that it may seem really hard, but actually, it’s becoming more and more of a thing. Associates are doing it because they’re in a stronger position.

[Jaz]
I’m just trying to get my head. I mean, again, being simple minded here, but I think this is going to help people because people are having the similar questions. Like, let’s say I’ve got this contract. I’ve been offered a job, got this contract.

Hey, Jaz, here’s your contract. Have a look at it. And then I look at the contract. I have no idea what it says, right? Because it doesn’t make sense to me because this is me when it comes to contracts. And so I’m going to say to the principal, okay, I would like to get this contract check on my behalf or the associate’s behalf, right? I’m sure you’ve done your due diligence ready. Please, could you pay this fee, which is Sarah’s fee, so that we can get it checked? Is that how it should go?

[Sarah]
Like that. Yeah. And it’s happening more. And because the practice owner wants to get this associate in, quite often they’ll say, yeah, actually. We’ll pay that for you go and get it checked because they want to engage with that associate and get them on board.

[Jaz]
That could be almost like a litmus test, right? To see, okay, is this principal, is this practice worth their salt? Right? Like if they’re going to say yes to that, then that’s already giving you vibes that actually this is the kind of practice you want to be in someone who’s actually doing things right.

And so this could be like for the in demand associate, a good practice. Great. Well, the next question then is retention. Let’s talk about retention because Neel mentioned that scenario. I’ve seen all sorts of contracts, the retention part. I’m trying to remember my old contracts and stuff. Some have gone on for 12 months, I think. But so what do you think is reasonable retention? And then also tell us some stories about some wacky ones.

[Sarah]
Okay. Yeah. So, I think this is one of the causes that people don’t pay enough attention to about how the retention works. So firstly, we’ve got the amount, which will vary from practice to practice. It can be a fixed amount that they retain, or it can be an average over, usually I would say the last three months. And that’s usually, but again, it can vary from practice to practice, but then what’s important is the next clause because people will look at the amount and think, Oh yeah, it’s okay. But actually it’s more than that.

It’s how we use that amount as the practice owner or how you allow the practice owner to use that. Because what you’re saying is that’s my money. You hold it on trust. And then if there’s any failed treatment, and they come back, I allow you to dip into that pot to sort out the failed treatment. And sometimes there’s a limit on the amount, so they might say, for example, I don’t want to hear about anything if it’s 250 and below, just do it.

Sometimes the clauses will say, actually, don’t touch that money, let me come in. Let me come back and check the patient and then we can have a discussion about what’s going to happen because I might be able to fix it or I might make a decision about whether to refund or what’s going to happen. And so those clauses are really important.

Then the next stage is when you get that back. And I think it depends on the type of dentistry that you do. So general dentistry, you should be seeing your patient within 12 months. Okay. So you would hope that you receive that payment at the end of the 12 month period. Then what’s happened to that money in the meantime?

So just to give you an example about why it’s important to get contracts checked and how they can vary and change. When I first started drafting associate agreements and advising on them, actually we were saying practice owner, you can hold that amount for 12 months. But I want interest on the amount.

Now, because interest rates have been so poor, that clause has fallen by the wayside. We never see that. It’s just a fixed amount that the practice owner looks after for 12 months, probably some interest on it, but you never get the interest of that amount. Now, because interest rates are high again, or high ish, that’s creeping back in.

So I’m seeing agreements where associates are saying, if you’re holding my money for 12 months. I definitely want interest paid on that amount. And that’s the kind of thing that people miss, but actually it could be quite a substantial amount if the retention is quite high. So it’s worth thinking about.

[Jaz]
Yeah. Very good. Yes. Yes.

[Neel]
You touched on something that was really important, actually. And again, I’ve had quite a few calls where the associates left the practice and the practice now saying, oh, they weren’t happy with their bonding or their business line got finished or whatever. And these associates aren’t allowed back in.

Now it might have been they’ve fallen out or they can’t accommodate them or sometimes it could be the principal not wanting them to see, not even wanting them to show them a photo of what’s happening to manipulate it to theirs. So I think actually, if you are looking for an associate contract, I think it’s quite a really nice thing to say, a mutual benefit, I will look at, come back and look at the patient. And so I think that at least have the option to do so because they’re getting shut out the door and then that’s leading to further conflicts.

[Sarah]
Yeah, absolutely. And I’m having access to their dental records. The practice owner, once you’ve left, is under no obligation to provide you with access unless it’s in the associate agreement. And again, you want to see that to see what actually is this failed treatment. We do come quite often across practices that will hold onto the money. Say they’ve used that money and because the associates are not probably confrontational or scared or don’t understand it, they ask for it. They ask for the retention back.

They get ignored and the associate just lets it go. And that happens quite often. And quite often it’s because either they can’t afford the legal fees. Or they don’t know where to turn to to try and obtain that retention and the practice anything. Well, I’ll see what they do. I’ll risk it. I’ll see if I can hold on to this for as long as possible.

[Jaz]
It’s a real, real shame that that happens in our profession, I think. One thing I would want actually is, looking back, thinking about contracts now, is one thing I’d like to see in a contract for retention therefore is if you are going to be claiming that I want a nice spreadsheet of someone’s name, what the issue is, I want clinical photographs and radiographs to support that.

It just seems like a reasonable thing to do rather than just going by blind faith, right? And so that’s an important thing to consider. So maybe that’s the kind of chat to have with someone you’re working with, when looking at the contract. The other thing, the other question I have financially is, and this is a genuine question, I have no idea is, let’s say we have a gross amount that you, earn every month, and then you get a percentage of that, right?

So when there’s remedial work being done, the patient is not paying again. It’s like done as remedial work, right? Usually, right? And therefore, should the associate be charged the gross amount of that treatment? Against their net pay and these kind of details should also be in the contract as well, because that would be quite, quite unfair. So is that the kind of stuff that you would actually go into that kind of detail, right?

[Sarah]
It’s really important. And it’s the kind of thing that’s looked over as in there’s not enough attention paid to it, but quite often there are clauses in there whereby the practice owner will have a contractual right to take a hundred percent of the fee, so you have got to be really careful.

It’s not always, by the way, the practice owner and trying to get one over on the associate, quite often as I said at the outset, it’s because they don’t understand either. At how it works and they think they’re putting the right causes in there.

[Jaz]
So it’s the template that’s been passed around. That’s to blame that someone made it and then they just use it in good faith, but actually they’re not realizing that actually it’s not quite fair.

[Sarah]
Quite often when the associate raises the issue, we go, oh yeah, that’s what I mean. It’s like, well, that’s not what’s in the contract. So let’s get it in the contract correctly. So yeah, definitely. It’s the detail that we need to look at. And I think quite often. Especially associates will open their associate agreement and think, oh, right. What’s the license fee? Great. I’m getting paid 50%. What’s the retention? Oh, it’s a fixed fee of a couple of grand. That doesn’t seem too bad.

How many weeks do I get off a year? And those will be the three things that they look at and forget about the rest. And yet these documents are substantial. They can run into 10, 20 pages depending on the practice and the associate agreement. So really important to look at the detail.

[Jaz]
Thanks so much. Anything more on retention before I move on to the next?

[Neel]
If you’re an employing or in your practice, an orthodontist, three months of their last remuneration is not really going to cover redoing two or three ortho cases. Have you, do they tend to have two year clauses and a larger amount or?

[Sarah]
Yeah, there tends to be a staggered payment back plan. So, if they’re withholding the monies for a significant period of time, they’ll hand some over and then it’s a staggered payment plan, I would say. That tends to be the way we’d offer.

[Neel]
And with so many people doing Invisalign now, I’ve seen it where associates are leaving, there’s still nine months left of Invisalign that someone’s got to pick up. So the world’s a little bit different to pre COVID with a lot of the new short term author or limited author. So I think, again, the older contracts aren’t reflecting that.

[Sarah]
Yeah, absolutely. And this is one of the things that I would always say, whether you’re an associate or a practice owner, is that contracts should be reviewed annually at least because the law changes so quickly and, but not only the law, but like you say, socially we change, things differ.

We live in an age now where there’s a lot of social media and I’m actually, I get lost with what’s the newest source of social media. I’ve got to say Instagram, Facebook, TikTok, all those. And how many of them are actually covered off in an associate agreement? How many of them are covered off in terms of what happens with your Instagram account?

Who does that belong to? What are you doing with my patient’s pictures afterwards? And it’s the ones that are moving with the times and actually the ones that include those causes within their agreements that then are preventing the dispute later on about when somebody thinks, oh, hang on a minute. They’re using my name on their Instagram account, but there’s nothing in the contract. So even that, we’ve moved on. Times have changed. We need to include it in the contract.

[Jaz]
Very relevant. Very good point there. Excellent. Next topic is something very close to my heart. Annual leave, right? This is really something that grinds my gears, right? And you hear this from all the associates, but I also understand the principal side of it, right? So I moan to principals, my friends who are principals. I’m a self employed associate. I should be able to take off time whenever I want, as long as I give fair notice. If I want to take 40 days off a year, I’ll take it.

If I want to take 20. I’ll take it. But actually in most contracts, we see actually there’s a contractual limit. So, if a HMRC get a whiff of this, surely they’d be saying, hang on a minute, how can you dictate the time off? But on the principal side of it, look, there’s a contract to be fulfilled. If your associates taking, going to Mexico every week, then it’s not going to happen. So I totally can understand both sides of it. Sarah, what do you make of this annual leave element in terms of the HMRC and also in terms of what is fair?

[Sarah]
Okay. So if we start with the point about a worker status, employee or self employed. If you are genuinely self employed, like you say, you should be able to take as much time off as you like. That is just one indicator. I always speak about indicators and what we try and have is as many self employed indicators as possible in a self employed agreement. And we’ll have some employee ones, but we want to try and have as many as possible, which is now employed because we want to ensure that that’s their status for tax purposes.

So, yes, if you’re genuinely self employed, you should be able to take as much holiday as you wish. I do have clients who do not dictate how much holiday their associates take. They will say, as long as you hit your KPI’s, your key performance indicators, whether that’s an NHS target, or a private target, whatever it may be.

I don’t care how much holiday you take. I have to know when you’re taking that holiday, because I have to arrange the practice. And do bear in mind, that if you take holiday after a certain number of days, you have to put a locum in place as well, to fulfill those terms.

[Jaz]
Okay.

[Sarah]
So yes, if you want belt and braces approach, you will not dictate holiday within a contract. Having said that-

[Jaz]
Most contracts do, right?

[Sarah]
Because the commercial reality of running a business is that we need to know when you’re around and need to put patience in. What I would say on this point is that you can make it work. If not to have a clause in. Regulating holiday, but you have to be super organized for it to work.

And this is why most contracts will say you can have this amount of time off, but you have to let us know within so many days. Going back to the HMRC point about status, it’s one indicator. Which doesn’t satisfy self employed status. We don’t look at individual indicators. We look at numerous ones. So the commercial risk is we’ll control holiday, but we’ll have lots of other self employed indicators in there.

What’s fair and reasonable? I’m going to say it depends on the practice, depends on the type of dentistry, and I would say-

[Jaz]
Associates everywhere now, inching closer to the speaker.

[Sarah]
All I would say is just watch out, because sometimes the time off clause or the time away from the practice isn’t always full holiday entitlement. It can include time off for CPD, training, things along those lines. So just be careful. Have again, it’s the detail of the cause that you need to look at when looking at holiday. But I see some practices that will have six weeks, eight weeks, 12 weeks. It depends. And don’t forget again, when we look at bargaining power, associates are in a strong position.

Again, so just because the contract has come to you and it says six weeks, if you would like a little bit more, go to this practice owner and say, six weeks doesn’t work for me. Can we push that to eight? and see what they say.

[Jaz]
Great. Lovely. Fantastic. The next one, which I think the medical legal element come in more into play here, Neel, is the whole thing about when you leave, you cannot work within the X miles radius within the clinic.

So from what I’ve read on the University of Facebook, is that is something that’s actually garbage and it’s not really enforceable. So you can ignore that is the kind of word on the street. So is there something that we can essentially ignore because it’s not enforceable or is this something that’s to be really highly respected? And then we’ll take it from there.

[Neel]
Well, from my point of view, it probably isn’t an indemnity question, but I think it’s one of those things, again, the whole point of all these things is the GDC gets involved at some point. I’ll tell you how, Sarah is saying unfair, or the associate doesn’t want to, or the retention fee hasn’t been paid.

The practice then wants to retaliate. Somewhere in the line, GDC gets involved. And again, the same with these exclusions there. Someone’s not that happy about something, the associate will say, they don’t wash their instruments, so they don’t change their needles, or the practice will say, oh, they don’t write their notes. So the whole point of the indemnity thing is we see it because these systems before, these contracts before, and the relationship isn’t like you have, you know, a trustworthy relationship. And unfortunately, not everyone is trustworthy, we like to think we are.

[Jaz]
So really the bigger picture here is if we focus hard on the initial bit of the contract to make sure that it’s worded in a way that’s tasteful for both parties, therefore it will help reduce claims overall because you’re starting on the right foot, right?

I don’t want to hear about these things. I don’t want to hear about some GDC thing and this and this and it’s over nothing. And it’s putting everyone’s fees up, for example, it’s putting our GDC fees up because they’re wasting time. And the poor people at the GDC waiting to be heard. Waiting two years because of these disputes which Sarah could have nipped in the bud.

[Sarah]
Yeah.

Interjection:
Hey guys, it’s Jaz interfering here with an important message. I just want to say thanks to Dr. Neel Jaiswal who represents Professional Dental Indemnity. It’s who I’ve got my insurance policy with and you may remember episode GF019 we talked about Indemnity Versus Insurance to actually understand what is the difference between those two things and why I went for an insurance product.

As well as Neel being one of the good guys in dentistry and always someone to support you with medical legal matters, i. e. looking at your existing arrangement, looking, picking out the flaws that actually have you considered this or have you considered that? And one of the things that Neel was able to introduce to our community, Neel is actually part of the Protrusive Dental community.

You can DM him on Protrusive Guidance and he’s super, super helpful. So if you’re getting to that time where you feel like you’re paying way too much, like every year your indemnity is increasing, and it’s about time you switch to an insurance product, assuming that’s correct for you, which is why you should probably reach out to Neel if it’s time to renew.

And you can visit protrusive.co.uk/insurance as part of your quote, you get a little discount about a hundred pound discount, which is nice, but the discount you’ll get compared to some of the other products out there for a very high quality insurance product that will cover you medically legally is well worth considering save me thousands. So I just want to pass that on to you. That’s protrusive.co.uk/insurance. And of course, reach out to Neel on protrusive guidance. Let’s join the episode again.

[Jaz]
Sarah, X miles away from the clinic, you can’t work, within X amount of time, whatever, what do you make of all this?

[Sarah]
Yeah, so, it’s been like this for years. Oh, they’re not worth the paper they’re written on, just ignore them, nobody does anything about it. Apart from, I make a living out of doing things about it. And I’m sure lots of other lawyers do as well. So I would say get them checked so important that you do get these causes check from a practice owner’s perspective It’s the only way that they can protect the goodwill of their dental practice, especially private dentistry because as a patient you like to know who’s putting their fingers in your mouth and you’ll go back to the same dentist you’d like to know who your dentist is.

We can brand and have practices where we’re trying to attract them to the practice but ultimately you still like to go back to your dental associate to look after you. So the only way a dental practice can protect its goodwill is by incorporating these restrictions and they have numerous names.

Restrictions, restrictive covenants, barring out clauses, binding out clauses. And what they do is they say, look, you’ve been in contact with my patient base. And what I don’t want you to do is take those patients when you leave. And sometimes they also say that in respect to the staff. And when we say take the patients, it’s contacting the patients, dealing with them, or I don’t want you to set up within a certain radius and be my competitor so that all the patients go.

And dental practices have a legitimate business interest to protect by putting these restrictions in. So what they do is they satisfy the first test for restrictive covenants to be enforceable. The next two tests whether you’re restricted for a reasonable period of time and whether you’re restricted within a reasonable radius.

[Jaz]
So, what is a reasonable, yeah, in your experience, reasonable terms?

[Sarah]
So, time is a bit easier because, again, it depends on the practice. So, general dentistry, 12 months, I would say, would be enforceable. For general dentistry, trying to stop somebody for 24 months. 36 it’s going to fail because you’re not being reasonable because within that 12 month period you should have seen the patient again.

So that’s the idea behind it. If you’re a specialist you might get a little bit longer. If you’re doing ortho treatment over a period of time again a little bit longer but in my experience 12 months seems to be reasonable. Radius it depends on the practice and where you are in the country. And where the people visit you because they travel to see you.

So if your practice is based in Cumbria and the nearest competitor is 10 miles away, 10 miles. If you’re in a built up area, your nearest competitor’s five miles, five miles. Wimpole Street. It’s a bit difficult to see what’s reasonable and that’s basically-

[Jaz]
500 yards.

[Sarah]
Exactly. And that’s basically how it works. And then again, then we come back to why these contracts need to be drafted to be specific to the individuals and what works for the individuals because it will differ. Just picking up on the point that Neel said, I do agree that what happens when two people get into a dispute is that they do try and armor themselves in lots of different ways and being regulated one of the things that dentists seem to default to is I will report you to the GDC if you don’t let me, blah, blah, blah, that tends to be how it goes.

I think what is quite good, I would say, is that the GDC do tend to understand when it’s coming out of a different type of dispute. In terms of, this is a contractual dispute and you’ve said this because you’re in the middle of a dispute, basically, they do tend to read between the lines, they look into it, don’t get me wrong, but we do seem to have that element there because one of the questions is, why didn’t you raise this six months ago? But yeah, it does tend to get thrown about a bit the GDC when people are in disputes, which is a shame that the body’s being used in that way.

[Jaz]
Totally, total shame. But I think we can conclude from this question is actually is, it is a reasonable thing to have in a contract as part of a practice viewpoint. And it’s just worth checking that the terms within it are reasonable to your individual clinic in the area that you work in. So fine, I feel better about seeing that in contracts now. The last thing we have to cover then, because there’s so many, there’s millions of things we cover, but in terms of maximizing our time here or maximizing the impact from our time is vicarious liability, right? So Neel, can you, can you explain what vicarious liability is?

[Neel]
Well, again, me just being a dentist, I’ve had to look at it quite clearly and try and understand it myself. And perhaps a little bit in layman’s terms as well, which I like it. So there’s two parts to it. There’s this non deligible duty of care, which our friend Simon Thackeray is always very good at talking about these things.

And again, I’m not sure we understand it, but for me as a lay person, I would say if a patient comes into practice and you’re my associate, and he sees you, but you come into my practice, does the practice have a responsibility to the patient? So the non deligible duty of care is something where the patient has, the practice has a responsibility to the patient, regardless of who is seen.

And I think as a practice, we’d probably agree on that as a principle, because we feel there are patients, even though you’re seeing them. We’re talking about not poaching patients. So I think probably we have a non deligible duty of care. So there is this thing is, you’ve come to Neel Dentistry.

Whoever you’ve seen in there, they’ll knock at our door when they have an issue. So we have a duty of care for them. Now, the vicarious liability part of that is, are we responsible for what’s happened to them? So if they had some negligence from the associate or who didn’t do perforated or did something right or wrong, does the practice have any onus in that? Now they might argue you didn’t give any instruments.

[Jaz]
Individual human error of the associate is that now, can you now point a finger at the practice, basically, right?

[Neel]
Exactly. And the famous lawyers who like to go after dentists and advertise tend to go after the practice because the associates can move around, they can go abroad, they can be off the list, and they know the practice has an address, has assets is an easier target.

So therefore we have to protect ourselves and I’ve got vicarious liability as a practice because it might not be to pay out a claim. Although I’ve seen that happen. I’ve seen something else I’ll tell you a sec, but it might be to defend the claim that actually we don’t have a vicarious liability issue here. We have a deligible duty, but we don’t have the VL. So that’s why you might need some money. or an insurance to have that set up to practice.

[Jaz]
So you mentioned you had vicarious liability as a practice, do you mean you had vicarious liability insurance as a practice?

[Neel]
Insurance as a practice. So we have it as a practice, and if you’re partners, you should have it. What I have seen is some principals have it as part of their indemnity. So there are a certain insurers out there will give you a week. We give you the L, but they put it on your policy. The problem with that, I feel is let’s say you went on maternity. Someone comes along, does some negligence, goes away abroad.

You’ve never seen the patient. Now the vicarious liability that is now here on the practice comes out of your own indemnity. So your indemnity, which might be three grand now goes up to 15 grand because you’ve taken a hit personally. So I think it’s better. And again, you’d have to get proper advice to have the entity.

If you on your own, or if you’re going to sell it to a partner or sell it to somebody, the business has the VL policy and don’t have it attached. We’ve seen a lot of people with a certain insurer have got attached to their individual policy. So I would keep them separate. So ensure the practice for the BL because you need insurance, not to say that you will pay out, but you have to defend it at least and you want to defend that VL.

But you do have the duty of care, which is why it’s in the best interest for the patient, which is what’s most important, is that the associate and the patient and the practice will all work together. I’ve also seen it in some corporates where a complaint comes into the front desk and the receptionist goes, oh, that dentist’s name is this.

It’s his GDC number. There’s an email. He’s treated you deal with it and that’s dropping the associates in the lurch and I’ve seen that at big corporates and again that doesn’t help anyone. So I think with all this, coming full circle is associates and principals, we’re tending to try and be opposites. We actually will be much better if we work together, whether it’s disputes, whether it’s contracts, whether it’s dealing with things, we’ve got to try and get the love back a little bit, Jaz.

[Jaz]
Absolutely. And so Sarah, they’ve been all very fascinating, scary as well. So how is this element of a vicarious liability managed in the standard contracts that you see and you help with and how much of the contract does this part take up?

[Sarah]
Yes, so, vicarious liability is a term which as an employment solicitor we’ve used for years because as a practice owner you have always been vicariously liable for the actions of your employees. So, to give the example, one employee discriminates against another employee. You might think, well, it’s between them two.

I haven’t done anything wrong, but actually it’s in the course of employment. You’re vicariously liable for their actions. So they will sue you as the employer. And that it, this has been the case forever, for as long as I can remember. I think why it’s really come into the dental industry is because we’ve had numerous cases whereby it was decided, as Neel has set out, that actually now the practice owner can be liable for the clinical treatment of the associates.

[Jaz]
Of the self-employed associates.

[Sarah]
Yeah, which was never the case before. And the reason why it was decided in those cases is because what the key here is that those relationships between the practice owner and the associate, it’s been identified that relationship is akin to an employment relationship.

So they looked at these indicators that we spoke about. And I think, as you said, Jaz, if we went into self employed indicators, we really could speak about it for hours. Well, I could speak about it for hours. But if we’re going back to, are they genuinely self employed? How many indicators do they have?

So that’s the first thing we would always look at and also make sure in the agreement to try and ensure that the relationship is not one that looks like an employment contract, so that’s the first thing. Secondly, yes, there are clauses within the associate agreements now about vicarious liability. Like, for example, if I become liable for your treatment and it’s you that’s made the mistake, but actually I’m the one that’s sued and I have to rely on my vicarious liability insurance to deal with this, you’ll indemnify me. So you pay me back, you’ll owe me the cost of that because I didn’t do it and you’re self employed. So there’s little clauses like that, that you need to leave it.

[Jaz]
And that’s fair, right? Is that kosher?

[Sarah]
Yeah, it’s kosher. Yeah, don’t have any issues with it if both parties agree to it. So, yeah, you do have to be careful and make sure that you understand those clauses and what you’re entering into.

But yeah, that those are clauses that we’re seeing where the practice owner is now trying to protect themselves from these claims being made. Because of course the practice owner will not, well, I say will not, but shouldn’t or doesn’t tend to have much to do with the clinical treatment that the associates providing.

They won’t mentor them day in, day out to this, the extent that maybe they would want to be or should be. Firstly, because they’re self employed, that’s the main reason for it. But also they are meant to be self employed clinicians. And we don’t, we don’t have the time to be mentoring associates to that extent.

So yeah, there are causes being included in the agreements. And again, we come back to make sure you understand them. And usually with the agreement. We would always say, make sure you have the right insurance in place that sits alongside it. And so there were always two elements, whether you’re the practice owner or whether you’re the associate, you need the contract, right? But then you also need the right insurance. That’s really important.

[Jaz]
I think the key message here is get every element of your contract check. I totally have a heightened awareness and importance of the contract for sure. Neel, is there a story, this final thing, is there a story you want to share before we wrap up?

[Neel]
It was just that a principal went on maternity, the associate fled the practice after some theft, et cetera, and 200 grand payout from the principal. So all these things have huge implications, right? And we always believe in justice, but the right and wrong on the end of the day, you’d never know what’s going to happen. So don’t go and trust, trust is a great thing, but just back that trust up with some proper due diligence.

[Jaz]
So in this day and age, although the contract very much still is, in my opinion, something you pick up when this disagreement happens or when you’re entering this hazy territory, you better make sure it’s a good contract, right? It’s good.

[Neel]
It’s too late by then.

[Sarah]
I know. Dentists completely understand. Prevention is better than the cure, so take that with your contracts as well.

[Jaz]
Fantastic. Neel, Sarah, thank you so much for your time. I really appreciate it. Sarah, but for those hundreds of associates now be reaching out to you to just get, can you just go answer my contract? How can they reach out to you?

[Sarah]
Yeah, of course. Thank you so much. If you can Google or go to our website, it’s www.BuxtonCoates.Com. There’s information about how you can get hold of us and they’re all our telephone numbers. There’s a contact. You can email us, but also on our website, there’s more information about this.

We do blog quite often to try and make sure that dentists and practice owners know what’s relevant in the industry and what they should be looking out for. So there might be some information there, but we’re always happy to help people. So thank you so much.

[Jaz]
Well, I appreciate you giving up time to discuss this really important topic. I think this has been the most tangible piece of content around contracts that I’ve ever been in discussion. I’ve ever been involved in more than any lecture I’ve ever been to more than any webinar I’ve ever seen. So thank you so much for answering those questions. So wonderfully, Neel, my friend, I hope you’re nodding there. You agree. How can we reach out to you, my friend?

[Neel]
Always happy to. You can find me on the protrusive app, which is obviously this really new platform that Jaz has. And-

[Jaz]
Totally DM Neel on there.

[Neel]
Yeah. You can just DM me there. Or I think there’s a, you get a special deal if you mentioned Jaz’s good name. So, yeah, Neel @ProfessionalDentalIndemnity. WhatsApp or Facebook or Messenger or TikTok. I’ll be, I’ll find you.

Jaz’s Outro:
Amazing. Thanks so much. I’ll put both your links and whatnot in the show notes. Thanks so much for a fantastic episode.

Well there we have it guys. Thank you so much for listening all the way to the end. I will put Sarah Buxton’s details in the show notes and also how you can reach out to Neel as well, of course, reminding you that if you do a renewal for your indemnity or insurance product, do check out PDI and the good guys at All Med Pros. The way to capitalize on that is. prortusive.co.uk/insurance.

Make sure you get a quote from these guys before you commit to renewing with whoever you’re with at the moment. This episode is eligible for CPD. You can get one hour CPD because let’s face it, this was very educational, right? You were listening and you learned something. So why not get a verifiable CPD Certificate and you can do this for this episode and the hundreds of other Protrusive episodes on our network Protrusive Guidance.

Just answer the questions and our CPD Queen Mari will send you out a certificate every week and also every quarter and every year she’ll remind you of all the CPD that you’ve completed with Protrusive. I just want to thank my team, Erika, Krissel, Mari, Nav, Gian, Emma, Rakesh and Sophie, the list is getting longer and longer week by week, for helping to keep me afloat, right? So there’s so many things to do in Protrusive, so that’s why I’m so thankful to having the team to keep our community thriving. And thank you once again for listening and watching all the way to the end.

If you’re on YouTube, please hit that like button, subscribe button, share it with someone. And if you’re listening on Spotify and Apple, again, you guys are the OGs. Thank you so much. I’ll catch you same time, same place next week. Bye for now.

View Details

Have you ever considered Dental Aid Work?

Imagine giving up your morning starbucks and your air conditioned dental surgery to work in a developing country that has just 7 dentists.

Fellow Protruserati, Dr James Hunter and his young family will be doing just this – they are preparing for a four-year mission to Liberia, Africa, to dedicate themselves to dental aid work.

Follow along as we delve into their story of skill, passion, and humanitarianism.

https://youtu.be/lzKVmuuUvBIWatch IC050 on YoutubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:
00:00 Introduction
2:52 From Theology to Dentistry
5:35 Dr. James on Dentistry
06:44 The Decision to Move to Liberia for Aid Work
09:52 Understanding Liberia’s History and Needs
15:28 The Future Plans for Dental Aid in Liberia
18:37 Motivations Behind the Mission
20:04 The Challenge of Committing to Charity Work
20:57 Financial Planning, Schooling and Adaptation for Children Abroad
26:40 Sharing Experiences and Encouraging Aid Work
28:13 Raising Awareness and Support for the Mission
32:09 Closing Thoughts and Encouragement

Be sure to visit https://www.thehuntersinliberia.co.uk/ for details on supporting charity work in Liberia. Additionally, explore other charity websites in your country for more ways to make a difference locally.

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Protrusive App!

If you enjoyed this episode, don’t miss out on watching “The International Dental Student – From Ukraine to Egypt to Slovakia – IC047”

Click below for full episode transcript:Jaz's Introduction: As dentists, we are in a privileged position. I know it's sometimes hard to fathom that and hard to come to terms with that because of all the doom and gloom that we sometimes like to focus on.Jaz’s Introduction:
But really, we are in a beautiful profession, and we can actually mold our profession how we want to. Now, there might come a time in your life, if you’re that way inclined, to take your career towards dental aid.

This could be at the start, the middle, or even towards the end of your career, which is quite popular, to donate yourself, donate your skills to charity. This could be in a refugee camp, this could be in a third world country, to provide a much needed dental service. So on today’s episode, I’ve got Dr. James Hunter, who, with his family, so him, his two kids, his wife, are moving to Liberia, which is a small country in Africa, and he’s going to be, hopefully, working there for about four years.

That’s his provisional plan, along with his family, providing dental aid, which I just think it’s so so noble. So, what this episode wants to do is basically let you know about the different aid opportunities out there. And actually, just had this interview with James to find out what are his motivations.

How do you get involved with this? But how did you even have that difficult conversation with your spouse, with your children, that you’re going to move to this country in Africa and for the next four years of your life you’re going to leave the rat race? You see, a lot of us would struggle to say, you know what, I’m going to give up the income, I’m going to give up the house, give up the practice, give up the cars and move to a third world country and work for free and just do a beautiful charitable thing, which is exactly what James and his family are doing.

But James and his family are very, very rare individuals. They are gems. They are the gems of this planet. And I want his story to come out and it might inspire you. It might inspire you to maybe take two weeks out of the year to do some dental aid work. It might inspire you to just take the next step and actually start researching about, hmm, at what stage in your career might it be worthwhile and possible for you to give back to the world? Because there’s so many countries where we could help. We could actually give some dental aid. We can actually serve through our skills and our knowledge.

Hello, Protruserati, I’m Jaz Gulati and I’m the host of Protrusive Dental Podcast. If you’re new to the podcast, great to have you here. If you’re a returning listener or watcher, thanks so much for coming back again. This is an Interference Cast. This is a non-clinical arm of the podcast. Got loads of other clinical episodes and CPD and this particular episode is not eligible for CPD, but it’s got lots of gems in there, but I think this will inspire. I think this is one of those episodes which you take away and you become inspired about such good out there in the world and we start focusing on and how you might be able to also contribute to the world and how our skills can benefit the world.

In this instance through a charitable cause. But we are in a privileged profession to be able to help and of course, get people out of pain and cure infections. So let’s listen to James now. Why is he and his family moving to Liberia for four years? Leaving the rat race and doing this beautiful, beautiful thing. Let’s find out.

Main Episode:
James Hunter, welcome to Protrusive Dental Podcast, my friend. How are you?

[James]
Yeah, good. Thank you. Thanks for having me on.

[Jaz]
I’m very excited to unpack your story. I mean, I have a gazillion questions. You don’t even believe that. When I read your proposition, which I’m so excited to tell everyone, I was like, how, like, it’s just brilliant. So just tell us about, like, just go back to the beginning. Tell us about you as a human, as a dentist, and what are the different steps that culminated in you doing this soon, this huge aid work abroad?

[James]
Cool. Yeah. I say, thanks for having me on again. I’ve been listening to you since my foundation training. So I say, I think, you’ve probably had a bigger impact on my dental career so far than my degree did. So yeah, it’s awesome to be on. So studied dentistry in Cardiff. Graduated reasonably recently. I’m 33 but did it as a mature student. So I graduated in 2019. Prior to that, I actually did a degree in theology.

So kind of back at A levels, I was more interested in humanities. So I did Latin maths and ancient history at A level, and then I went to Exeter to do classics. And then I kind of, during the summer, wanted to switch to do half classics, half theology. And then after my first week there, I decided I never wanted to do Latin again.

So, did a three-year degree in theology, which I loved and in first year met my wife. So got engaged at the end of second year. And it was at that point where I was like getting ready for our wedding at the end of third year. And I was like, flip, I need to get a job if I’m going to get married after this.

And it suddenly like dawned on me Theology, like I really enjoyed studied it, but it’s kind of a degree that leads you to apply for kind of grad schemes. And I realized none of those really suited me. I mean.

[Jaz]
That’s a huge transition, isn’t it? That’s a huge transition going from the humanities and theology to dentistry. So yeah, I mean, tell us more about that.

[James]
Well, I think I was really not sure about what I wanted to do and felt like I was dawdling. So I kind of got, tried to get as much work experience as I could in different places. I got a work experience place with my old dentist and absolutely loved it. I just thought, how have I not thought of this as a career?

So I made a really big change and decided to apply for a dentistry degree. So I had to do it with a prelim year. So it ended up, there was only a few uni’s which offered that, but ended up getting into Cardiff. So we got married and moved to Cardiff. I did a year, preliminary year at the beginning. Which I hate to say is, I don’t want to say it’s a waste of time, but it was probably a bit of a waste of time that first year. Like I remember one of my first assignments was doing a prostho project on nudibranchs, those sea slugs.

[Jaz]
Oh, wow.

[James]
So I remember thinking this didn’t feel super relevant to dentistry, but so I did that, absolutely loved dentistry at uni. I really kind of feel like, even though it wasn’t something that was on my radar, kind of through school. I feel like when I started, I just realized it was a really, really perfect fit for me.

[Jaz]
Can I just unpack that? Cause we’re talking while we’re recording, it is in the middle of a stress awareness month. So decisions that we make and where we go into like your perception of what dentistry was.

As a mature student, someone who had a few more years under your belt, had been the real world a bit, and then you did some work experience and you thought, okay, this is cool for you. What is it that gripped you about dentistry at that work experience? What are the things that you saw that, okay, this suits you better than the grad scheme? And then also just tell me, when you became a dentist, did the perception meet the reality?

[James]
So I think the two main things for me were just the variety of patient interaction. I absolutely loved that. I really loved watching that guy for a week and just seeing the variety of patients coming through the doors, interacting with kind of sweet old ladies with their dentures and kids.

And that coupled with, I think just a really, really intricate kind of technical aspects of dentistry. I used to love doing kind of airfix models when I was a kid. And so seeing him kind of working through his loops and doing these kind of fine mechanical things, I thought I’m going to love that.

And yeah, that’s kind of the elements of dentistry I really enjoyed throughout my degree. And then I think now working in general practice, that’s definitely the element I love. Yeah. In my happy place is kind of working on a tooth under rubber dam, just little fine things. And then, yeah, just getting to know patients. Like I’ve been working at the same practice for about three and a bit years now. And it’s just really lovely kind of seeing the same patients in the now getting a relationship with them.

[Jaz]
So, but you’re leaving them all now.

[James]
I would say the thing which put me onto it the first bit. Yes. Yeah.

[Jaz]
So tell us about this huge, I mean, so it’s basically like, probably in the intro would have already spilled the beans about you moving to Liberia with your family, right?

[James]
Yeah.

[Jaz]
So just tell us about how this came to fruition.

[James]
So I guess short term and long term. So like long term my wife and I had always, since we first met, we’d like the idea of going and doing aid work in some capacity in the future.

[Jaz]
And your wife is, what kind of industry is she in?

[James]
So she’s been a stay-at-home mum for the last five years. So she did the theology degree. After that, she did a master’s and then worked for a charity. So she’s non-medical.

[Jaz]
But the relevance there is that she already had this, she already worked for a charity. She had that sort of inner desire to help and very charitable values already embodied within her.

[James]
Exactly. Yeah. So I’d say it was kind of a mutual thing that we’d both wanted to do that in some capacity. And then, making the change to do dentistry, suddenly it gave me something tangible and practical to use. Right at the very beginning when I was kind of applying for the dental degree, it was timing that in that summer after my theology degree ended, I went out to Sierra Leone for a few weeks to visit some friends who were doing kind of kids aid work in a charity in Crewe Bay in Sierra Leone, and I saw there was a local dental practitioner in the hospital there.

So I went and saw him for a day right at the very beginning. And I think even just spending a day with him in this clinic in Sierra Leone, kind of stuck in my mind as, okay, I think this is something which we should work towards. It was kind of all through the back of our mind during like the dental degree.

So actually we’ve got a five year old boy and a three year old girl. And we had my son at the end of fourth year. So kind of had him, had a kind of a new baby also fifth year. And it meant that wasn’t the ideal time. It’s funny. It’s a mix. It was tough in some respects, but it was also so lovely.

You know, the hours at uni, although you’ve got a lot of tough study, quite flexible. So, I remember kind of walking around the park in Cardiff with him strapped onto me with my flashcards, like revising, which, was lovely in some aspects, but so we kind of, I did my finished my degree then had my foundation training in Cardiff and yeah, we kind of looked into doing maybe the kind of an aid work move straight off the foundation training, but then COVID hit.

Bang through the middle of it. So that put a bit of a halt on everything there. So we kind of just into the back of our mind and then we can kind of get onto the way we heard about it. Like, so all through the dental degree, I’ve been part of the Christian Dental Fellowship and they’ve got a kind of a quarterly newsletter, which they kind of go through.

They’ve got a few kind of mission work aid work partners around the world. So they were kind of talking about different things which they were doing. So I think that again, kind of put us onto that as something in our mind to go do, and basically now our kids are five and three. We both earlier last year felt that now was maybe the time when they’re young prior to being more established at school. And so, yeah, we’ve been kind of pushing that door for the last almost 12 months now.

[Jaz]
Amazing. So your five year old is in on it. He, is it he or she?

[James]
Yeah, they’re all in on it. Yeah. He, yeah, Max.

[Jaz]
Max knows. Max knows and he’s come to terms and he’s looking forward to it kind of thing. You brainwashed him enough. Yeah?

[James]
Yeah, absolutely. Selling it to him, yeah, selling it to him so he can go, yeah, hunting crabs on the beach and stuff like that.

[Jaz]
Very cool. Well, why Liberia and where is, for those who may not be geographically gifted, where is Liberia in the world and what is the current situation? Why do they need aid work?

[James]
Okay. So Liberia is a relatively small country in West Africa. It’s about half the size of the UK in terms of size. And it’s got a population of just over 5 million. It’s bordered by the Atlantic Ocean, Sierra Leone, Guinea, and Ivory Coast. It’s in that kind of area of Africa. Yeah. I mean, the reason we’ve ended up choosing there is that through that Christian Dental Fellowship magazine.

We heard about an organization called SIM, which is kind of like a Christian organization, which has lots of different things. They do kind of disaster relief, sports, teaching, Bible translating, and lots of medical stuff. And so they’ve got kind of dental outreach things all over the world. And they’re kind of set up for longer term stuff.

And so we just sent off an application to them and just said, we would be interested in kind of hearing about what the options are and, I think that, big takeaway is that there are a lot of opportunities for dentists to do aid work. We are really needed all over the world. And so we got sent Madagascar, Peru, Paraguay, Senegal.

Yeah. Lots of different places, but one of them was Liberia. We found the dentist who’s currently the lead dentist of the clinic we’d be going to a YouTube presentation about his work out there. Although maybe a Africa wasn’t our first choice from kind of a top destination to go to. I think, you know, we got off at some places which were basically like Madagascar would be really cool to go to, but just hearing about this guy’s work was really amazing.

I don’t know. I can talk a bit about the, kind of the, I think the context of the recent history of Liberia is quite useful to set up maybe kind of why and what they’re doing. Yeah. Liberia is basically a country where it’s super tough. recent history. They got a new country. It was set up like at the, basically the early 19th century as an outpost for freed slaves from America to go back to Africa.

[Jaz]
Hence the name Liberia, freedom, liberate.

[James]
Exactly. And even like the Liberian flag is kind of like a single starred version of the United States flag. I don’t think it was ever officially a colony, but it was kind of originally established as that. And so over the course of about 25 years, 4, 000 or so freed slaves from America moved to Liberia.

Only about 1800 people survived just from the harsh conditions and tropical diseases, but it eventually achieved independence in 1847. And after that, basically the. America Liberians, who’d been these free slaves, they kind of ruled or were in charge more or less socially and politically of the country.

And that led to quite a lot of tension that eventually kind of bubbled up and led to a violent military coup in 1980. And so the America Liberian president was killed. And the first indigenous Liberian president kind of established control as the new president, his government was kind of overrun with nepotism and corruption.

And there was persecution of rival tribes. And that led to then a really brutal seven year civil war from 1989 to ‘ 97. During that period, about 200, 000 people were killed and hundreds of thousands of Liberians were kind of had to flee as refugees. There was a tentative two year piece at the end of that.

The guy who came It was in control after this guy called Charles Taylor, I think he campaigned on the slogan. He killed my ma. He killed my pa. We will vote for him. So it was kind of a tentative piece for a couple of years. And then that spilled over into a second four year civil war in 1999. And that led to almost a quarter of a million people being killed and almost a million people being displaced into neighboring countries. So it’s had a, like in recent history, a really devastating history that’s left the whole country kind of in a really-

[Jaz]
Well James, thanks for educating us. But like how is how is it now? Is it are you scared not just generally because the change but regarding the political stability and that kind of stuff Is there a fear element there?

[James]
I don’t think so now. Yeah, which is really good. So since that finished since that civil war finished in 2003, they’ve had kind of fair and free elections, most recently Former president was George Weah, who was former FIFA footballer of the year. He spoke at AC Milan and he recently lost and there was a peaceful transition.

So I think that the takeaway is that it’s a country with a hard past, but it’s, it’s like rebuilding itself. And the thing that’s hard is that in the backdrop of all this, a lot of the infrastructure for medical stuff was destroyed. And so on the organization that we’re moving with, they established a radio station prior to the war and then hospital.

A lot of that was just destroyed. It was rebuilt after the civil war. And in 2008, the mercy ships were in Freetown. So not in Freetown, in Monrovia. And two dental clinicians felt that there was a real need for a land-based facility for dental care in Liberia. So it was nothing like that at the time.

So they established a dental clinic in the hospital on the compound that we’re going to be moving to. That was kind of originally manned by kind of a mixture of expats and Liberians. But most recently in 2017, the guy who’s currently running it, there’s this guy called Simon Stretton-Downes, OBE, which I’ll mention, so don’t tell me off otherwise.

But, he moved there. It was going to be run by a couple of Liberian clinicians who weren’t dentists but had kind of some informal training and they were doing things like extractions and fillings and cool stuff like jaw wiring after motorcycle accidents. They taught Simon how to do that. And so he turned up. And. he’s kind of transitioned the clinic into a new phase, which I could talk about unless you want to, you want to jump in. I’m talking.

[Jaz]
I have a million questions. Cause I think what you’re doing is so noble, so brilliant, but just tell us about just some facts. Like you’re doing this project. You’ve got like this, you had some time, think about it. You’ve had time with the family to make a position. What is the plan? Like when are you going? And when do you envisage you’ll be done? Is there a tentative end date where you think, okay, we’re going to come back to the UK. Like what are your rough plans?

Obviously, life throws things at you and you may change and you make decisions dynamically. But what’s your rough plan?

[James]
So our rough plan is to move out there January 25. The reason why we’re kind of hoping to go with that period of time is that the guy who’s running it at the moment is in his kind of mid 60s and he’s due to retire.

They’ve kind of had a, I think, seven years there and they said that they were going to stay until the dentist who was originally there, or the guy who was originally when they arrived, they put him through dental school in Nairobi, waiting for him to graduate. And so he’s graduating hopefully beginning of next year.

And then they are looking to retire in the middle of the year. And so they’ve got a team of four expat dentists at the moment, the main guy, Simon, Lady Melvina, who works there a couple of days a week. And then two dentists who arrived last year from India called, Renju and Serin. But all of them, apart from Melvina, got kind of maybe a bit of uncertainty about how long they’re going to be staying there.

So it’s in this transition period. So we’re hoping to try and arrive and fill that gap. One of the things that’s amazing about what Simon’s done is he’s kind of worked on the clinic. To expand that, there’s a team of about 40 now, about 20 clinical, one Liberian dentists, three more who are due to kind of qualify in the next few years.

What’s really cool is that he’s established the first kind of dental training facility in Liberia. So he started something called the Liberian Dental Therapy School. And the aim is for that to be a really sustainable, ongoing positive impact for the dental care in Liberia, because they have no dental school, no training.

They’re really relying on people training externally and coming in or expect dentists coming in. Whereas with this plan, they’re training hopefully seven therapists a year. The aim is 70 over the next 10 years to basically receiver degree is being credited by Peninsula Dental School and there’s a university in Liberia who are kind of awarding it.

And the aim is that they’ll learn how to do basic dentistry that they can carry out with DentAid field kits, which are being kind of donated to the graduates. And then they’ll go back to their counties. At the moment, only kind of a small area of Liberia has any kind of dental care. And so we’re kind of going to be there probably for the first stint about we’re aiming for a four year initial period, the organization, which we’re going with want us, they kind of want us to come back at two years and reassess, which we will do. But the guy, Simon, he was kind of more or less saying, look, I’d mentally prepare for four because your first year is going to fly by.

Just at year two, you’ll probably feel like you’re getting your feet under the table. And then all of a sudden you’ll be leaving. So the aim is January 25 for about four years. We’re kind of mentally preparing for.

[Jaz]
When you think about when we were entering dental school and then people had different motivations in life, right? People had, I’ll be honest, lots of friends will say, openly say, or secretly say to me, you know what? I kind of Googled high paying jobs. I saw a dentist and I went into dentistry for that reason. A lot of colleagues will say that. A lot of colleagues also say, oh yeah, I like my work experience or I had braces and therefore I like the positive impact it gave me.

I like the cosmetic side, whatever. You’ve sort of described about your journey in dentistry, but what I want to know now is, what is your prime motivator in doing this amazing thing in Liberia to help a nation, help a community, help with such a huge task, healthcare related? What are yours and your family’s motivation over the next four years to contribute to this?

[James]
Yeah. So I heard you on the dental masters podcast once say, don’t talk about politics or religion, but-

[Jaz]
Go for it. I’ll make an exception.

[James]
Yeah. My wife and I are both strong Christians. And so I think even when we first met. Wanting to, to go do some kind of aid work in some capacity was really on our hearts, ultimately as a Christian, I think I have one life and I want to use it well to do the work that I feel God has installed for me.

And I’m not saying that I decided to do dentistry for purely altruistic reasons or anything like that. I thought it was a career that really suited me, and I really love it. But I think just at this period, it works really well for our family, for this to be a period where we explore going to do this and it’s been on our hearts and minds for a number of years now, and my wife and I both felt that kind of tug kind of grow last year. And so yeah, ultimately I would say that-

[Jaz]
The Christian values is to fulfill those Christian values, isn’t it really?

[James]
Yeah.

[Jaz]
Yeah. Very good. I mean, what I’m thinking is-

[James]
I give an account from my works.

[Jaz]
Yes, absolutely. Well, I think a lot of co colleagues, if you said to them that, okay, drop everything you’re doing, drop your practice, drop your Invisalign, drop your tools, and do some charity work, four years, it sounds like a great thing to do.

Obviously it sounds wonderful. But to actually commit to that is a huge deal because what happens is we enter the rat race, we enter the rat race, we get a mortgage. We think, okay, keeping up with the Joneses, get a two bedroom house, get a three bedroom house, expand, get a practice, get a second practice.

The whole thing about possession, the material, you enter the rat race. And that’s one of the reasons why me and my wife went to Singapore when we did, because we hadn’t entered the rat race. We were just fresh out from hospital. And we thought, okay, if we get a mortgage now, we’ll enter the rat race and we’ll never get to travel kind of thing.

And so we did that. We worked in Singapore privately, which is great. And we also traveled, which is great. What you’re doing here is like, wow. Like it’s altruism, but it’s also this scratching an itch of doing something that is a really once in a lifetime, like amazing thing that you’re gearing up to do.

But do you have any doubts about leaving the rat race and your financial future for your kids? And also, I also want to just talk about schooling and what the schooling situation will be like, and what have you got for the future? I’m just very interested in thinking about the kind of doubts average dentist would have about dropping everything four years.

[James]
Yeah, I mean, I 100 percent agree with that. One of the things my wife and I always said was that we would like it ideally to kind of coincide with a transition period in my job. I’ve been really fortunate. I straight out of foundation training year, got a job at a really lovely practice that I love working at.

It’s basically private. So I’ve been able to go straight into kind of doing dentistry to the standard I really wanted to be able to do it to. It’s 10 minute drive from my house. So it’s by the beach. So it feels like it was. Kind of a bit of a mad decision to blow up what such is a lovely setup, but my practice principal is kind of getting to the stage where he’s maybe looking to retire and I think it’s probably going to coincide maybe reasonably nicely as a transitional period where maybe I would be having to look for different work anyway, and you’re right.

It kind of, that decision you were saying about yourself, I kind of figure if actually, if we don’t do it now, if I stop handing my CVs out elsewhere and get established in a new practice, then all of a sudden my kid’s going to be older and it’s going to be harder to do. But yeah, definitely have doubts. I hope that it all goes really smoothly.

[Jaz]
And we all do. We are all on your side.

[James]
Oh, thanks man. We’re fortunate as dentists in that we do have a really well paying job. And so I think that takes a little bit of, not the stress off, but-

[Jaz]
Anxiety, maybe like financial anxiety.

[James]
It’s going to be four years. Yeah. So I think, we’ve been able to save up money to put towards this. We’re fortunate that we own our house. We’ve got a mortgage, but we own it. And there’s probably a bit of peace of mind that comes from knowing that, okay, four years.

Maybe we’re not earning, I could have been earning in the UK or anything, but hopefully I’m going to be able to come back with maybe even more increased skills and walk into a job that’s really well paid again. And I’ll have maybe had a bit less for my retirement, but it’s not going to be the difference between my family kind of not having, roof over their head. So, we’re fortunate in that position as dentists.

[Jaz]
I mean, in the four years, you’re not wealth building in these four years that are coming, but what you are building is, I’m just amazed, I’m just imagining you there now and the quality time that you get to spend with your children and what you get to teach them about the world.

That whole, all the learning experiences. So tell me about just schooling. Like, are you going to be homeschooling? Is there a school? I mean, obviously you’re doing better both obviously as well. What do you got in mind regarding schooling?

[James]
I think if homeschooling was on the table, my wife would a hundred percent not go. Like my boy is really busy. So there’s a small kind of co op led school. So the place we’re going it’s kind of a campus compound just outside Monrovia. It’s got a hospital, it’s got a radio station, dental school. And then it’s got a small school for the workers who are kind of working within the hospital.

It’s a little bit unsure as to whether or not, or how that’s going to work yet. There was a little bit of uncertainty with the teachers just because people come and go, but yeah, basically they’re going to be going through an accredited US style schooling system. So we went and looked at it. It was really sweet, kind of multi year, just all groups, 18 different nationalities, all in the school of kind of 50 kids, maybe it was even less than that.

But so yeah, my boy will be kind of jumping in there. My little girl, I think will be at the beginning a bit young for it. So I think she’s in the kind of a more of a preschool sort of age. Yeah, it’s mixed for the kids. I know they’re going to be homesick within some capacity. We’re taking them away from a really lovely place.

I live in Cornwall by the beach and my kids just love being in the sea. One of the things that’s really amazing is that the campus is literally just on the Atlantic ocean. So the little bungalow we’ll be in a stone’s throw from the beach. So I’m kind of selling it to my son that he can catch crabs and boogie board, every day after school.

And they’ve got, it’s going to be exciting for them. And I think they’re at an age where I think when we went there, all of the kids who were younger were having an absolute blast. And then there were a couple of teenagers who were maybe having a bit less fun because the people who they’d grown up with had left and they are maybe missing out on maybe the more teenage sort of age.

But my son’s five, he’ll be six when we go and we’ll come back when he’s 10. I imagine he’ll have a blast and it’s nice, like you say, spending quality time with them. My little boy will be able to just bicycle up the road to the clinic I’m working at and come hold my mirror if I’m taking out teeth and stuff like that. He can be part of that.

[Jaz]
Absolutely phenomenal. It reminds me of Alicia yesterday. I saw a patient, lovely lady, and she was telling me how she went to Argentina just last Christmas. I was seeing her the next checkup, so before the last checkup and this checkup, she went to Argentina for Christmas.

I said, why did you go to Argentina? And she told me, okay, her son actually was meeting her there, and her son lives in Costa Rica. And she’s telling me that her son is, he tried the whole corporate route and stuff and it just wasn’t for him. And so what he does now is he’s like, I don’t even want to say a deep sea diver.

He’s some sort of a, he works in the water and he basically saves turtles and tortoises, like an orphanage looks after them, right? And she said to me, look, he, all he owns is a rucksack. That’s all he owns, right? But he’s found a life partner. He’s got his rucksack and he goes from place to place in Costa Rica, saving these turtles, right?

And he’s happy. Right? And I thought that is the ultimate liberation. That’s living life on your terms, doing what you want to do, exploring the beauty and nature of life. I’m not comparing what you’re doing to what he’s doing. They’re still very different. But what I’m trying to say, I’m trying to just highlight the fact that you are living life on your terms, James.

You decided, you and your wife have decided, and your family decided to do something absolutely epic. I wish you and your family all the success. And success, I measure as a number of people that you’ll be able to help. The number of experiences and memories that you’ll be able to make, that for me will be success. So what I would love for you to do, James, is, are you on Protrusive Guidance?

[James]
Yeah.

[Jaz]
I want you, if you can, when you get the chance, every month, just put a photo. How was your month? A little blog. We would love that. Honestly. And like, if you want to put like a GoFundMe link there, we would love to support it.

Just, just keep posting us. We want to support our community. So I would absolutely love to see some photos of your son in the beach with the crabs or some of the patients able to help or just the Atlantic ocean from you and your bungalow. It would be absolutely brilliant to keep the story going to give us a flavor of this. Would you be up for doing that?

[James]
Absolutely. Yeah. I’d appreciate that. And yeah, I’d really, yeah, I’d love to. Yeah I’m going to try and look at a website under progress and try and get some social media around. So yeah, I’d absolutely love to share it with you guys. That’s one of the thing I really want to, I’m so grateful you’re having me on this podcast is that, I really want to get dentists involved and behind me so I can share our difficult clinical experiences.

[Jaz]
And do you think there’s scope for maybe dental students doing an elective with you or dentists come out and spend a couple of weeks to help out? Have you thought about this kind of stuff?

[James]
I have thought about it. Yeah. I’d absolutely love that. I think probably the sort of thing I’d need to work out when we’re there, but yeah, definitely. I’d absolutely love that.

[Jaz]

Please, please think about it. Please sort of set up a program, something to make it easy for dental students or dentists to come and help you out and just get a flavor of this as well. I think that’d be a great thing for your clinic to get some more help, but also for people looking for an experience, looking to actually be altruistic and give back to the greater community of the world, which leads me to my last question is like, obviously, with the magazine that you had and the Christian values and stuff, you found this place.

But what are the other options that dentists have to do aid work? Obviously, we’re in the UK, so we’re talking from a UK perspective, but this could be anywhere in the world. Dentists from America, dentists from New Zealand, wherever. Where can you find aid work to contribute to?

[James]
Yeah. So, I mean, I think, like I said, there’s an abundance really, I think it’s probably helpful to kind of split it up into maybe short term and long term short term is a lot, I think, easier to find because there’s a lot of organizations which are set up for that.

So, in the UK you probably heard Dentaid. There’s another one called Bridge2Aid. There’s one called Work the World, which is for kind of student electives. The Mercy Ships, people have heard of. There’s another one called, World Medical Mission, which is a kind of organization with Samaritan’s Purse who do the shoe boxes and the Doctors Without Borders. But so all those-

[Jaz] There’s also the refugee camp for the displaced refugees in the Greek islands and stuff. There’s lots of great work by Dr. Ola Hassan. They’ve been doing that as well. So you’re right. I think you just have to start looking for it. When you open your eyes, when you open your mind to the opportunities, opportunities start coming to you, right?

[James]
Yeah. I almost feel like you can pick a country, type in that country, dental aid work, and you will find something.

[Jaz]
Let me try this. Las Vegas. No, I’m just kidding. No, no, I mean, I think you’re right. I think there’s so many different ways to do it. What other advice could you give to someone considering aid work?

[James]
So I hope I have more advice when I’m actually out there. Did you do an elective as part of?

[Jaz]
Yeah, I’m so glad you mentioned my elective. Did it in Vietnam. We did it with a charity East meets West, and that was fantastic. Went to this remote area of Vietnam. We helped out with extractions, fillings, fluoride, fluoride, oral health instructions.

And then we had this little trailer next to a school doing fisher sealants and stuff. And that was great. And actually, the funny thing about DentAid is I asked DentAid, this is like 13 years ago, I asked DentAid, look, can you contribute something? Can you give us something? We’re going there. We’d like to give them some tools.

And so this huge shipment of like luxators and forceps and stuff comes to our uni flat. And like, how the bloody hell are we going to take this to Vietnam by international airways? And no one put a line. It went through security, went through everything. No one said anything. We took all these like instruments and stuff, some in our rucksack, some in luggage, they may all manage to get through.

And then we gave it to them and then they said, okay, how much is it worth? And I don’t know where it’s worth. So we just wrote 10, 000 on it. Cause it’s really heavy. We were at 10, 000 and we gave it to them. Like here’s all the instruments. So shout out to DentAid for being so helpful back then, which is amazing. So yeah, elective, you’re right. We just searched it up and we knew some people who’d done East meets West before. So that was a fantastic experience.

[James]
That’s cool. It’s funny. We went out to Liberia last year as a RECCE and we had a similar experience and brought two, three suitcases full of dental stuff and they got really sketchy about all the anesthetic car peels since we spent the first three hours in the security in the back room in Liberia airport. And I explain to them what we’re doing with all these drugs and needles.

[Jaz]
No, but here’s a funny thing, James, is that of all the instruments and stuff, right? You know what they hung me up on? You know what they stopped me in security for? They didn’t stop me for the Luxator. They didn’t stop me for the metal instruments. They stopped me for my hairspray.

[James]
Nice.

[Jaz]
Sorry, you were saying?

[James]
Dangerously stylish.

[Jaz]
So that’s the beard.

[James]
I was just saying for the longer term stuff, I thought it almost seemed a bit harder to find longer term stuff, but I guess all of the short term. Institutions have people working longer term for them. So I think if you probably are well connected in all of those, you can find other ones, but I think the rest of them is, it seems to mostly be kind of medical clinics that have set up kind of by either mission or aid or religious organizations.

So yeah, I found it was maybe a little bit tougher to find longer term options. Yeah. I think the same sort of rules apply. And just changing the search to this country longer term mission support, longer term dental aid.

[Jaz]
You’re right. I think if you open up yourself, the opportunities that there will be there and keep speaking to people in that space. So James, I want to know, are you looking to raise some money towards the mission stuff? How can we help you, my friend?

[James]
Yeah. So we are the group we’re going with. They operate on a kind of a support raised fundraising platform. So the charity itself doesn’t have money, which it’s able to give to the workers. It’s kind of set up a bit like a mercy ship. So my wife and I have been thinking about this for a long time. So we’ve got a reasonably substantial amount of savings, which we’re able to put towards it. But the budget for our year, which is, all our flights, accommodation, medical insurance, evacuation insurance, food and drink, internet, electricity, basically all of our living expenses in Liberia comes to, I’m in the car, I’m running a car, comes to about 50, 000 a year.

Which was way more than we’d originally thought it would be. But I think as a result of basically the destruction of the infrastructure in the country, it’s just, everything’s really, really expensive. Yeah. And schooling, for the kids. So we’re looking to raise that from kind of friends and family.

That’s also why I really wanted to get dentists involved because I feel like, although my friends and family kind of understand what we’re doing, unless you are clinical, I think that it gives you kind of a different perspective on the sort of need that might be being met. So I really would love just to have, like you say, have the Protruserati behind me just to say that I feel like I’ve got people to talk to if I’m having that, if I need to about things and just to share the journey with other people.

[Jaz]
We would love that. We would love for you to speak to us and we would love to post images. And I would love for you to just keep reminding us of that donation link, because it might not be the right time for someone now, but in three months time, it might be the right someone. If everyone just gives up their 10 pound latte for a couple of weeks and actually just puts it towards your fantastic cause, it’ll be good.

[James]
I mean, that’s my thought. I mean, it feels, it feels really weird asking people for money, but you know, I kind of think if I can get, if we can get lots of people involved, if we had a thousand dentists who thought this was a cool thing and they gave a pound a week that would more than cover our year.

And it means that we’d be able to stay for as long as we need to. I think it’s a sensible idea, but our organization, they don’t allow you to go until you’ve raised 90 percent of your first year because they don’t want a situation where you’re out there and then run out of funding. So we’re kind of in a bit of a limbo land at the moment where we’re kind of mentally preparing to go in January, but it’s contingent on us actually getting the funding required. We’ll be in a bit of a funny position, I guess, in towards the year, maybe getting a bit.

[Jaz]
Let’s see what the Protruserati can do. They’re very altruistic bunch as well. They helped a lot with Nafisa, who’s just about raised a million dollars. Like this wasn’t all from just Protruserati, this was from all over the world.

A lot of the stuff they did, but they, they were very generous. And so it’s nice to support charitable projects like yourselves, James. So what I’m going to do is, do you know the link off by heart? Is there a link that I can, I’m going to, we’ll talk about the link and I’ll put it in the show notes anyway. But is there a link that you can publicize now?

[James]
I think the easiest thing is to go to our website. So it’s just www. thehuntersinliberia. co. uk. And that has kind of all the information about what we’re doing. It’s got social media links and it’s got links to the ways in which you can support us either through one off givings or regular givings. So yeah, all the information to be found on there.

[Jaz]
I will definitely be setting up something like a regular thing for you. So leave that to me. I’m going to make the website protrusive.co.uk/liberia. And I’ll get that to basically anyone who goes on that website. We’ll go to your, we’ll just redirect basically to yours.

So I’ve just written that a note for that. So, Erika, Krissel, team, can you please help me set that link up? That’d be great. So they will do that. And please, please keep us posted about the wonderful work that you’ve been doing in Liberia. I hope everything goes amazing. We’re all rooting for you. And hopefully it may even open up the door for students and dentists for the protrusive community to visit you and help out and maybe visit neighboring nations and really create a movement here, right of helping just this wonderful thing that you’re doing. So James, thanks so much for your time, but thanks so much for being just a fantastic human.

You and your family have touched me. Like, I’m feeling very, just privileged to be able to speak to someone like you, who’s doing sending out good vibes into the world, like really into the world. So more power to you. And I hope, I wish you guys all the health and success.

[James]
I appreciate it, man. It’s been, yeah, it’s been awesome being on the podcast. Thanks so much for having me.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. If you’re feeling inspired, if you have some budget, you know how as a business, if you contribute to charity, that’s actually tax deductible.

I think every business should be looking to allocate a percentage of its pot to a charitable cause. So if you have some funds left in your annual budget for your charitable donations, then please do consider supporting one of our own, Protruserati, James and his family, so they can deliver this aid work in Liberia.

I would want you to visit protrusive.co.uk/liberia, but also join Protrusive Guidance. On Protrusive Guidance, which is. www. protrusive. app so you can actually access on Safari or Chrome, but you can also download the native app as well. And on there, I’ve asked James, once he goes there, to do monthly updates.

Now that you’ve listened this far, don’t you wanna see what James gets up to? His adventure, his charitable, beautiful cause that he’s looking to do in Liberia. So if you want to stay up to date with everything he’s doing, do join Protrusive Guidance and watch out for those posts, but once again, it would be great for us to kind of club together and help support, I’ll be setting up a monthly donation myself for this cause.

So if you want to get involved, check out protrusive.co.uk/liberia to donate to James. James, we wish you all the best. We are so, so proud of you really are a rare individual and you wish you all the best to the protrusive community. Thanks again for listening to the end. I’ll catch you same time, same place next week. Bye for now.

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Have we fully shifted towards lithium disilicate overlays and onlays?

Are full crowns considered a sin in 2024? (Maybe just on Instagram then!)

Spoiler: Crowns TOTALLY have a place, and so do large direct composite restorations!

Dr Alan Burgin and I share our decision making trees for indirect restorations as part of ‘Crowns and Onlays Month’ on Protrusive Dental Podcast.

Find out which clinical factors sway us more towards a Overlay vs a Vertiprep – and the rationale for each type of restoration.

https://youtu.be/Gntb083yUOQWatch PDP189 on YoutubeProtrusive Dental Pearl: Use Vaseline on the gingivae when carrying out a ‘smile trial’ or bis-acryl mock-up – will result in an easier clean up!

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:
01:54 Protrusive Dental Pearl
02:44 Introduction – Dr Alan Burgin
18:20 Types of Indirect Restorations
31:16 From Onlay to Crown
44:40 Crowns – Traditional vs Verti-Preps
54:00 Reflection
57:48 Alan’s Prep Course

Join us on Protrusive Guidance, our own platform for dental professionals. No need for Facebook anymore!

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Clinical Dentistry is a steep learning curve – it can be frustrating, frightening and quite frankly exhilarating.

This episode (better late than never! My wife finished her MSc so now I’m back on track!) picks up the theme of Stress Awareness and I discuss with Emma Hutchinson, our Protrusive Student, how students can manage stress effectively, prioritize their studies, and identify their unique learning styles.

We also address imposter syndrome and the various difficulties encountered while learning something as complex as dentistry.

https://youtu.be/EIXeUvlTamsHighlights of this episode:
00:00 Introduction
03:25 Welcoming Emma Back
04:16 Protrusive Students
06:30 Dentistry Students vs Other Courses
08:24 Hobbies and Activities Outside of Dental School
12:50 Communication Style
14:48 Student-Life Balance
19:01 Past Papers during Exam Time
21:00 Networking in Dentistry
28:51 Burnout and Mental Health Perspective
33:45 Next Month – Orthodontics

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Protrusive App!

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. Join us on Protrusive Guidance, our own platform for dental professionals. No need for Facebook anymore!

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Class II’s are only easy when they are small (but not too small), supragingival, easily accessible with straight-forward anatomy.

In other words, about 1% of the Class IIs we encounter – because the vast majority I see are subgingival, wide, with awkward root concavities and tricky access.

I went from using sectional matrices 97% of the time to now just using them 30% of the time – this is thanks to a circumferential matrix I started to use last year which is a game changer.

I now do not need to use a wedge in most scenarios (something I used to think was a crime!) and have been using the ‘contact opening technique’.

Meet Dr Sunny Sadana, who has brought the Greater Curve system to the UK and taught me a lot about efficiency with direct restorations.

We also discuss fee-setting and patient communication – this part of the video is only available for those on our Protrusive Guidance network.

https://youtu.be/QF3b8V_29VwWatch PDP188 on YoutubeProtrusive Dental Pearl

Pre-wedging; use this technique beforebeginning any restorative work on the tooth you are working on, this will allow a greater field of view to work in. It also helps suppress the papilla to get better access to the caries. This can all be achieved by numbing the area first and wedging with adequate enough pressure for there to be separation. It also reduced iatrogenic damage and is also worthwhile considering using a wedge-guard/fender wedge.

Check out the DRE Composite Course

Access the CPD quiz through our app on https://www.protrusive.app, either on your browser or by downloading our mobile app.

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PDP188 with OBAB ad

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From softwares to enhance communication with prospective patients, and clever ones that utilise AI for radiographs and note taking, Prav Solanki and I deep dive into some products we currently like to use or have heard good things about.

https://youtu.be/50GNVjVHJQgWatch AJ007 on YoutubeIn this episode, we discuss the many ways that AI is now streamlining things in our workplace and ensuring that we are able to protect ourselves from a medico-legal perspective, as well as providing the patient with confidence in their treatment plans. Get ready to get techy!

Softwares mentioned in this episode:

LeadFlo – CRM System for Dentists

DigitalTCO – AI and Voice Assisted Dental Notes [Affiliate Link]

Dental Audio Notes – Secure Audio Recording

CareStack – Cloud Based Dental Software

Software of Excellence Exact – Practice Management

Loom – Async Video Messages

SmileCloud Smile Design

Chairsyde – Consultation Platform

Pearl AI – Radiographs in Colour

MakeMeClear – Treatment Plans that Explain Themselves (25% off using ‘protrusive’ – Affiliate Program]

Highlights of this Episode:00:00 – Intro
03:22 – Protrusive Dental Pearl
04:53 – Introducing Dr. Prav Solanki
05:35 – Skillset Enhancement
07:45 – CRM Introduction
09:02 – LeadFlo
12:52 – Follow-up Strategy
18:20 – Building Trust
20:33 – Lifetime Value Focus
23:45 – Simplify Plans
30:40 – Communication Tools
42:27 – Best Patient Management Systems
58:10 – Visual Communication
59:40 – Video Disclaimers
64:54 – More Software Options
80:10 – Final Words

Access the CPD quiz through our app on https://www.protrusive.app, either on your browser or by downloading our mobile app.

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How long should you wait after a root canal before starting Orthodontics?

Should we be scared of orthodontic movement in those taking bisphosphonates?

How do you decide if diastemas should be closed restoratively or orthodontically?

Dr Daniel Neves answers every one of the questions and several more sent in from the Protrusive Community

These questions are the tricky case-specific ones we ponder about and crave guidelines for – straight talking Dr Neves makes it all tangible.

https://youtu.be/ZufVChjEJk4Watch PDP186 on YoutubeProtrusive Dental Pearl: Retention is not a ‘one and done’ process. It should be customised for the individual and maintained appropriately – including at every routine check up.

Highlights of this Episode:
04:40 Protrusive Dental Pearl
05:53 Introduction to Dr Daniel Neves
12:16 Reducing the Risk of Relapse
17:20 Anterior Diastema
21:47 Temporary Anchorage Devices (TADs)
26:20 Jaw Issues in Adults
29:20 Root Resorption
34:25 Recession Cases
38:00 Timing of Orthodontics after Root Canal Treatment
39:39 Bisphosphonates and Orthodontics
40:16 Aligners around Implants
42:22 Final Thoughts

If you liked this episode, you will also like GDP Alignment vs Specialist Orthodontics [STRAIGHTPRIL] – PDP068

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We need to talk about the ‘S’ word and our mental health.

I never, EVER want to lose a colleague again due to the pressures within Dentistry.

This is why I interviewed Dr Mahrukh Khwaja, a positive psychologist and Dentist, to help us with strategies to improve our mental health.

Why is it that we have so many support channels during a crisis, but no structured pathways to help us AVOID burnout, crisis and stress in Dentistry?

https://youtu.be/3JKwoO_nEeoWatch PDP185 on YoutubeProtrusive Dental Pearl: What are you doing on a daily, weekly and monthly basis to look after your Mental Health? Do not wait until a crisis, as we already know that prevention is better than the cure.

Take the first steps in looking after your mental health with Mahrukh and her Mind Flossing Toolkit

Buy Mahrukh’s new Book on Resilience and Well-being for Dental Professionals

Highlights of this Episode:
3:01 Protrusive Dental Pearl
4:22 Dr. Mahrukh Khwaja Introduction
7:34 Seeking Professional Help
12:10 Helping Dental Professionals
17:08 Suicide Issue within Dentistry
20:02 Reducing Suicidal and Burnout Rate
24:24 Inner Voice
29:51 Cognitive Reframing
36:31 Toxic Work Cultures
42:24 Signs to Look Out For
49:30 Learn more from Mind Ninja

If you liked this episode, you will also enjoy IC036 – The Secrets to Finding a Passion in Dentistry

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THIS is the most impactful interview podcast I have published in almost 6 years of podcasting.

Do you resent bringing your work home with you (treatment plans, letters, CT scans)?

Do you struggle with work-life balance?

Do you have days where you feel unfulfilled?

The honest advice and mindset from Jorge Andre Cardoso might just change your career and YOUR LIFE. This is the real deal, Protruserati!

https://youtu.be/GJExz_vEH2wWatch IC048 on YoutubeAs Stress Awareness Month continues, we’re taking a close look at the challenges dentists encounter, from making clinical choices to achieving work-life harmony.

Protrusive Dental Pearl: Explore Jorge Andre Cardoso’s Cementation Guide. This resource allows you to access specific protocols tailored to your needs by simply selecting the type of abutment, retention type, and the cement restorative material you plan to use.

Highlights of this episode:

02:39 Protrusive Dental Pearl
03:41 Catching Up with Jorge Andre Cardoso
05:50 Jorge Andre Cardoso’s Introduction
08:32 Practice Ownership: From Stress to Success in Dentistry
13:17 Balancing Clinical Work and Life
19:38 Education and Work-Life Balance
22:34 Embracing Diversity in Dental Practices
24:19 The Importance of Foundational Knowledge in Dentistry
30:27 Maximizing Practice Efficiency and Personal Fulfillment
37:44 Learning More with Jorge Andre Cardoso

For those interested in attending the Conscious Leadership Course this October or November, please act quickly.

Visit Soft Bites online to learn more from Andre and Manuela and secure your spot.

If you are interested in joining a Protruserati cohort – please indicate your interest in Protrusive Guidance.

Got stress management tips of your own? Share them in the comments! just tell us about what was the most impactful thing that you gained from Andre in this episode.

Access the CPD quiz through our app on https://www.protrusive.app, either on your browser or by downloading our mobile app.

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I remember being a dental student and a simple ‘check up’ could take HOURS! Then the tutor would come along and complete the observation in 30 seconds…

‘How does a routine general dental examination work in the real world?’, asks Emma, our Protrusive student.

The humble ‘check-up’ – as far as you can get from sexy before and after cases. The stuff no one is posting about on socials…until now!

https://youtu.be/AutQvQBlg4oWatch PS003 on YoutubeJaz and Emma dissect a ‘routine oral health exam’ and Jaz even includes a full video of a standard check-up, complete with the banter, bitewings and bad explanations!

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When the patient feels pain during an ID block. When a matrix does not seal the cavity perfectly. When the shade of your crown doesn’t blend as well as you would like. When the endo you did last year failed.

All of these cause us anxiety. All of these are failures in some form, and as Dentists, it eats at us.

Let’s admit it: we are perfectionists.

Life isn’t about being perfect, but it is all to do with the effort we apply to better ourselves day to day. Failure is a major part of success, but being hung up on our shortcomings will only lead to a downward spiral, which in turn will affect our results and general practice. In this episode we are joined by Dr Marco Maiolino, all the way from beautiful Sicily, Italy.

One of the biggest takeaways from my chat with Marco was the abolishment of the ‘gold standard’ or the standard of perfection – but rather, let’s aim for the ‘daily standard’

https://youtu.be/jRbgvgSpqLkWatch PDP184 on YoutubeProtrusive Dental Pearl: We cannot be depressed AND grateful at the same time. Let us find moments in our day and in our Dentistry to be grateful.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the Episode:
01:43 DENTAL PEARL – Be Grateful!
02:37 – Dr. Marco Maiolino
05:13 – The Technician’s Perspective
08:15 – Beating Imposter Syndrome
10:55 – Ideal vs. Real: Marco’s Take on Dental Perfection
13:00 – Lessons from Aviation
17:48 – Embracing Imperfection
31:00 – From Failures to Standards
42:08 – How to Bounce Back from Failure

Learn more from Dr Marco Maiolino

Access the CPD quiz through our app on https://www.protrusive.app, either on your browser or by downloading our mobile app.

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Dental Student in THREE different countries?!

This is a story of grit and determination. I hope that it will allow us all to reconnect with that burning desire we once had to enter our profession.

In this episode, we meet Nav, AKA the_stu_Dent who has had the craziest journey as a Dental Student. Not only defined as a mature student, but as a British born overseas one now working his way to qualifying in Slovakia, with hopes of eventually returning to the UK where he wants to practice full time in the near future.

https://youtu.be/wK1INeI_gdQWatch IC047 on YoutubeCheck out this entertaining episode, where we uncover what makes the_stu_Dent tick and why he ended up pursuing Dentistry with such determination, the highs and lows, and how he ended up trying at 3 different Universities in 3 different countries, just to fulfill his dreams.

Need to Read it? Check out the Full Episode Transcript below!

Highlights
01:35 – Nav, the-stu-dent Introduction
04:25 – Why Ukraine and what year did The-stu-dent enter?
09:18 – How did Egypt come about?
14:16 – Failure was not an option
16:24 – What happened when The-stu-dent visited Egypt first-time around?
19:14 – 3rd STOP – Slovakia.
21:54 – What are the fees like in Slovakia?
25:13 – What was the decision behind choosing Slovakia over alternative countries in the EU?
27:15 – What has The-Students experience of Slovakia been like, and how much clinical exposure do you get?
30:58 – Are you working part-time to fund your dentistry?
35:17 – What are The-Stu-dents final words of Wisdom?

Access the CPD quiz through our app on https://www.protrusive.app, either on your browser or by downloading our mobile app.

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Rubber Dam isolation can be tricky enough sometimes – it is especially awkward when the TERMINAL MOLAR needs restoring. How on earth does one isolate AND matrix this tooth?

In this episode, Dr. Celine Higton delves into the intricacies of rubber dam isolation, particularly focusing on the last tooth in the arch. This discussion ties into the broader theme of mental health, highlighting how mastering such techniques can lead to a more enjoyable and stress-free practice.

https://youtu.be/VeoPTNShAcsWatch PDP183 on YoutubeProtrusive Dental Pearl: “Cow Mode” as a technique to improve access to the mouth’s hard-to-reach areas, especially around the last molars. By instructing patients to shift their jaw to one side, akin to a cow’s chewing, this approach aids in better oral hygiene practices and facilitates procedures like rubber dam isolation when clamping the terminal molar.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

02:24 Protrusive Dental Pearl
5:36 Introduction to Dr Céline Higton
7:07 The Journey from Architecture to Dentistry
9:15 Mastering Rubber Dam Isolation: Tips and Techniques
14:12 Types of Clamps Ideal for Isolating the Last Tooth (Upper)
18:01 Dental Pearl – Cow Mode
19:22 Accessing the Last Tooth
22:13 Dr. Céline’s Personal Choice of Rubber Dam
23:11 Proper Lubrication for Rubber Dam
25:00 Correct Flossing Technique
27:01 Matrixing the Last Tooth
32:09 Cavity Preparation
35:37 Isolating the Last Tooth (Lower)
37:28 Coronoid Process in Clamp Placement
38:36 How to get in touch with Dr Celine

Reach out to Dr. Céline Higton via her Instagram, @drcelinehigton and via her website, #RUBBERDAMFAM

Access the CPD quiz through our app on https://www.protrusive.app, either on your browser or by downloading our mobile app.

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When we studied occlusion at Dental School, our textbooks forced the idea of having dots at the back and lines at the front. We are continually told about CR and how to manage patients into canine guidance, but does this all work in practice?

Today we dive into the best way to approach occlusion cases with our patients, keeping in mind that there is no such thing as a silver bullet to treatment. Join Jaz and Dr Michael Melkers in this podcast to learn how it may just be time to throw away the textbooks and begin writing your own conclusions on occlusion… try saying that ten times quickly.

https://youtu.be/3Sk1paKW8d0Watch PDP182 in YoutubeDental Pearl

Using PTFE in the dental sulcus offers a better seal compared to cord, functioning like a dam to keep the area free of gingival fluid, ideal for Class 5 restorations. However, PTFE may stick to instruments, which can be mitigated by moistening the instrument with water or saliva before positioning the PTFE, significantly lowering the likelihood of sticking.

Check out Dr Melkers and Dr Lane Ochi LIVE IN LONDON on 27 and 28 July!

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the Episode
00:00 Intro
02:05 The Protrusive Dental Pearl
02:52 Dr. Michael Melkers
02:53 Mentoring Journeys: AES and Beyond
04:04 Foundational Influences: Splint + Occlusion Mastery
04:30 Fear of Failure: A Dentist’s Drive
05:25 Early Beginnings: Lab Tech to Dental degree
06:00 Avoiding Full Mouth Rehab: A Dental Mission.
07:20 Homage to a Mentor: The Positive Impact
07:25 Group Function Vs Canine Guidance
08:00 Beyond textbooks: real-World Dental Challenges
09:00 Encouragement to Question: A lesson in Bravery
10:16 Chasing Perfection: A dental dilemma
12:00 Masters of Occlusion: Group Function Insights
14:31 Past as Prologue: Learning from destruction
15:10 Pain Points: Focusing on the At-Risk Patients
16:53 Smooth Transitions: The Ideal of Disclusion
18:30 Occlusal Schemes: Debunking the Malocclusion Myth
20:20 CR Reconsidered: The Healthy Majority
22:44 Diagnostic Vision: Seeing Beyond Occlusion
25:15 Rebuilding with Purpose: Beyond Aesthetics
34:35 Appropriate vs Ideal: A New treatment Paradigm
47:00 Key to Dental Success

Access the CPD quiz through our app on https://www.protrusive.app, either on your browser or by downloading our mobile app. For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you liked this episode please feel free to check out episode PDP160 – Fremitus and Occlusal Overload – Dental Occlusion Geekiness

Click below for full episode transcript:Jaz's Introduction: In this episode, I'm going to share with you the four ways that I document my daily dentistry. And I'll give you six great reasons in reverse order. So like my top six, if you like. So six, five, four, the countdown all the way to the number one reason. So if you listen to the end of the episode, I'll tell you the number one reason to document your dentistry.Jaz’s Introduction:
And when you grind your teeth left and right, the canines, for example, are taking a load at that point. And when this is happening the patient’s joints are in centric relation. So the condyles are as fully seated position is snug position, and there are no quote unquote interferences or slides. I don’t worry if you don’t know what those things mean just yet, but some of you may remember seeing this.

Maybe you don’t understand or internalize what this actually means, but you learn what the perfect occlusion was. But then you started to see patients and you realize very quickly that these naturally dentate patients, your normal patients with the normal teeth. Whether they were 30, 50, or 70, they had all sorts of restorations, or sometimes no restorations.

But they had anterior open bites, cross bites, and none of it looked like the bite in the textbook. No one had the perfect occlusion. And that made me really question what was going on. And when I did check my patient’s excursions, lateral excursions, most of my patients were in group function. In fact, guys, the next time you check this, don’t just get the patient to slide their jaw left and right, get them to bite firmly and grind left and right.

You’ll notice that very few patients are in true canine guidance. And even the literature supports that those in canine guidance are the minority, not the majority. But the textbook, the textbook said Canine Guidance! And we kind of have this perception that group function was bad or inferior and canine guidance was like the thing to aim for.

So what does that mean? Does that mean our patients who don’t have canine guidance, they are diseased or disadvantaged in some way and we should be restoring the canine guidance on these patients for every single patient? Well, this is a huge topic and it may sound simple, but my goodness, I had a challenging but a fun time with my mentor, Dr. Michael Melkers. I know he’s been a mentor for so many of you as well, but he’s the guy I think of who really helped me in my journey so that occlusion and occlusal appliances really started to make sense.

Dental Pearl
Hello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl. This one is about working with PTFE. It can be quite difficult. For example, when you’re trying to use PTFE in the sulcus, kind of like cord, I find this gives you a really superior seal that kind of like dams the sulcus, so no gingivocricular fluid can come up. Your tooth is going to be bone dry.

I like to use this technique for class fives, for example. Now, when you’re actually handling the PTFE, it can be quite tricky because the PTFE sticks to your instrument. So what should you do? It’s actually really simple. You just get your instrument, whether it’s a flat plastic, a wards carver, or a fancy cord packer, and you either dip it in some water, like in a dappin spot, or you dip it in some pool of saliva.

Not yours, the patient’s. And then you start pushing the PTFE. The PTFE will have a way less chance of sticking to your instrument, and you’ll have a lot more success. Now let’s join the main episode, and I’ll catch you in the outro.

[Michael] Mentoring Journeys: AES and Beyond
Hello everyone, I’m Dr. Jaz Gulati from the UK, and we have a very special guest, Dr. Michael freaking Melkers from Hanover, New Hampshire. Oh, Michael has been a mentor of mine for so long, and he took me to the AES, where it’s in the joy. So, without further ado, let’s bring Michael on.

[Jaz]
That is- But for those who are listening on Apple and Spotify, I’m sure you got a kick out of that because that was actually Michael, not me, just in case anyone confused that. But what you didn’t see was Michael had this like a COVID mask as the make do beard and like these black tape there as a mustache. And you’re just missing the turban, man. Should’ve got like a black towel and just like, ah, that’s like a swimmer.

[Michael]
Yeah, I look like, I don’t know what I look like, I don’t like that look, that’s not a good.

[Jaz]
Like some sort of ninja. Anyway, Michael, it is a great pleasure to see you again, you kind of did the whole intro for me. You’ve been on the podcast before, but just for those people who may be new to the podcast or haven’t heard of you I’m going to say a little bit about you, if you don’t mind, before I’d like you to introduce yourself.

Foundational Influences: Splint + Occlusion MasteryBut Michael has been a huge inspiration to me in my career. So much of my occlusion and splint comes from Michael. He is such an approachable person, kind, and his expertise and influence in terms of communication and the style of communication has been absolutely fantastic. Michael, what drives you?

What are you about my friend? If someone’s listened to you for the first time, how do they introduce you? I just feel as though I know you too well. So I’m going to let you introduce yourself like a speaker roster kind of thing.

[Michael] Fear of Failure: A Dentist’s Drive
Well, first of all, I think my top credential is I’m a massive coward. I hate failure and that’s really what does drive me. I like to avoid failure as much as possible. And I like to share that with others because I think some of the things that beat us up the most in dentistry are our failures in ourselves is we think we’re supposed to be perfect. And anytime anything goes wrong that our mom wouldn’t absolutely think we’re the best thing in the world.

We’d beat ourselves up. We want to quit dentistry and go into diesel truck driver training school. So I’m a restorative dentist. I’m not a specialist. I’m a generalist. I practice in Hanover, New Hampshire, full time. Aside from that, I wear a few different hats. So I’m visiting faculty at the Pankey Institute.

Early Beginnings: Lab Tech to Dental degreeI’m also on their board of advisors. I have been faculty at the Spear Education where I taught with Frank Spear. I have been a laboratory technician for my father since I was about 14 years old, until I graduated from dental school. So I have studied under Kois, Spear, Dawson, Jeff Brucia, many of the UK people, Lane Ochi is my teaching partner.

I know you’ve had Lane on before and we’re all good friends. Some others might not know that, but all the way back to the beginning, I’m a wet finger dentist and I pay my bills with single crowns. And just all the same patients that you do. Yes. I do a lot of full mouth rehabs, but that’s not my focus.

Avoiding Full Mouth Rehab: A Dental Mission.In fact, I’d like to keep people from needing full mouth rehabs. So in a nutshell, I guess, that’s who I am. I’m my father’s son and I’m hitting my, believe it or not, I’m hitting my 30th year in practice. And if you throw in my laboratory technician side, I am coming up on 50 years of practicing dentistry on one side of the bench or the other.

[Jaz]
What a remarkable introduction there. Things that you didn’t mention is you’re a cat lover and a hot dog lover, which I learned. I mean, I remember Mahmoud eating into that hot dog. What was it? Is it a chili of the caper? What was it that spilled in the dill? Was it that spilled in your eye?

[Michael]
Oh yeah. He bit on the sport pepper, which is basically like a little teeny pepper chili and it squirted across and it just hit me right now. Thank God I had my safety glasses on. So otherwise I would have gone blind.

[Jaz]
And when you came to Dental Tubules a few years ago, I remember I had the pleasure of introducing you on the stage there, and I introduced you as a crazy cat person. And literally, like, for those who don’t know this, Michael was Whatsapping me just before he went on.

He was like, I’m just going to find a relatively cat free area, but there we are, just behind him, guys, he’s pointing to a cat silhouette right behind him. Well, Michael, I love your intro, I love everything about you. Today I want to discuss on the podcast, kind of like a philosophical topic when it comes to occlusion.

Homage to a Mentor: The Positive ImpactLike you are, in my eyes, like you are a master and everything you do, huge inspiration, like I said.

Group Function Vs Canine GuidanceBut one of the things that I’m sure, because I’ve done it, that young dentists are googling when they’re trying to make sense of occlusion is group function versus canine guidance. They’re just trying to get a grips with it, like, which is superior? It’s almost like a battle. And if you don’t mind, I’m just going to share my own confusions when I qualified from dental school.

[Michael]
Sure.

[Jaz] Beyond textbooks: real-World Dental Challenges
That you look at this textbook and you see this, the mutually protected occlusion, the dots at the back, lines at the front, the cuspid guidance, and everything, the condyles being fully seated and everything touching together, i. e. the patients are fully and beautifully equilibrated intercentric relation. But when you go on the clinic, or when you go in the real world, my patients have anterior open bites, cross bites, all sorts of a word you don’t like, interferences, we’ll go into that actually. And it just didn’t match the textbook. I remember that, of course I remember that. It just didn’t match the textbook, and so I came out of dental school being very confused. In fact, Hap Gill, who was my principal.

[Michael]
Good friend, yeah.

[Jaz]
Hap’s obviously trained with Panky as well. And I remember shadowing him. Like, one year out dental school and he was finishing up an orthodontic case and he was checking the occlusion. And I noticed that it was very nice and smooth group function. And when the patient left, I said, Hap, what about the canine guidance? And he said to me, Jaz,, whoever filled your head with that nonsense, get rid of it. So let’s try and unpack the journey of learning inclusion.

I don’t even know how to like, begin to asking you the about these questions, except the first place I’m going to start is, did you also have this similar feeling in terms of what the textbook was saying and what the patients were displaying to you when you qualified?

[Michael] Encouragement to Question: A lesson in Bravery
Yes and no. The reason I say I didn’t have the confusion, I don’t think I was bright enough to ask the questions. I was given this instruction book that was, Peter Dawson for me, when all those dots and lines. And so in the U. S., dental school is four years after university. So we have our undergraduate degree and then our dental degree. So when we get into that, we’re still doing two years of basic sciences before we even start treating to patients.

But we’re given a book the first year with all those dots and lines, and we have no idea what they mean, and we have no idea how to apply them, but yet for two years we basically study full mouth rehabilitation in a class one environment. So it’s a perfect dentition with perfect dots, perfect lines, and then you go into the real world and you realize those people don’t exist.

The analysts of anatomy did a study a few years ago and they looked at a hundred people and none of them were in centric relation being equal to MIP. And that’s a whole nother story before, maybe before we even get to group function versus canine, or maybe we can talk about it later. When you talk about this, that everybody needs this perfect occlusion, it’d be like if we’re ophthalmologists and go, Oh my God, mate, you have two eyeballs.

Chasing Perfection: A dental dilemmaYou need glasses. We need to get you glasses because you have eyes and but that’s how we approached occlusion is we think everyone has to have this perfect occlusion and at some point you and I both and I appreciate all the kind words you say to me and I remember all the times that we’ve met and we’ve gone over all these things is you have been a master at erasing all the BS that goes along with the mythology. So I welcome the chance to chat. Get me back on track here, Jaz. I went down five radicals on you.

[Jaz]
No, no, because this is such a huge, huge topic. And it’s very difficult to boil down, but we will try our best. And I love the direction that we’ve already gone in. But essentially you said that those perfect occlusions, they don’t exist.

And it’s trying to then make sense in how it goes. And also in the TMD world, I got more and more into TMD, and when a dentist is speaking to me, and they’re wanting to describe a scenario of their own patient, what they start with is, Jaz, I have a patient with TMD. Their group function on one side and canine guidance on the other side.

And they expect me to just give them the answer in terms of what’s wrong. And so I think we’ve put like so much emphasis on this sort of characteristic of the occlusion. And so I think what we really need to do is just go back to basics in the sense that when we see that perfect occlusion in the textbooks and the fact that we don’t see in the real world at all virtually like no natural occlusion that I’ve seen in someone who’s 50, for example, will ever match what the textbook says.

So how about we just for the sake of the dental students, let’s just spend a minute to revise. What is the ideal occlusion as per Dawson and the textbook? Let’s just go from there and then say, okay, what do we see in the real world? And then try and fill in the dots in between.

[Michael] Masters of Occlusion: Group Function Insights
Well, filling the dots in between. It’s funny if you go back to Dawson and many of the heritage masters. They didn’t believe in canine guidance. They believed in group function, but we didn’t listen because the exam that we took, the correct answer was canine guidance. Canine guidance is a component of group function. And so, if we’re going to talk about this, we have to talk about terminology. And I’ll ask you, Jaz. When you were taught group function, what were you taught that it actually met?

[Jaz]
I was taught that group function was when someone goes to one side to their working side, so the right excursion that they’ll be touching on. It could be their canine, for example, but it would also be at least one other premolar.

And ideally, I think probably if I’m really trying to tap into being an undergrad again, it was like when someone goes to the right, all the molars and premolars are touching as they’re grinding. And that’s kind of what I probably remember from that stage.

[Michael]
Okay. So one, I’m glad you brought it up and that you could remember some of that until you’re being honest about it. Now, if you actually look at the definition of group function, it actually doesn’t name any teeth. So, I am one of those weirdos. So, the glossary of prosthodontic terms, which started in 1956, I have read every single issue up to the current one that just came out. So, there are about nine, 10 issues. So, prosodontist.

As a professional or recognized in 1947 by the American Dental Association. It took them nine years to figure out what the heck they were teaching because there were no terms and they weren’t defined. Group function wasn’t defined, I don’t think, until the 70s. I went back into prosthodontic terminology and what it says, and I actually, I actually printed it out just so, just so I don’t miss it.

And it says group function, multiple contact relationships between maxillary and mandibular teeth and lateral movements on the working side, whereas simultaneous contacts of several teeth act as a group to distribute occlusal forces. Now, you were taught the same thing I was by my teachers, that it involved a premolar and a molar.

That has never, ever once been written as a definition. It’s just more. It’s group. So that group could become a canine and first bicuspid, a three and a four. It could be a three and a one. It could be a three and a six. It doesn’t matter. It’s just the distribution.

[Jaz]
They could also be anterior group function, which I learned many years later.

[Michael] Past as Prologue: Learning from destruction
Yeah. And that’s how I practice if I can’t. So canine guidance, someone, we look at these patients that have destroyed their canines. We’re like, oh, we have to give them back canine guidance. I’m like, why? They just destroyed it. They’re going to destroy it again. Past is prologue to destructive schemes.

You know that Janine and I have the largest retrospective clinical on wear patterns in the world that’s ever been done. We followed 386 people over 10 years. And there were patterns. And the thing is, over those 10 years, those patterns and that parafunction did not change pre ortho, post ortho, pre equilibration, post equilibration, even pre and post orthognathic surgery is one thing we have to clear up is we’re not going to stop them from doing it.

Pain Points: Focusing on the At-Risk PatientsSo when you say which people need our occlusion stuff, it’s ones that are at risk. So if they are destroying, or if they’re in pain. Are there modifications that we can do to help them stop doing that? Ah, let’s just do this, Jaz. You’ve done it before. Okay. Second motor context. Sixes, fives, threes, ones. So, we’re going to take a finger. You too.

[Jaz]
Let’s do it.

[Michael]
Take your finger, Jaz. Okay. You’re going to take your finger. You’re going to go all the way back to your seven. Tap, tap, tap. Once, and only once, light is 180 p. m. Ouch! And stop.

[Jaz]
Uh huh. Yep.

[Michael]
Yeah. Got it? Okay. Take your second finger, your middle finger, go up to your three, your canine. Go tap, tap, tap. Once and only once bite as hard as you can. Yeah, good. What did you experience there in the difference?

[Jaz]
So not as severe as a molar and I could hold it a bit longer. It’s not very pleasant I wouldn’t want to hold it for any longer.

[Michael]
Okay, so let’s go to a third finger. Let’s go 2-1 and I’m going to go to my 2 1 because my implant and I could go-

[Jaz]
And I have resin bonded bridge in the lower anterior so I’ll pick a tooth as well.

[Michael]
You’ll be okay because you’ve got your soft thing there. So you can, so I’m going to go 1, 2, and 3. Bite as hard as you can. Bite, bite, bite, higher as you can. Ah. Everybody’s got one of those? So what you- you got your little occlusal love mark, that love bite right there. What we’re saying is when we hit on molars and let’s just go MIP, okay.

That’s a hundred percent. Molars were still at a hundred percent muscle activity. We go up to the canines, we’re at 70%, not 70 percent reduction. We’re still at 70 percent muscle activity. And then when we go to the centrals, the midline, we’re at 30%. So where does it make sense to have our disclusion? As far forward as we can.

Smooth Transitions: The Ideal of DisclusionAnd what Peter said, what Dr. Dawson said was canine initiated disclusion with a rapid transition to a more anteriorized contact. And from us just biting on those three fingers, what that means is start on the longest, strongest tooth in your mouth, but you’re still at 70 percent muscle activity. So as fast as you can get up front.

And that is where we get crossover. So, when we cross over the tips of the canines, we want to have that smooth transition. So, the things that we want to do to help promote longevity is we want to reduce either the time that we’re in high muscle resistance or we want to reduce the angle that we’re in high muscle resistance because those are the two things that lead to stress and strain either on our enamel or on our ceramics.

[Jaz]
So in other words, the patient who has very steep cusps who is locked in is unable to move their jaw and is rubbing on their molars a lot while they’re doing it. That’s the worst form of forced attribution. that we could have compared to someone who’s got shallower cusps and it’s initiated by the canine and very quickly moves to centrals for example, just giving examples for the younger listeners, that will be a less stressful bite if you like.

[Michael]
Right. And the key word that you said, or key phrase that you said in there, if they do it, because a deep bite and long, steep guidance doesn’t mean anything in and of itself. It matters the intensity that the teeth are brought together.

Occlusal Schemes: Debunking the Malocclusion MythAnd you’ve seen that. You went back a little while ago and you were talking about TMD and occlusion. It is the University of Florida looked at all different occlusal schemes and there was absolutely no relationship between malocclusion and quote unquote proper, by the way, proper occlusion is an orthodontic board exam requirement.

It’s not a health requirement. So what you’re saying is when they’re hitting a canine, 70%, and a molar, 100%. So they’re really distributing 100 percent muscle activity between a canine and a molar. So when you go to a canine and a central, now you’re at 70%, but you’re distributing between two teeth. So, long and steep off the canine and then when you get up towards the incisal edge That’s where you’d have unsupported enamel or ceramic and that’s where you want to have that transition to a more anterior as contact I think we’re talking about that clearly is this because this is your playground So I know some people are going to see all our hands and some people are just going to be listening.

[Jaz]
And I think this is where people can get a bit lost. So if you were to speak to me when I was just freshly qualified and I hadn’t been bitten by the occlusion bug and the fascination and if I had been seeing a patient and I was as part of my examination doing the occlusal exam and I was checking for the excursions and I was seeing that, whoa, there’s a lot of back teeth rubbing here, that this isn’t what the textbook says, then sometimes we can write or maybe I would have written back then that, ah, this patient has some occlusal disease.

What’s your viewpoint on someone looking at a patient’s occlusion and seeing that, ah, there’s a big deviation to what the textbook says, and therefore thinking, hmm, as part of restoring the caries, fixing the perio, we also have occlusal disease because it doesn’t match the textbook. Because that for me is a very dangerous sentiment, but it goes back to exactly what you said with the glasses.

CR Reconsidered: The Healthy MajorityThe way I think about it is, if 97 percent of us, right, or maybe even more, and depends on which study you see, are not in a fully seated position, are not in centric relation, then secondly, the 97 percent is the healthy and normal, it’s the 3 percent that we idealize and we aim for, the ones centric relation, that are the diseased ones.

When that penny dropped some years ago, I was like, wow, okay, fine. So maybe not everyone needs to be in central collation. So what would you say to that young dentist who’s looking at these occlusions and thinking, whoa, okay. As well as treating the caries perio, the bite is wrong. Therefore, I’m now going to do some dentistry to idealize the bite for this patient.

[Michael]
But if I could put that on hold just for a second. So when you talk about CR, centric relation, let’s change our brains. Like, let’s just talk about these words. CR is a joint based position. It is defined by the joint, nothing to do with the teeth.

MIP, maximum intercuspidation, is completely defined by the teeth and has nothing to do with the joint. We’ll get to CO later. So if you are in the most seated position, everything is anterior guidance from the joint. So the whole purpose of having centric relation, it’s not a health position. It’s not a pathology position.

The only people that are in CR all the time are dead. They’re not moving. But all of the rest, we’re not static beings. We move all over the place. So now going back to your young dentist question. I think we need to start looking at how to-

[Jaz]
Let me give you a clear example. Can I give you a clear example to maybe channel this in? Something you taught me in Stockholm, right?

[Michael]
Yeah, yeah.

[Jaz]
You said we look at someone’s occlusion and at dental school someone taught us that, ah, that’s a non-working site interference. And therefore, we think, oh, this cusp shouldn’t be touching when the patient’s going to the right. Therefore, I should get my bur out and maybe start drilling it.

Or maybe this can now go as a diagnosis entry saying, oh, there’s a non working site interference. This is bad. Well, how can we send a message out to everyone that actually just because it doesn’t match the textbook doesn’t automatically mean that it’s disease or that it needs treatment. Okay.

[Michael]
You’ve given me PTSD. You’ve used the interference word about 15 times. So we’re going to, you promised me we’re going to get back to that cause that’s what we have to talk about. I’m starting to stutter. All right. So what I’m going to tell those people is stop looking how people move. Start looking for signs that they do that movement.

Diagnostic Vision: Seeing Beyond OcclusionStop looking at how people move. Start looking at if there are signs that that is how they move. So, what I mean by that is it doesn’t mean put paper on there, or film, and have them move and see red and black marks. What I want you to do is just use your eyes and your brain and say, is there wear? Is there fremitus?

Is there mobility? Because all of those things are symptoms and signs of that motion pathway. Because you can have people with absolutely perfect occlusion, perfect canine guidance transition to crossover, and they are in miserable pain because they have such high intensity when they do that. Then you have these people that have a crossbite every other tooth and their curve of speed and Wilson are just like, and their occlusal planes are like up and down like merry go rounds.

And they still have all their parakamana. They still have all their mammelons, and they have absolutely not a wisp of wear anywhere. And you want to correct that? What are we correcting? Is, I think, one of my favorite things that Gary DeWood said, and he’s one of my mentors from Panky, is he said, I’ve equilibrated hundreds of patients in my career.

Half of them probably needed it. The problem is I don’t know which ones because when I started doing it, I was just doing it because they had eyeballs and I wanted to give everybody glasses. We have to have a reason, not only for our treatment, but for our diagnostics. Is there wear that needs to be addressed?

Is there pain that we have to figure out where it’s coming from? Are there functional or aesthetic concerns? And I think too many times we go into all of these little boxes of diagnostics, especially in occlusion, when there’s absolutely no reason to do that, unless there is.

[Jaz]
Unless there is. Absolutely. And I’m just thinking of scenarios. And I think sometimes by pitching different scenarios, we can bring these concepts home. And I’ve got a few more points to make thereafter to try and make this all go around in a circle and make it fully tangible. But canine rises, for example, right?

They’re a treatment modality. They’re a technique to give someone back their canine guidance who had lost it. Do you use this technique as a standalone in your practice? Have you used it in the past? And if you answer that one first and then we’ll go from there. So canine rise, I know lots of clinicians do, but where does this fit in into your practice?

[Michael]
Okay. So if someone has lost canine guidance, I have to look, what is their goal? Do they have an aesthetic goal or functional goal, or do they just not want to break stuff and make it worse? So just purely putting back canine guidance, the two components of introducing shear forces are increasing overlap.

Rebuilding with Purpose: Beyond AestheticsSo if you’ve lost canine guidance, your canines are short and you put them back, you’ve actually increased overlap, which increases your time and disillusion. So if they broke it off, what are we doing different to make it not break off this time? And that’s where I’m going to look at how can we move things forward.

And when I say forward, I mean towards the ones. And that is canine initiated at 70 percent muscle activity towards the ones. And this will always come to me when I’m doing some sort of smile design. And I don’t do all full mouth rehab. Sometimes it’s just the anterior floor and maybe fixing the lower incisal plane.

So this is probably one of the most typical cases. Two most typical cases that I’ll see is we’re treating the 2-2 on the upper and we have a worn super erupted plane on the lower. So you have the stepped occlusion. So what I want to do is how do I want it to look? So how do I want the 2s and the 1s to look?

And then how do I get that in transition of canine guidance over to the ones? And that is usually by doing some corrections on the lower occlusal plane. Now, the other one you kind of talked about, Jaz, is what about people who are not class one? So, what if you can’t even get canine guidance? Do you make the canine like five times as thick as it is tall?

No, then you’re in group function and the group function might start on the four. And then you go from the four to the three to the one. What about the two, Mike? Yeah, good question. The two, let’s just skip those. That’s a weak, wispy two.

[Jaz]
And for our Americans, obviously you’re making it British for our British followers, but the lateral, laterals. Yes, yes.

[Michael]
Sorry, sorry about that. So in a class two, you might start on the first bicuspid. Then go to the canine, skip the lateral, and then go to the central. Why do we skip the lateral? Because it’s this teeny little wispy tooth, and if you’re coming off 70 percent muscle activity on the canine, and you hit the two, that’s where disaster strikes a lot.

[Jaz]
And I like to actually use canine rises more in the following scenario. When someone is exhibiting a little bit wear on that lateral incisor, for example. Right? And when they go into excursion, just like you said, you observe with your eyes that actually the wear sets are matching up. Sometimes the role of the newly placed canine guidance or canine riser or the canine disclusion is actually to give you that space to restore that lateral and lengthen it so that it’s not going to be crashing in.

And so sometimes it’d be strategically used like that. But the kind of point I want to make to young colleagues is don’t look at someone’s occlusion and see group function and think that that’s a disease and therefore that you need to give everyone back kind of guidance.

I think we did, we’d covered that in that sense. But here’s another way to think about it. If and when we are doing full mouth cases. At this point, when you are now designing things in WAX, and you kind of mentioned already we want to be mindful of past this prologue, what did they do before, and I love that saying of yours, but when you are designing the occluding scheme, do you have like a goal, occlusal goal in terms of, I would like to give this patient canine guidance because you kind of have a bit more freedom in wax.

Obviously, we’re limited by their skeletal base. But if you had a choice that you could, I should give this patient group function. You open up the articulator. You’ve got a bit more space now, or you can prescribe canine guidance. Which one are you doing? And why in this kind of a case where you kind of have committed to a reorganized case, i. e. we are committed to doing some comprehensive dentistry involving several teeth at least in some maybe full arch.

[Michael]
Okay, so I’m going to take that as the step back to your simple case of their clipping on their incisor, because that can be in the limited case or the full case is my question is why are they clipping on that lateral incisor?

Did they lose canine guides or did they never have it? So let’s, okay, simplified. Some people call this the Melker’s mantra. How do you want it to look? How do you make it fit? How do you mitigate threats? So in a full mouth case, and I’m going to make some assumptions on a full mouth case that there is going to be some aesthetic component to it.

Even if they don’t want cosmetics, they don’t want me to make their teeth look worse. Except for one patient. That’s a long story. Most people don’t want you to make their teeth look worse. So, how do you want it to look? That’s going to be your uppers. How do you make it fit? You’re going to think that I mean dots in back and I don’t.

How do you make it fit? The next thing I want is edge to edge. Because that’s the end point in parafunctional control. Why do I want my upper centrals and my lower centrals to be edge to edge? Because that’s in compression so the two forces that we have in dentistry that threaten our success and our restorations and our reputations are sheer and compression. So everything works better in compression.

Denton and now I’m sorry, dentine, Denton for the Americans, enamel, compositor, composite ceramics, gold. It doesn’t matter. Everything works better in compression. So sheer is where we’re at with the canine. So how do you want it to look? Then how do you make it fit edge to edge?

Then how do you mitigate is bringing it back from edge to edge to MIP. And what that journey backwards is actually that muscle stroke that actually pulls the condyle to a seated position by the masseters and the temporalis being at high level of activity. So if I got two esoteric there for you, Jaz, what do I want my full boss to look like?

I want one single at least one single contact point on all my back teeth, premolars and molars, on a flat receiving area. You’ve heard me talk about landing pads. Then, what I would like in the anterior is canine initiated disclusion, if possible. Why? Because it’s the longest, strongest tooth in the mouth and it can take the abuse.

Up until it gets a little bit past the cingulum. Past the cingulum, you still have dentin behind you, whether you have ceramic or enamel. Once you get past your core material, and that’s old school because we have so many monolithic emaxes and zirconias, but once you get past the dentine underneath supporting that, you’re actually at shear and about the incisal quarter. So that’s when I want to start transitioning anterior. So canine initiated with a smooth transition to a more anteriorized contact that’ll be in compression. And so that, that’s kind of my thing.

[Jaz]
So I knew you were going to say that because I’ve done your programs. I’ve learned so much for you and I can’t wait to get out of you. And really the point I wanted to make for all the listeners here, right. And just want to untap a lot of things that Michael’s taught me. over the years. It’s something I’ve also reflected on in the orthodontic circles, which is basically, when I started to learn orthodontics, I did a diploma. I found that no matter what patient came through, the way orthodontists make a problem list is, okay, they want everything to look like a class one on a model, basically, right?

Canines in class one, right? And so they find everything that’s wrong. About this patient that’s not class one and their basic treatment is what can we do to get them into a class one, right? So it’s kind of like a rubber stamp and they put it on and this is the end goal every patient must look the same and this is the truth.

I feel as though this is what orthodontists do. This is this is how the pressure works Not all orthodontists obviously, but class one is the goal class one canines at least is the goal. Now the way I see this being applied in terms of occlusion and canine guidance is for our general patients. You know how Peter Dawson, he’s Dr. Dawson. He’s a general patients and complete patients.

And they’re two different things. And our general patients day to day who generally their things are working. Also, Frank Spear. I love what he says. Quiet muscles, noisy muscles, right? Lovely saying if someone’s generally got an occlusion that’s working for them.

And yes, if you look check with paper, just like you said, Mike, they might have these non-ideal features. Whoa, whoa, whoa. Non-ideal. I mean, according to textbook, they might deviate away from that textbook. I’m not going to say the I word. Okay.

[Michael]
Thank you.

[Jaz]
They might have these non-ideal features about them. But because generally it’s working, they’ve got quieter muscles and they don’t have a need for treatment. However, when we have the opportunity to give the patient what they want. So Michael’s first question always they want their teeth to look better or they’ve destroyed their teeth. And we are now have a blessed opportunity to they’ve entrusted us to treat them.

Now, we do exactly what Michael said, which is, how do you want it to look, okay? How do they fit together? And the last one is mitigate the forces. And a accepted, one accepted occlusal scheme is the one from the textbook. Just like the orthodontist go for class one, this is a example of applying a mutually protected or minimally stressed occlusion.

So I guess there’s a roundabout way of saying is that what I learned and the conclusion I came to is that the ideal occlusion and the textbook, we cannot apply that to our day to day dentate patients who have an occlusion scheme that’s generally working for them. We do have to pick up the book though, when we have an opportunity to completely redesign everything. What do you think about this way I’ve kind of like philosophized over this?

[Michael]
I like it, Jaz. There are a couple of points in there that brought it together for me. One when you talked about the orthodontist getting a rubber stamp, that’s literally what they’re getting because that was their board requirement. That was their board requirement for the cases.

[Jaz]
The midlines had to be perfect. They had to have the canine in exact position. And that was the par score. All their metrics are based on that.

[Michael]
Exactly. And so second one is there are restorative dentists that actually do that same approach. As I say, I have to do everything. So I have to control the occlusion. So instead of saying ideal and going back to the textbook and say, we need to do ideal. How about we change that word ideal to appropriate? Because the appropriate care can be limited. Or vast in scope, an application depending on the patient’s needs. And now I need to go back to the I word. So what is the I word? Yeah, say it. Say it out loud.

[Jaz]
Interference. Interference.

[Michael]
What does that word infer?

[Jaz]
It means we need to do something about it is a bad thing. Negative connotation.

[Michael]
Exactly.

[Jaz]
Pick up the bur.

[Michael]
Exactly. And that’s why I have a huge issue and I know you joke with me about it and a lot of people do. I have a massive problem with that word because it infers that it needs to be corrected. So an interference to what? A, because group function can be interpreted as interference, but if the group function is appropriate for that patient, it’s not the interference, it’s the optimal occlusal scheme for that person.

So I hate that word. I will never stop hating that word. And I’ve been in therapy over that word. So thank you for letting me get that off my chest.

[Jaz]
Well, now everyone knows why Michael hates the interference word. And just generally speaking, One thing I was taught actually was, if you If someone has that feature of their occlusion, then perhaps we should refer to it as a non working side guidance.

Not a non worker side interference because for that patient it’s appropriate for them. It’s working. They’re not breaking anything. They don’t even have wear there. They don’t have any issues perhaps and a lot of our patients don’t have any issues. They have those features, but they don’t have any issues. So perhaps for that patient it’s appropriate to name that a non worker side guidance.

Whereas actually if there is a significant problem being created by having this type of relationship in that patient’s mouth, maybe then in the selective cases, we may be able to use that term because in that patient you are planning to treat that or correct that so that we can, going back to what you said, anteriorize things, reduce, dial down those forces, because this is a destructive patient, for example.

[Michael]
Okay, so let’s talk about. working side contacts posterior to a canine. Okay. So that’s the traditional group function area. So when is that a problem? So that can be a problem. If they have muscle issues on that side, their teeth look fine. That can be that they have wear or fracturing or chipping on those teeth.

Then it’s an issue. Now, the third one, and you touched on this almost at the beginning, but we’ve talked about periodontium. What if the teeth look fine? They don’t have any pain. They don’t have any chips or cracks. What’s the other one I’m going to worry about is fremitus. So ink lies to you like, can we swear?

[Jaz]
Yes.

[Michael]
Like a bastard. Ink lies to you like a lying, cheating bastard. And because if you put ink over there and you’ll see one thing, but the teeth might be moving. You’re like, oh, this is fine. He has perfect balance, occlusion. What I do is I stretch my gloves, I turn my fingernails on the side and I put it against the facials of those premolars.

And when I have them, I don’t have them move to that side, I just have them power wiggle. And so, if I see no chips, no wear, no fractures, no muscle issues, but I feel fremitus, then those working side, and I’m going to call them contacts, because contacts without interpretation, it’s not a good or bad, it’s just an is.

So, if they have working side contacts on the bicuspids, And those bicuspids are inframedous and those are the teeth that will almost always be inframedous from occlusal. Oh my God. I almost said interferences.

[Jaz]
Overload.

[Michael]
So, from occlusal contacts, then we have, yeah, we have to go to the why. We always have to go to the why. Why are we looking? What are we worried about? Are we worried about breaking down of the system? That system can be above or below the gum line.

[Jaz]
And it’s good because you made this point about if you check with articulating paper, everything seems normal, but fremitus is sometimes overlooked because of that, because we see that, oh, the tooth looks healthy.

And of course, when we take a radiograph, we see that I’ve got very good bone levels and you think, hmm, what’s going on here? And you’ll see that once you change the occluding scheme for that patient, that quite often these teeth will start to firm up as a response to their new environment.

[Michael]
Absolutely.

[Jaz]
You can see why, Michael, that there never has been an episode that I’ve found on any dental podcast ever with this title of Canine Guidance vs Group Function because A, it gets people into, not us, but it gets people arguing and fighting. And in that spirit, I’m going to ask you now two naughty questions that could upset some listeners and viewers. So let’s do it. Okay. Number one, Michael’s nervously looking around, he’s getting his mask on now. Okay. Does Michael Melkers believe that abfraction exists?

[Michael]
Maybe.

[Jaz]
Me too.

[Michael]
Abfraction by definition, infers the defines the cause. So an abfraction is a cervical lesion that is caused by occlusion and occlusal flexure. So if you look at the work of Zakovich versus G. V. Black and all the way back in the day, actually abfraction versus non carious cervical lesion, go back into the 1800s. This is not a current argument. So, abfraction means the teeth are flexing and then we’re getting cervical notching. So, non-carious cervical lesion means there’s a notch down there, but we have no idea where it came from.

Or it does not infer causation. So, I am of the belief that I don’t know everything. And my sister would agree with me on that one, but I believe in multifactorial. You have acid, you have toothpaste, and you have flexure. Zakovich’s work showed that it has nothing to do with the stiffness of a brush. That the stiffness of a brush, hardness to softness, neither will affect enamel.

Then on exposed dentine, neither will affect dentine. You have to bring a dentiferous into it. So you have to have, bring an abrasive into it. So I am much further leaning towards this being a mechanical erosive than it being occlusal trauma.

[Jaz]
Brilliant. I just wanted to get that out there. And the second controversial thing I’m going to mention is, I’ve recorded some episodes with like amazing dentists, like Sandra Hulak, for example, teaching with Kois.

And recently when we saw Dr. John Kois at AES, he mentioned his very famous paper that he wrote, like the myth of anterior guidance. I’ve read that with great fascination. I use some principles from that, but essentially the point that I’ve seen him make before is, why are we checking patients in lateral excursion, because that’s not a functional movement.

And we don’t do that in function. I get it because just like you said, as well, parafunction is starts on the inside and goes outwards. Function is outside in. But where I am at the moment, I feel as though I’m just going to check for both and I’m just going to account for both. That’s my current stance.

Like, okay, I see what you’re saying and I see what the other camps saying and you know what? I’m going to try and make sure that things don’t clash together in function and I’ll check for parafunction and I’ll make sure that things are working harmoniously in parafunction as well. But my question to you, I guess, is, Michael, I just don’t know how you can get away with finishing inclusion and not checking the lateral excursion.

I just feel as though it’s something that is part of, it should be a checklist that you do. Because if there are these overlaps and time in resistance and high forces in resistance on a parafunctional patient and sometimes they may become parafunctional in the future, then we still need to account for this.

I just feel as though if we exclude that element, because some camps believe that only 1 to 2% of people are bruxo maniacs, and therefore we don’t have to check. This is much better just to check functional movements. I just don’t see that sitting well with me. What are your thoughts on that?

[Michael]
My first thought is that one of the worst things we’ve ever done as a profession is in fight. That is in fighting, not inviting, is fighting between each other is we are literally making all this stuff up and it’s theoretical. If it wasn’t theoretical, there would be far more proof to support either functional or parafunctional.

So, Dr. Kois, I have known each other for a long time and we shook hands and butted heads over the years on this. So. I think I agree with him in that one of the things that we check is lateral excursions. Lateral excursions is when the muscles are actually at their weakest, because the lateral pterygoid is overcoming the temporalis of the masseter.

And it’s actually the return stroke that that’s where the destruction is. And that’s why I said, how do you want it to look upper edges? How do you make it fit lower edges to upper edges? Because it’s the stroke back from there that I’m actually worried about. That’s where the masseter and temporalis.

And that is where you can really get confused between parafunction that is movement without purpose and function, which is movement with purpose. So functional movement with purpose is not just eating. It’s swallowing and it’s talking. So as I referred to before, Janine, aka Dr. McDonald, my wife and I followed 385 patients over 10 years in their wear patterns.

So that was not a double blind or even a single blind study because all of those patients were patients in my practice that needed splint therapy. They all ground. So this one to two or even 10 percent number, I think is, I don’t want to say garbage because that would be disrespectful, but I can’t think of another word.

[Jaz]
Can I just add that since, since you taught me to color in the dispense all those years ago with the sharpie, right? And I’ve yet to find that patient who doesn’t make that beautiful triangle shape in it with the apex force and so you think, hmm, surely if some a lot of these patients weren’t bruxist and I kind of got it wrong that everyone would come back without much on it. So in my experience to follow on from yours to add to what you yours and Dr Mcdonald’s work and I totally agree in terms of the evidence I see out there suggests that there is a degree of parafunction. Sometimes it’s less and sometimes more, but the activity is happening. It varies to each individual.

[Michael]
We have tried to stop parafunction by changing joint position, changing vertical dimension, changing dots on teeth and currently sleep apnea. And that’s actually going by the wayside. That we’re saying, even if we correct apnea, people are still bruxing, and my research shows that.

Now, when I think about this, when I’m doing restorative dentistry, what’s the harm in us providing and looking at that lateral or return stroke? We’re just covering our unknown basis. Now, I will bring this up, Jaz. So when you look at Dr. Kois’s work and the paper that you referred to, The Myth of Anterior Guidance, and he wrote that with Dr. Betsy Bateman.

In his diagnostics, he says, I believe it’s Dr. Bateman says. Aikman says is put some articulating paper between the patient’s teeth and then have them simulate a chewing stroke until their teeth come together. And they’re doing that to evaluate whether teeth touch. So they’re actually, with their words, this is in that article, is they’re telling people to chew until their teeth touch.

And then they’re saying that’s proof that teeth touch when people chew. But I mean, that baffles me. If you look at the work of Lundin and Gibbs and their chewing stroke cycles. Patients don’t touch their teeth when they chew. And if they do, it is a sign for them to be immediately disclued.

[Jaz]
And then eventually encourages the swallowing reflex. That’s the signal to the brain. Okay, now the food is mushy enough that we can go ahead and swallow. And those fleeting contacts there weren’t significant contacts of teeth. And they were fleeting. Little touches here and there. Rather than huge grabs and lots of rubbing of the cusps clashing into each other.

[Michael]
Yeah, I will layer this on there, Jaz. Whether you say it, whether I say it, whether Kois, Spear, Dawson, Bruchess says it, none of us should believe it. We should look for proof and put it through the filter. I remember being at the equilibration society at the 50th anniversary and looking at the legends, Tanner and Neff and Dawson and they said, we made all that stuff up 50 years ago.

There was literally no occlusal knowledge. We just made it up. It was a theory. You look at original Pete Dawson’s textbook, he self-cited a lot and then people cited him and then he cited the people citing him. So there was all this circular logic and Pete was a good friend. That’s why I keep calling him Pete.

Key to Dental SuccessDr. Dawson was a good friend, but they were very honest that they made that stuff up and that’s neuromuscular. Some of it worked. Some of it didn’t and the proof is fleeting patients are different You can have the exact same dentition and put it into you, me, Lincoln Harris and Janine McDonnell but if we have different risk factors, we could do different things with those dentitions so Lane Ochi, it’s not his quote, but he uses it.

What we need is a semi adjustable articulator, but a fully adjustable mind. We need to stop regurgitating what we were told. We have to come with everything. I think, God, that’s one of my favorite quotes is, we have to fear the present. Respect the past. If we are to provide for a safe future, it’s like always question, always be thinking, always be improving. And we should do that as a cohesive profession of colleagues that respectfully agree and disagree with each other. That’s how we’re going to move forward the best.

[Jaz]
And I just want to thank you for taking those two tough questions. And I think you did an amazing job with them. And if there’s one thing that people are chopping onions, they’re busy commuting and they’ve got this far and they think, oh yeah, there was a lot to take in and take home there.

Let me just remind you of a wonderful thing that Mike said is the occlusion that’s most appropriate for that patient. If we just start thinking away from the textbook and looking at our patient and say, okay, what would be appropriate for this individual? And then you’re 50 percent there to the answer.

If you actually just think in that way, I love that. You also mentioned about landing pads. And also I can tell you guys that what Michael has to teach when it comes to communicating with patients and the way to do co diagnosis along with Lane Ochi is well worth it for those things.

So I’m encouraging everyone. If you have the opportunity to be in London in end of July to come and see Dr. Lane Ochi and Dr. Michael Melkers lecturing together for the first time in London, I believe.

[Michael]
Yeah.

[Jaz]
I think that’s 27th and 28th of July. I’m going to put the link there. I really, really do implore all my audience who are in Europe, let alone London, Europe, if you’re in Europe and you can come, heck, if you’re in States, you want a tax deductible trip to London, and you haven’t seen Mike and Lane together before, it is really, or if you’ve maybe seen them before, like their stuff is worth repeating. So those kind of things. Are you excited for this trip to London with Lane?

[Michael]
I am so excited for this trip for a number of reasons is one, I love London. I think all the way back to the first time I taught there in 2005 or going back to the BDA. But Lane and I changed our program every single time is we are never static in this.

And even if it’s the same information, you’re going to hear it differently, but we have people coming from the Baltics. We have people coming from all over Europe. We have people coming from Sweden, Norway, Finland, as far away as Leeds. So we have a group, not only that I’m excited to share the information, there’s so many people in that room that I’m excited to actually meet for the first time and see you there.

Actually Jaz my sister, Julia, who you know, she and I have done some research together on radiation dosing. She’s actually going to be in the UK at the same time, so you might actually get to meet another one of my family members as well.

[Jaz]
Lovely. Now, I’m going to put the link there, but just can you give a flavour to these dentists of like, it’s a two day thing. It’s a two day, what exactly are you covering? Because I know it’s case planning, it’s occlusion, it’s communication. To give like a flavor to these dentists, because some of what we talked about is going to be covered. Like the whole landing pads, Lane’s told me, is a great concept. Generally thinking about case planning, phasing. But I want to hear it from you. What have you got in store for the dentists?

[Michael]
I think what’s really different. No, I don’t think so. I know what’s really different about our program is what was the kind of take home message, what matters the most in all these occlusal decisions that we’ve talked about?

It’s the patient, right? It’s the variant in patient. So Lane and I are going to provide the attendees with didactic information, but we’re going to support it with patient specific application. We’re going to go from single teeth to quadrants to arches to full mouths. We’re going to show you our words and our cases that fell apart.

We want to talk about why. And the way we get to do these cases is not by having occlusal knowledge, but actually being able to listen and communicate with our patients. So we’re going to blend communication, case planning, and occlusion together. How do you want it to look? How do you want it to fit?

How do you mitigate forces in patient specific applications and their stories? I have so many patients that are just so generous. They give not only their permission to share their cases. But their faces, their stories, their tears, and really what brought them to dentistry and why they needed us. So that’s really what helps us get the cases. It’s not knowing dots and lines. It’s actually knowing Dolores and Bob and Mrs. Bender. And you’re going to get to meet all of them.

[Jaz]
I just love everything about you and Lane, and Lane recently came on the podcast and he gave such amazing tips. Everyone’s been commenting on Protrusive Guidance. I saw you join recently. It’d be great to see Lane’s view there. And Lane’s been posting so many great diagrams and advice.

I actually emailed my entire list with some of the zirconia stuff that Lane very kindly has been sharing. And he’s been so giving and kind with his advice to the younger colleagues on there as well. So if you guys want to DM Mike on Protrusive Guidance and learn more from Mike and Lane, check it out there.

But I’d highly encourage you to check out that London course. If you couldn’t make it, honestly, this is something that was important to me in my journey learning from you. And now more recently, I know Mahmoud has learned so much from Lane. In fact, Mahmoud always says that over the years, he’s learned so much from you and Lane on Dental Town.

And he’s so excited to see you there together in person because obviously Lane wasn’t the

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As part of Documentation Month, Jaz dives into the crucial realm of documenting dentistry. In this episode, he shares four methods he utilizes to document his daily dental practice, followed by six compelling reasons – in reverse order – why documenting your dentistry is indispensable. So, get ready as we count down from six to one!

But first, let’s recap: In our previous episode, we explored the marvels of employing AI to automate note-taking, saving precious time and boosting efficiency. If you missed it, make sure to catch NEVER WRITE NOTES AGAIN! HOW I USE AI FOR AWESOME AND EFFICIENT DENTAL RECORDS – PDP181.

https://youtu.be/e6pNhWhyhNUWatch IC046 on YoutubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:00:53 Utilizing Intra-Oral Camera
2:30 Investing in good DSLR Camera
3:16 Documenting with Intra-Oral Scans
3:51 Camera Mounted on Loupes
4:56 Portfolio Building
7:34 Monitor Changes
9:00 Patient Communication
11:35 Good Mentorship
13:24 Medico-Legal
14:29 Fulfillment in Dentistry

Join us on Protrusive Guidance, our own platform for dental professionals. No need for Facebook anymore!

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THIS is the best thing in Dentistry since local anesthetic!

I HATE typing notes even more than I hate cracked teeth. The quest for good, detailed, contemporaneous record keeping in 2024 means so many of us stay behind after patients to ‘tidy up’ our notes.

With the power of audio recording and AI, I am pleased to present to you NOTES THAT WRITE THEMSELVES!

In this episode I share my current protocols using DigitalTCO – a website that uses live transcription and AI to write your notes for you (genuinely awesome notes).

https://youtu.be/F1RKQ_qZfrcWatch PDP181 on YoutubeProtrusive Dental Pearl: Register for a free EXTENDED trial with Digital TCO and transform your note-taking process by simply speaking into a microphone connected to your computer. Forget about typing out notes after appointments— the intelligent AI will craft them for you as you dictate, making everything sound fantastic.

Using the Protrusive link to sign up DOES mean that we get a commision, but I also ensured you get 50% off (for the lifetime of your subscription) AND 28 days to try this instead of 14.

‘Jaz Mode’ lets you speak to patients and nurses during consultations, with AI compiling the notes for you. Named “Jaz Mode” in my honor by Kevin, it’s still in beta but offers a glimpse into innovative note-taking. To try it out and see why I’m excited, visit protrusive.co.uk/notes. Watch for a demo video, including my recommended microphone.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:
04:28 Introduction to Kevin Shannon
07:10 Kevin Shannon’s Journey: From Clinical Dentistry to Tech Innovator
10:03 AI-assisted Note-Taking Journey
12:21 Downfall of Templates
15:27 DigitalTCO – Never Write Notes Again
23:19 Jaz Mode!
27:55 The Protrusive – DigitalTCO Collaboration
37:51 Let’s Talk AI

As promised, this video shows an example of how I use DAN and DigitalTCO to write my notes for me.

https://youtu.be/mI5qplWxMQsWatch this video on YoutubeLet’s compare the Blue Yeti microphone: https://amzn.to/3INYop3 (Affiliate link) Vs the Rode Wireless Go 2 microphone: https://amzn.to/49ffgzA (Affiliate link)

Join us on Protrusive Guidance, our own platform for dental professionals. No need for Facebook anymore!

Rode Wireless GO II Single Channel Wireless Microphone System, Black

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“How long should I tell my patients their posterior composites will last?” – what a great question from dental student Emma Hutchison!

As part of our new Protrusive Students segment we’ll be bringing you monthly episodes packed with valuable insights, tips, and tricks specifically tailored to dental students like Emma.

https://youtu.be/PP1XICgI-lgWatch PS002 on YoutubeWhether you’re navigating clinical rotations, honing your skills in phantom head, or gearing up for those daunting exams, we’re here to support you every step of the way. And kicking off this segment, we’re diving headfirst into the topic of adhesive dentistry!

Link for further reading regarding the longevity of direct restorations – A retrospective clinical study on longevity of posterior composite and amalgam restorations – PubMed (nih.gov)

The Art of Treatment Planning – The Art of Treatment Planning: Dental and Medical Approaches to the Face and Smile: Amazon.co.uk: Romano, Rafi: 9781850971979: Books

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:
00:00 Adhesive dentistry
03:41 Bonding systems
07:00 Self-etch vs. total-etch vs. selective-etch
14:38 Post-operative sensitivity
16:10 Communicating risk with patients
17:42 Polymerisation shrinkage
19:38 The snowplow technique
21:13 Instruments
23:19 Consent
25:30 Longevity
28:05 Risk factors
37:37 The next episode

If you liked this episode, you will also like PDP077 I Can’t Believe This Sticks

Click below for full episode transcript:Jaz's Introduction: So welcome to Protrusive Students Episode 2. In Episode 1, we introduce you to Emma Hutchison, who's the Protrusive Student. I'll be releasing one episode with her every month to answer questions from a dental student's perspective. And every month, we will release some of her revision notes, which are absolutely epic.

Jaz’s Introduction:
I’ll check them myself on the Team Brandsim. All of these notes are going to go in the Crush Your Exam section of Protrusive Guidance. Protrusive Guidance, if you’re brand new through a podcast is our little family. It’s our little home on the internet via the web browser, or even it’s native app via Android, iOS.

All dentists and students can join it, but if you want to verify yourself as student, you have to email student@protrusive.co uk. So when you apply to join the network, which is on protrusive.App. Once you apply, you fill in some details, you explain that I’m a student, and then you should email student at protrusive. co. uk with some proof that you’re a student.

That way we will add you to our secret space called Protrusive Vault. So as part of your benefit of being a student on Protrusive Network. You had access to a paid space. There’s also student clinical videos, which we’ll be adding soon, as well as more episodes, just like this one.

Hello, Protruserati. I’m Jaz Gulati. Protrusive Students is part of the Protrusive Dental Podcast. If you are a dental student, don’t hoard this, share it with your colleagues. Eventually they’re going to find out anyway. So you might as well be the person who shared it with them. I’m hoping that on Protrusive Guidance, we can help you on your journey.

Look, there’s almost a thousand dentists so far on Protrusive Guidance, and these are the nicest and geekiest dentists in the world. And by being someone who is a keen learner, who listens to this podcast, right? Not everyone does, right? Only those who self select themselves as a keen learner listens to stuff like this.

And so it’s time for you to meet your tribe and start learning and growing together. Now in this episode, which was supposed to be released in February, but life got busy with kids. It’s actually Adhesive Dentistry. Questions from Emma Hutchison all around the topic of adhesive dentistry. Like for example, some of the things we’re going to cover is the longevity of composites.

This is such a fundamental thing. And actually what I love about doing these series now with Emma is everything she’s asking is so foundational that even the dentist listening and watching, I think will gain from this. So let’s go ahead and join the main interview with Emma, all about adhesive dentistry from a student’s perspective, and I’ll catch you on Protrusive Guidance.

So Emma, have you started on the clinics yet? So we’re talking about adhesive dentistry today, you’ve got some questions for me. Have you done your first composite on a patient yet?

[Emma]
I have, yes, I’ve actually been quite lucky. I’ve had quite quite a few patients. So I’ve done maybe about 10 composites so far. I know some of my friends have had zero, so I’ve actually been very lucky at the start of my third year, had some good patients.

[Jaz]
Very good. Well, you, you’ve done 10, but you’ve seen thousands, right? From your experience in nursing, which is great. So you get even more from that. So you would have seen different bonding systems being used and whichever one you’re using at the end of school. Just curious thing here, this wasn’t scripted, but when you’re doing your bonding stages, like you’re etching, bonding, everything, what’s going through your mind? What are you thinking about?

[Emma]
What I’m thinking about is just, I’m a nervous hummer. So you know that I’m concentrating, I’m going to be, I’m just so in the zone. You just need to especially early on, I’m just concentrating so hard. I come out, I’ve got a sore jaw after. But honestly, it’s just etch, prime and bond, etch, prime and bond, just repeating that in my head over and over, but just total concentration mode. I forget it after, I was concentrating so hard.

[Jaz] Bonding systems
I remember working on the clinics as a student and this is like our first year in the clinic and the dental student in the bay behind me, I won’t name and shame him, I don’t want to embarrass him, but the patient left, he was like, oh no! I forgot. I forgot to bond. I etched and I put my composite, but I forgot to put the bond.

So I’ll never forget that. So I see what you mean. You etch prime bond. Don’t forget the stages because when you’re so new. Exactly. But the reason I asked you that, Emma, is because what goes through my mind is a bit funny. Interesting. I think scientifically, I just wondered, are there any other dentists out there?

Maybe if you guys are watching on the new platform, just comment below whether this is you or not. I am imagining, the scanning electron Microsoft images of dentine and stuff, right? I’ve got these tubules on mine. And then as I’m doing the etching, I’m seeing these enamel, like etched enamel, like the sort of scanning electron Microsoft part of it. Then when I’m putting my primer, I’m seeing that hybrid layer being formed. So that’s what I’m visualizing. I don’t know if I’m the only one who does that.

[Emma]
I’m just trying not to cry at this point, but I cannot, I cannot.

[Jaz]
I love it.

[Emma]
I just need to just etch, prime, and bond, etch, prime, and bones, because if you miss that, then, your patient will be back in next week.

[Jaz]
Look, when you start endo, your head will explode.

[Emma]
Yeah. No, definitely. Yeah, we’ve been doing endo down on the phantom heads and things and it’s just so I’m dreaded. No, I won’t say I’m dreading it. I’m looking forward to the first endo patient, but it’s a lot. It’s a lot.

[Jaz]
It is. What this chat reminds me of is I remember being a third year student and I was living with fifth year students at the time. So it’s pretty great. I was like constantly getting advice and stuff. So you finished your morning lectures. I’d come home and I literally lived in a flat, like two minutes walk from the dental school, right in Sheffield. It was amazing. And there we are standard, you get a bit sandwich and you start playing FIFA as you do.

So I’m playing FIFA with a fifth year dentist. And I say to him, when do you get to a stage where you don’t have to like do a step by step memory of exactly what you have to do next and endo? Yeah. And he said, I’m still not there yet, but I’m almost there. And then when you speak to, when I used to speak to dentists, when I was a dentist, he would say, hey, endo, yeah, you don’t have to memorize it.

It just comes instinctively. It’s like something that just gets etched into your brain and it does happen eventually. And now you can, when I’m doing a composite, you don’t have to think about the different steps. It’s just part of the procedure. You’ve done it thousands of times. So don’t worry. It will normalize. It’s like driving. You get, you don’t think about it anymore.

[Emma]
Yeah, yeah, no, eventually, eventually it’ll all fall into place.

[Jaz]
It certainly will. Now, Emma, you’ve got some questions for me, depending on time. You’ve got some questions for me that are going to make this topic tangible. I’m actually excited to cover these because I think this will generally make a really good educational episode in dentistry in general. So, it’ll be nice to serve students and dentists together in this episode. So come at me.

[Emma]
Okay. So my first question sort of spawns from, it was our first day or our first lecture of second year. And bearing in mind, this was the first time we had been in the dental hospital because in the first year it was COVID.

So I didn’t get into the dental school until second year. And then we had a year out. So that was technically my third year of university. And I remember our first ever lecture was on boarding systems. And I’m sitting there in the lecture theater and I’m like, what is going on? I’ve had no introduction to composite.

Self-etch vs. total-etch vs. selective-etchNo introduction to anything. And everyone was just sort of like, I remember thinking, it was just a bit, a bit mind boggling. And then, obviously I understand we need to know all these different protocols, etch, prime, bond protocols, but there’s just so many different, different things that we’ve covered. You’ve got like, your total etch, your self etch, selective etching, different steps, two, three steps, etch and rinse bonding systems. So I just wanted to know, would you use different protocols in different situations? Like, what are the basic, what are the most common protocols? What do you do yourself, your day to day?

[Jaz]
Great question. Really real world questions. And I think where I’m going to start to answer this is in the real world, believe it or not. I mean, it’s really good to know all this stuff, by the way. I think Dental Materials is like that one textbook that you still keep because it’s really nice to connect with it. And we’re using dental materials every day, which are ever improving. And it’s great. But to have the foundational science behind it is good.

What you’ll find is that wherever you get a job, when you start practicing, start working as an associate, you’re kind of at the mercy to whoever made a decision at one point in that practice, be it a group of associates or being a principal about which dental bonding system that they’re going to adapt in that practice.

So every surgery is stocked up with that same one usually, right? It just for think about stock, like when you were nursing, like if there was five different types of bond, I mean, they’d expire, there’d be a ordering issue. Did you ever work in a practice that had different types of bonds or was it just usually one or two bonds?

[Emma]
I’ve mostly worked in mixed NHS private practices and usually there’s one for private patients and there’s one for NHS patients. That’s about it really. That’s about it. That’s all that I can remember.

[Jaz]
So yeah, so there was like one or two basically and generally that’s usually how it is. And so you are at the mercy of whichever supplier had that buy three bonds, get two free offer. And then the practice said, okay, let’s go for it. Let’s buy a year supply of bond. And so the most important thing is, figure out which bond it is you’re using, okay, the actual name of it and download the DFUs, the directions for use, right? The most important thing I think is whichever system you’re using, please use it in the way that the manufacturer intended it to get those bond strengths, okay?

The biggest sin you can do is like, for example, we were saying earlier, etch prime bond, etch prime bond, that kind of stuff. But imagine you are using a, what I’m using, like I’m using a G-Premio Bond I think it’s like a sixth or seventh generation, right? It’s like a newer generation. I don’t even know exactly which generation it is, but I know exactly how to use it, right? That’s more important for me. It is a self etch. Okay. And so the worst thing you could do is use your phosphoric acid etch on the dentine.

[Emma]
Right.

[Jaz]
Wait 15 seconds, wash it away and then use this bond. You’ve dramatically reduced the bond strength. Big time.

[Emma]
Okay.

[Jaz]
Because the directions are, you do not etch the dentine here. That’s specifically the direction, you do not etch the dentine. You actually weaken your bond strengths that way. The self etching primer, it does all that kind of stuff for you with the dentine.

And so what I’m using at the moment is G-Premio Bond, because that’s what we decided as a practice that we’d like GC products. Okay. And it served us well. And so what I would do typically is once it’s all clean, what I mean by clean is personally, I’m using air abrasion. Are you familiar with what air abrasion is?

[Emma]
Yeah, I’ve worked with dentists that use air abrasion a lot, yeah.

[Jaz]
So I’m using like 27 micron or 50 micron aluminium oxide particles blasted. What that does is it, most important thing, is it gets things clean, right? You get rid of the biofilm. That’s the most important thing. And supposedly gets a nicer structure of dentine to bond to. That’s actually debated, but you definitely remove the biofilm, which I think is the most important thing.

So I’ve got a nice clean surface. I’ve got rubber dam isolation. I’m a big believer in rubber dam isolation only because like you look away and if you don’t have rubber dam isolation, that’s when I’m stressed. Like the patient’s tongue goes there. It feels a saliva. The gingiva starts to bleed into the cavity.

It’s just a stressful. It’s more about stress. My mental health and stress will benefit from having rubber dam on. So I’ve got my rubber dam on. I’ve got my abrasion on. And so what I would do is I would use my etch first on the enamel only because of system that I’m using. So whichever system using follow that the system I’m using, I will do a selective etch technique.

I. e. I’m selecting, I’m choosing to etch the enamel only. Then I will wash it. So I would typically wait 20 seconds to 30 seconds. Okay. I’ll wash it and observe that frosty enamel. Okay. I want to see that frosty enamel. Okay. Not overly frosty, but you just want to see some degree of frost frost there. Then I will get my G-Premio Bond.

Post-operative sensitivityOkay. So I don’t, there’s not a separate priming stage in a separate bonding stage. Like a fourth generation one will be OptiBond FL, which is supposedly the gold standard. Have you heard of OptiBond FL? Have you heard of it?

[Emma]
I’ve heard of Octobond, but not OptiBond. It might be the same thing that I’ve heard of, yeah.

[Jaz]
Probably. I mean, they have OptiBond Solo, and they have a few different varieties of stuff, but one of the ones that a lot of pedantic dentists like to use is OptiBond FL, because the initial research in the 90s and 2000s was like, wow, this is amazing. And people, once you have a system that you can trust and things work.

It’d be silly to deviate away from it. And so the way that one works is that you do a total etch. Total etch is when you etch the enamel and you etch the dentine. And typically what you do is you etch the enamel first. Then by the time you get to etching the dentine and then you wash it, that means the enamel had more time than dentine. Is that what you do at the moment?

[Emma]
Yes. That’s what we’ve been taught at class school. Yeah.

[Jaz]
Do you know what bond you’re using at the moment in the

[Emma]
No. I should, I should, but I know it’s got the pink or purple color. That’s all I know.

[Jaz]
That’s totally cool. Emma, that’s totally cool. I don’t remember the bond I use at dental school. If you ask me when I’ve done 10 composites in, listen, as long as I remember to use a damn thing, I’m happy. Right? So these are the things whichever one that be in the real world, when you get there, it will be so different to what you use in dental school that you must take a moment to pause and look at the directions for use.

So back to the OptiBond FL, you do the total etch, which is the etching, the enamel, then the dentine, then you do the primer stage. Separate. Okay. Get nice and dry. Another coat get nice and dry. Okay. You don’t wash that that way, then you put the separate bond adhesive. So the primer goes into the tubules, okay?

Okay. And then it links to the adhesive that you put next, and then that hybrid layer is formed. Then you put the composite on top. Whereas what I’m doing, back on the newer generation, is everything is in that one bottle. So after I have selective etched the enamel only, we’ve put the G-Premio Bond, which has got the prime and the bond, everything inside there, and it’s got the etching ability to self etch the dentine.

[Emma]
Okay. Yeah.

[Jaz]
Then I will dry and it, this stuff goes to like four microns thin. So super thin, we will cure it and then we’ll go proceed with our composite restoration. So the real world lesson here is to make sure whichever system you’re using, you make sure that you follow the directions.

And if for those of you who want to really get deeper into this, but in a really tangible episode, there’s an episode that I did with a guy called David Gerdolle. So the episode we call it, I can’t Believe This Sticks Extreme Bonding. It was PDP 077. I would encourage anyone listening to this right now.

And you’re interested in learning more about what are the most important things to do? And what Dr. Gerdolle said was that as long as you get the tooth, clean and rough. Out of the six different things that you’re trying to do when you’re bonding something, the two most important is clean, no biofilm.

And what you meant by rough is get that nice etch pattern, like optimize your surface to bond to. And if you can do that, things will stick. So we talk about air abrasion, we talk about etching protocols and that kind of stuff. And so the whole bonding thing, whichever one you’re using nowadays, they’re newer, they’re supposedly better.

The issue, Emma, with using the more gold standard fourth generation earlier bonding is it’s technique sensitive, right? You have to get the whole what we call wet bonding where you have to make sure you don’t over dry the dentine and the risk of over drying the dentine increases when you’ve etched it.

If you’ve etched it and now you have to wash it and then you have to dry it, how do you know you haven’t overdried it and whatnot? That’s why it’s supposedly technique sensitive. So the new ones actually make it a lot easier for me.

[Emma]
Yeah, okay. That makes total sense. That’s good to know, actually, because I’ve never seen anyone do the separate prime, the separate bonds. I had never even heard of that. And then when they’re talking about it in this, maybe that’s the drawback of doing dental nursing, actually. I’ve never seen that before. So putting that into context for me was really, really difficult, actually. So no, that’s good to know, just follow your manufacturer’s guidance and don’t just take any random bond and use it willy nilly.

[Jaz]
And if you could do this for me, Emma, for homework for the next monthly episode is, I want you to find out exactly which bond you’re using. Let’s look at the directions for use together for that one. Okay. And let’s evaluate what you were doing well and what you weren’t doing on your first two composites so we can actually learn together. If you don’t mind, that could be a nice reflective thing, right?

[Emma]
Yeah. Yeah. Perfect.

[Jaz]
You know what? You asked a good question, which I didn’t answer. Would I use something different in different scenarios? Personally, I don’t, because we just, that’s what we have, right? Like the real world answer. That’s what we have.

Communicating risk with patientsThat’s what we use. And some of my biomimetic dentists are like, oh, Jaz, you shouldn’t be using that bond. You don’t get as high as bond strength is like clear fill or that kind of stuff, which I get. But I have heard this thing on some webinars that I went on whereby. If you have got some caries, which is not close to the pulp, which is not close to the pulp, then in those scenarios, you should consider using a gold standard total etch.

So we’re etching the enamel and the dentine. If you are in a scenario where you’ve got deep caries close to the pulp, then the theory is perhaps we don’t want to put that 37 percent phosphoric acid etch right next to the pulp, right? So that makes sense to me. And then for those, you might decide to use a self etch, which actually when I heard that, like, five, six years ago, it made a lot of sense to me. But in the real world, do people do that? I’m not sure.

[Emma]
Yeah. No, I mean, I’ve just never had the conversation. I just sort of pass what I’m supposed to pass. So no, that’s good to know. Very interesting. Very interesting. The next question I had for you, Jaz, was we’ve talked a lot about like post op sensitivity can last for quite a few weeks. Do you think, do you notice that there’s any certain patient populations or specifically situations where post op sensitivity is more likely and how do you address this?

[Jaz]
Again, fantastic question. The only thing that comes to mind to me is people with cheese molars. M I H. Have you heard of M I H?

[Emma]Yeah.

[Jaz]
So molar incisor hypomineralization, and these molars, which for those dentists who might be not familiar with this, this is when at the point of development, when the enamel is developing on the sixes and the centrals and whatnot, is hypomineralized.

Polymerisation shrinkageThere’s not enough mineral content. These teeth are weaker, and there’s different sort of degrees of it. It’s mild, moderate, severe kind of stuff. And if it’s severe, as the tooth erupts, the enamel is just breaking away and that tooth’s got to come out. Whereas if it’s mild, they have like these yellow patches and white patches on it and the yellow patches is why they’re called cheese molars.

Typically, these teeth can be a bit more difficult to numb and what I have found and what I’ve read is that they will be a bit more prone to post op sensitivity. So that’s the first thing that comes to mind. The other one that comes to mind for me, I don’t know if this is evidence based or not, is people with pre existing cracks in their teeth.

If you’ve got a crack in the tooth, especially if it’s a wide one or deep one, then that nerve is already upset, especially if they’ve already got symptoms of crack tooth syndrome. Every time they chew something hard, they feel like some sensitivity. That pulp might already be upset. Deep caries.

Especially if they’re already symptomatic whenever I look at a tooth and I think what risk level should I inform my patient, right? So should I tell my patient that you are low risk of needing a root canal? Are you a high risk of needing root canal? Number one thing I look at is how deep is the caries and if it’s close really close to the nerve, then not only is their risk of root canal treatment going to be higher, pulp necrosis, but also it just makes sense that the settling period might be longer.

And I think generally speaking, Emma, my patients don’t thankfully experience post op sensitivity very much. And I think the reason for that is is I got anything just like damage a dollar to us, get everything clean and rough. So I’m using rubber dam isolation. I’m not allowing that saliva or blood to touch my cavity, super, super clean, following my bonding protocols rigidly.

I’m doing the air abrasion, so I’m trying to do everything really gold standard here and I’m not rushing it. It easily will take me 45 minutes plus to do these restorations. And so my experience of post op sensitivity, because I do like to ask my patients when they come back has been pretty good over the last 11 years dentistry, especially even more that as I’ve developed as a dentist.

The snowplow techniqueBut people with deep caries, I would expect it. This is just a given and perhaps people with cracks, that’s the only ones I can think of. But thankfully, when you follow good bonding principles, it’s not normal. If someone’s saying that, oh, post op sensitivity is normal and every single patient will get it.

Then I think I would look at the protocols. Are they using their bonding agent properly? Are they perhaps etching the dentine where they’re using a self etch bonding agent and that would then help lead to the sensitivity problems. The other thing I do, Emma is when you’re placing composite, if you don’t mind me asking, what have you been taught in terms of the exact way to do it? So you don’t remove, but you’ve reduced the impact of that polymerization shrinkage or the polymerization stress.

[Emma]
Very small increments. Your depth of cure around about two millimeters, definitely not any more than that when you’re not trying to like connect the walls together.

[Jaz]
Okay. Yeah, yeah. Makes sense. You’re not doing like, for example, you wouldn’t join the buccal in the lingual wall straight off the bat and cause that shrinkage stress. And that’s, that’s correct. I would agree with that. So also depends on how you’re placing it. Anything else?

[Emma]
Make sure you’re doing your full cures. Don’t ever, I know some people do the 10 seconds and then build up the other cusp. Do that 10 seconds so that your first increment gets 20 seconds. Fine, but sort of just making sure that everything’s fully cured. You don’t want that. I don’t know in Glasgow we call it a soggy bottom. I don’t know where to start. Yeah, there you go. No soggy bottoms, thanks. Yeah, very small increments. Just taking your time with it and building it up nice and slowly.

[Jaz] Instruments
Great principles there. So yeah, don’t join the walls together. Smaller increments. It all makes sense. What I found is that when you look at radiographs of your work some years later, you find these little air voids and air bubbles in there, right? Because like I imagine as a dental student, you’re not heating your composite, right? You’re just using normal cold composite, right?

[Emma]
Yeah.

[Jaz]
If you work on like a tooth model, that’s clear and uses clear bands and you start doing these increments and if you can see the actual composite in place, you’ll notice that when you add one increment and then you add another increment and when you, whatever instrument you use and then you retract it, sometimes the composite gets pulled away a bit or that to two increments, they don’t meet together beautifully, that wettability isn’t there.

And so you get little voids, right? Which is not ideal. And if that void happens at that sort of where the hybrid layer area is, you might get more sensitivity, right? It just makes sense if you haven’t been able to do that. So what I’ve been doing for the last seven years is something called Snowplow Technique. Have you heard of this?

[Emma]
No, I haven’t. No.

[Jaz]
So, a dentist called David Winkler taught me to do this when I used to work for him in Windsor, and he used to teach a lot on composites and fantastic dentists. And then I started to read the literature behind it. A lot of great dentists do this, whereby before so, you’ve done your whole etch bond, it’s ready to now put your composite in.

Before I put my composite in, which, by the way, I am using heated composite. In practice, again, to get more wettability, right? Something that’s hard and stiff and cold compared to something that’s warm. It’s just going to get in all the nooks and crannies, right? So that’s also helping to reduce this void issue.

I will put a tiny, tiny, teeny, weeny drop of flowable first. Then I will put my composite increment. Okay. And then I will adapt it and cure. And then before the next increment, again, a tiny little bit of a flowable composite. And so that’s called a snowplow Technique, basically. And so, that’s-

[Emma]
I think, I’ve seen people doing that.

[Jaz]
You’ve seen that in practice. Yeah?

[Emma]
Yeah, I’ve seen people do that, yeah.

[Jaz]
It just makes sense to me. And so I’ve been doing this for years and I feel as though maybe that may or may not be relevant. I don’t know if the study’s been done where there’s a snow plow technique versus no snow plow where that actually really makes a difference. But in terms of my radiographs, I’ve seen that issue where you used to have these little random voids. That’s definitely been eliminated.

[Emma]
Okay, cool. So is that something that you would only really use with heated composite?

[Jaz] Consent
You can use that snow plow technique even without heated composite. In fact, I think the need for it probably gets even higher when you don’t have the benefit of the heated composite, right? But I just like this, the way it all seamlessly mixes together so nicely, which actually takes me to my next point. What are you using as a dental student to adapt your composite? So you put increment, what instruments are you using now to actually get the composite where you wanted to go in the cavity?

[Emma]
So, I am actually, not just saying this, I’m a big fan of a flat plastic. But then also I’ve found just a dry microbrush. I quite like a dry microbrush. One of the dentists I work with he’s a huge Protruserati, actually he was the person who said to me, you should definitely go for this job, you should do it. He’s a huge nerd.

[Jaz]
Give a shout out, give a name.

[Emma]
Oh, his name’s Pearse Hannigan.

[Jaz]
Of course it is, hello Pearse, good to see you.

[Emma]
He’s a huge Protruserati, so he is just a huge fan of just using a dry microbrush, and I’ve been trying it and it’s just getting into all these wee bits and bobs. I’m still sort of, I’m definitely still in that realm of figuring out what works for me, but a flat plastic and a micro brush are my sort of holy grails at the moment.

[Jaz]
I’m the same. So I’m using a micro brush. So I knew when you said that you use a micro brush, that I knew that’s not something that you would picked up from dental school. I knew someone in the real world would have taught you that. And so shout out to Pearse for this great advice. Something that Jason Smithson taught me years ago.

So yes, when you’re adapting the composite, when you use a micro brush, some of the reported benefits of this is you don’t get that. It doesn’t stick to the micro brush, so it doesn’t sort of pull up. And also if you look at it like you use something like something spiky on the composite and it makes this like a roughness even within the composite ready for the next increment.

Now, just so we know a reported disadvantage of using a microbrush is when you look at those scanning electron microscopes, you have these, your composites are a bit hairy, like the microfibers are actually breaking off into the composite. So what we know is try and use a more expensive, higher quality microbrushes rather than the cheap ones, because that might be more of an issue with the cheap ones. So just in case everyone starts to switch, make sure using a nice microbrush that’s going to be strong enough.

[Emma]
Okay, no, that makes sense. Yeah, I suppose you don’t want hairy composite.

[Jaz] Longevity
That’s right. And so I think all these things together are what reduce your post op sensitivity.

[Emma]Okay. Okay. Perfect. Is that something that you would ever, I know you’re saying it doesn’t happen to you that much, but is that something that you would put in a consent form? Is it just something you generally mention at the end of an appointment? When do you address that?

[Jaz]
Every time. So there’s always a pre chat, right? There’s always like a debrief before we start the restoration. So usually I’ve got the photo of their tooth because at the checkup, I would have taken a photo of the tooth, showing the caries, showing the issue.

So I’ve got the photo on the big screen already as they walk in and I say, Mr. Smith, do you remember what we’re doing today? And usually my patients are like, I have no idea what you’re doing today. They don’t remember. They’ve got memories like fish. So they come in and say, have a look at his tooth, right?

I describe them. Can you see that there’s a bit of discoloration? There’s an issue over here. Oh yes. Yeah. Oh, now I remember. Yes. We’re doing a filling. So yes. And then I showed them the radiograph saying, okay, based on, the fact that you’re not in pain at the moment and you’re not having sensitivity and it’s not super close to the nerve, the chance of your nerve dying after this and needing something called a root canal is thankfully low.

It’s not zero, but it’s low. And then obviously I do the reverse and I really exaggerate it in terms of, okay, this decay is really close to your nerve. This is really bad news. We are doing CPR for the tooth here. We’re going to give it the best shot we can, but if the tooth dies, don’t worry.

There’s a solution. We can still help you. But here’s the things that we should watch out for afterwards kind of thing. And then I’ll remind him at the end as well that, okay, Mr. Smith is totally normal to have a bit of sensitivity to hot and cold for a couple of weeks. It will settle. The bite will feel a bit funny initially.

It will settle. Be careful not to bite your lip when you have food today. The usual stuff that you will always, always, always say. And so there was another podcast we did actually consent is like an onion. Right? Consent is like an onion. I don’t know if you listened to that one. And Sean said this amazing thing in terms of what patients remember from the appointment.

And what they remember is peak end. There’s two things that patients remember from any dental appointment is the peak, the highlight of the appointment. Was it a funny joke? Was it something bad that happened? Like they can remember the peak of that appointment and the end. So it’s really important to utilize the end and end on high to make sure that they remember and end with the most important bits.

[Emma]
Okay. Yeah, that’s helpful. Yeah. Save it all till the end. But that sort of overlaps with my next question talking about how do you assess, suppose predict the longevity of your adhesive restorations in your patients like are there specific maintenance or follow up protocols that you recommend just to make enhance the durability of your restorations over time?

[Jaz] Risk factors
That’s an interesting question in terms of, I think we’re coming to is that, okay, when we see the patients again, checkup after checkup, what should we be watching out for? Is there any way that we can intervene to help these patients get the most? I think there are a few things actually that we can talk about here, but let’s take a step back.

How long, when I’m placing a posterior composite, how long do I expect it to last? And I think this figure in my mind has changed a lot over the years as I’ve gained more experience and read more things. In terms of what you’ve been taught, I don’t know if you’ve been taught this or seen this in terms of the research or in terms of what the lecturers have taught you at dental school, how long should these fillings last?

[Emma]
I still don’t think I could tell you. I don’t think I could tell you to five years. I don’t know.

[Jaz]
And so let’s start with that. So some of the key literature that I was looking up for in preparation for this episode was a guy called Nick Opdam, who’s done lots of great work on longevity of restorations and composites and whatnot.

In fact, funny story, when I was a DCT, like one or two years out of dental school, there was this conference at King’s, and Nick Opdam was there. And I came up with him. And I was like you’re a total celeb. Can I get a selfie with you? And it must have been the first ever selfie a dentist has ever taken with him, right?

Because he was completely taken aback. He’s like, what? Someone wants a selfie with me? Like, how do you know who I am? My face is never on all these papers that I write. But I recognized, I saw his name and I saw the lecture. I was like, oh my God, this is Nick Opdam’s a legend, right? So I’ll see if I can dig out that photo.

Go to my Google photos from like 2014 and see if I can dig out this photo actually. So anyway, absolute legend. And I think 2007 he did this retrospective study where they looked at almost 3, 000 restorations done by two dentists and they followed it up. And I’m just going to see if I can get numbers. I don’t want to say anything wrong here in terms of their good work.

But it was 82 percent longevity. Okay, of composite at 10 years. Okay, so 82 percent at 10 years. And for amalgam, interestingly, it was 79%. Okay. And I think what counts as a failure is, caries, fracture, and sometimes with an amalgam, the tooth fractures rather than the amalgam, right? So that would be a failure.

And so 82 percent at 10 years, we can make what we can of it. But what are the things to consider was the annual failure rate of 1 to 3 percent is generally what’s said in the literature. So every year, 1 to 3 percent of composites will fail. But the most important thing I think to come to directly answer what you’re saying is when the restorations perform the worst, is patients with high caries risk and on cases whereby you had to do more than one surface, every additional surface that you had to do.

So if it’s just an occlusal, great. If it’s an MO, okay, still okay. If it’s an MOB, okay, that’s stretching If it’s an MOBL, right, it’s an MODBL, like the more surfaces that are involved in a composite, the more complex it becomes. Trying to get a good contact point. I don’t know if you’ve found this on your restorations. Have you done like class twos already?

[Emma]
We don’t actually, is that black’s classification? We don’t use Black’s classification.

[Jaz]
Really? My God, what do you use?

[Emma]
We don’t. Just whatever surfaces it is.

[Jaz]
MODO.

[Emma]
Yeah, yeah, yeah. We don’t use Black’s classification anymore.

[Jaz]
That’s mad.

[Emma]
I’m always Googling, when I’m editing your episodes, I’m always Googling what’s what.

[Jaz]
That’s alien to me, that’s crazy, I wouldn’t even expect that. Okay, fine. So, MO or DO, have you done the interproximal on posterior teeth?

[Emma]
I believe. Yes, yeah, I have, yeah.

[Jaz]
I think one day we can talk about matrix selection and that kind of stuff. I think that maybe would be really good, connecting the real world. But you probably have one or two matrices available in dental school to use for posterior, right? Do you know which ones and the names of them?

[Emma]
We’ve only got one, actually. What are they called? It begins with an O.

[Jaz]
Omni-Matrix.

[Emma]
Yeah, we’ve got Omni-Matrix, I think. Yeah, just the standard Omni-Matrix. And then your clear cellular strips and that’s about it really.

[Jaz]
When you’ve done your restorations, have you done some MOs or DOs yet?

[Emma]
I’ve done one.

[Jaz]
Okay.

[Emma]
All the others have actually been anteriors. So, yeah.

[Jaz]
Nice.

[Emma]
So no, just one.

[Jaz]
One thing that I would struggle with, even struggle now, I’m much better now and I’ve got some videos I even recorded yesterday actually, which I’ll upload to the portal of just getting a lovely tight contact and the way you can check for a tight contact, it’s not.

Yeah, it helps to floss and see, okay, how tight it is. But even more important is you try and bring the floss out. And does it click on the way out, right? Does the floss hang there? That’s a really good test to see if you’ve got a nice tight contact. And so as a dental student, we were using a siqveland , whatever you want to call it.

And we’re doing amalgams back then. And then, yeah, some composites. And I was really saddened by the contact points I was getting like floss was passing right through and I was like, Oh my God, the patient’s going to get food packing, recurrent caries and stuff. But, but what we know is that more important than our skill, more important than how well you do the restoration is the patient’s caries risk.

[Emma]
Yeah. Okay.

[Jaz]
So caries risk and the more surfaces involved. So the number one thing we can do for our patients to make sure that they get as long as possible from their restoration is trying to actively work on reducing their caries risk, right? So all the usual things, diet advice, be very meticulous with their oral hygiene, keep giving them the coaching that they need, fluoride application.

If you can do this, it will make the restoration last longer. The other thing is making sure the patient takes ownership of it. The patient needs to understand that, okay, I’ve done the restoration, but now the restoration belongs to you and you need to look after it. And I think that’s the most important thing.

Just to share some more studies, actually with, with Nick Opdam, he then also did a systematic review meta analysis. They only include studies that had five plus years follow up and there were eight authors, again, about 3000 restorations approximately. And the same thing, they found caries risk and how many surface were the most significant predictors of failure.

So once you’ve done the multiple surface composite, The only real way to improve your success rate in the future is upgrading that to an indirect restoration that covers the custom stuff, right? So that’s one way, certainly if you’ve pushed the boundaries, maybe because Emma, you might be at a scenario where you got deep caries and you don’t want to do a crown.

Because this tooth might need root canal. And so you might do what we call a posh core, right? You do a giant, ginormous composite and try your best. And we see, okay, at the one year mark, is the nerve still alive? Or is it, has it gone kaput? And if it’s still okay, you might then say, okay, there’s no pain, there’s no issues, but this composite is going to fracture.

It’s just too big. It’s not fit for purpose. We should now do an overlay or an onlay and that’ll be a good thing to do to reduce your fracture risk and to reduce your caries risk would be all the things that we talk about prevention back to that study, they found an annual failure rate. This most important thing, annual failure rate of 4.6% on people with high caries risk and 1.6% on patients with low risk. I mean, that is really, really a big, big, huge difference.

[Emma]
Okay. So there’s loads of different factors, but the main takeaway is I suppose you can do the most beautiful composite or restoration in the world, but if it’s got a higher caries risk then it might not last as long as someone that doesn’t. Okay. That makes sense.

[Jaz]
And if it’s bigger, you’re more likely to run into fractures and issues. And so the larger a restoration gets, the more the tendency to go towards something like an indirect restoration of crown, although there are other parameters, which I know we will be talking about one day as well.

The other thing to consider is. When would a composite fracture? And a composite would fracture is perhaps if it’s been placed quite thin. Thicker the composite is going to have more strength, right? And so maybe if you’ve not added enough thick bulk because you’ve tried being ultra conservative, you might then get that failure of a fracture.

Or, here’s an important one which I didn’t learn for a few years after dental school is when you look at your cavity, is everything nice and smooth on that floor, right? If there’s like, sharp, spiky bits of dentine sticking out, perhaps you removed an old amalgam, right? You removed an old amalgam, and there’s spiky bits of dentine.

Just get your rugby ball, red bur, and smooth that sharp bit away, right? Because when you’re putting your composite on, it likes this nice, smooth surface. It doesn’t want these sharpnesses, which leads to my final point, which is not evidence based, not evidence based in terms of outcome, but evidence based in terms of process, which is what burs we use on the teeth.

Any guidelines that you’ve been shown or decision making in terms of when you’re removing caries, when you’re treating a tooth, what kind of burs are you using? What kind of shape of burs are you using?

[Emma]
So I’d say upon our main restorative clinic, we’ve got all your usual burs, like your rounds, your fissure burs. I have seen burs out there working as a nurse that I’ve never seen in the dental hospital, which is fair enough, I suppose, but a lot of clinicians will have different opinions on what you should be using in certain situations, like I’ll be using a large round bur to do something and the clinician will come in and say, I really think you should be using a fissure bur. But I don’t think, I really don’t think I’ve had that much experience in terms of using loads of different types of burs. Just your standard ones really.

[Jaz]
The main takeaway here Emma is like, if you look at the shape of the bur, things that are round in nature, so pear shaped and round, are more favorable before composites than your sort of fissure burs or square, rectangular, tipped.

Because, if you imagine cutting tooth structure away with the rectangular one, the corner that it has, it actually causes these micro fractures in the teeth. And you get left with these sharp bits in the cavity. If you’re using a round bur, you’re less likely to have those sharp bits and things are allowed to be smoother.

So a little thing like that, basically, which again is more process driven than outcome driven. But these little things, and if you look at all the things that what can we do to make sure at the time of restoration, we reduce the failure rate? Well, I think again, going back to isolation. Nice, clean and rough.

So following the bonding protocol, reading the directions for you. So bringing together the entire episode that we’ve discussed so far and making sure you do get a nice contact. And we’ll talk more about contact points in the future. So make sure you get a nice contact so you don’t get food trapping there, right?

And you coach the patient so that whatever cause the caries, it doesn’t happen again. You lower the patient’s caries risk and make sure that when you are doing your restoration, it’s thick enough and it’s not on a bed of sharp dentine that everything is nice and smooth. And with these foundational things, we’re hoping to get beyond 80% at 10 years and that would be nice.

[Emma]
Yeah, yeah, perfect. That’s actually really, really hard for me to hear about the round fissure, because I’m a fissure bur kind of gal, so that’s hard for me to hear.

[Jaz]
Maybe higher up for, if you use a fissure bur on a fissure, it makes sense. If you’re using a fissure bur down with the contour area, it doesn’t make sense to me.

[Emma]
Yeah. Okay. No, that’s perfect. That’s fine. Lots of good tips and tricks in there, Jaz.

[Jaz]
What’s the number one thing, Emma, that you think you’re going to change about and the change is harsh because you’re so new to it all, right? I would just love to know, what’s your big takeaway from our chat today on the really good questions that you come up with? What’s your big takeaway?

[Emma]
I suppose to take away today is just know what you’re using, what prime and bond am I using? I don’t know. So know what you’re using, know how to use it. Look at the manufacturer’s instructions. But yeah, just knowing what you’re using, how to use it, don’t just stick with what you’ve had forever and use the same techniques for everything, because all the materials are different for a different reason. So yeah, know what you’re using and know how to use it.

[Jaz]
Perfect. And so next recording, we’re going to find out which bond, do you think you’ll find out by then, right?

[Emma]
Yeah.

[Jaz]
Which bond you’re using, and then we’ll dig up the DFUs together and we’ll have a look at what does this particular bond say? And so just to whet everyone’s appetite for next month’s episode with Emma, we’re going to be talking about documentation. And so I know photography and videography is not something that you really get to do as much at dental school. But some things that we can talk about, maybe like documentation. What are the things that we’re looking for? How do we do a routine checkup? What do you think that would be useful when you’re actually doing checkups? What are we actually checking for? Would that be helpful?

[Emma]
Absolutely, like, one of the things that I found very hard at the beginning of third year, how do I do a checkup? And it’s easy enough learning about it in a lecture, you do this, this and this. But what does that actually look like with a patient and, okay, I’ve done this, I’m going to do this now. Like, how do you actually communicate that with a patient? And, yeah, like, just your steps and I know you find your own little way to do it in your own sequence. But how do you do a checkup like that was one of my huge questions and it seems so silly like it’s one of the basic things.

[Jaz]
It’s not silly. I remember Emma. I remember having this exact same thought like I remember being like a third or fourth year student and the tutor coming and is doing the checkup and I was really trying hard to watch exactly how they hold the mirror, exactly how they’re holding three in one and what they’re trying, what are they actually looking at?

How are they so quick? I was like, how are they just so quick and looking around? Like why am I taking like five minutes per tooth? So I’m super excited now to talk about my checkup protocol. And the lesson I can give you now, even before we record that is there’s a book out there and it’s called The Art and Science of Treatment Planning.

I haven’t read it. I don’t know if it’s any good, but it is the art. And the science. So what I mean by that is that my checkup will be different to the other hundred of checkups that you’ve seen with a hundred other dentists. And have you ever seen a routine examination that’s exactly identical between two clinicians?

[Emma]
No, never, never. It’s always a wee bit, it’s always a wee bit different.

[Jaz]
Well, then I think it’d be really good to, for me to share. So as part of documentation month, we’ll share my checkup, but also I’d like to know about some quirks or some things that you’ve noticed with some dentists that you’ve worked with, and then we’ll get everyone on the comment section to chip in.

I think this would make a really educational thing. I might pick up a few things that some colleagues are doing that I’m not doing at the moment and vice versa. So I think spontaneously we’ve decided our next topic quite nicely.

[Emma]
Yeah, perfect. No, I’m excited. I’m really excited for it and just getting more and more. I’m like a sponge at the minute, just taking in all the time.

[Jaz]
Never lose that, Emma. Never, ever lose that about you. It’s so, so important to have that enthusiasm and be like a sponge throughout your career. It will serve you well, serve me well so far. I’m still a sponge and I think not to insult the Protruserati, but we are sponges. We’re all sponges. Not spongers, but sponges. All right, Emma, thank you so much. I’ll see you next time.

[Emma]
Thank you so much.

Jaz’s Outro:
Well, there we have it, guys. Our first proper Protrusive Students episode. Thank you so much, Emma. You’ve got those revision notes promised in the crush your exam section of the Protrusive Guidance app.

Once again, you want to head to protrusive.App, the website, make your account, make a free account. And then email student@protrusive.co.Uk with your proof that you’re a student and try to join with your own personal email address. So even after you’re done with being a student, like I know we’re students forever.

I get that. But once you’re no longer at dental school, you want to have an email address so you can continue to engage on Protrusive Guidance. Once you do that, the team will invite you to the protrusive vault. And of course you get access to the crush your exam section and the student clinical videos. And lastly, we will see you on our own student forum.

So I’m excited to see the growth of Protrusive students. I’d love to see where everyone’s from, right? All I envisage dental students from all around the world. Remember some years ago when I was still early in podcasting, this German dental student, I bless her, I forgot her name now, but she reached out and she said that yours is my favorite English dental podcast.

And I don’t know if she’s qualified or not yet, but those kinds of interactions wherever you’re from in the world. It’d be great to have you on Protrusive Guidance. And I hope you gain from this. I hope you really, really gain from everything we’re doing with Protrusive Students, and I would love for you to hit the like button or comment below if you’re finding this helpful.

We’ll catch you same time next month for every monthly episode of Protrusive Student, but of course, there’s so many protrusive episodes you can listen to in the meantime. Bye for now.

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Managing patient expectations in Dentistry – there are some MAJOR lessons we can learn from facial aesthetics practitioners.

We’re diving into a conversation with Dr. Katherine Bell that’s really going to open your eyes about communication. Despite beauty being subjective, we find a lot of similarities in how we talk to and get consent from patients, whether it’s for facial aesthetics or dental procedures

So, even if facial aesthetics isn’t your cup of tea, think of this episode as a deep dive into communication and consent. Plus, it’s Documentation Month on Protrusive Podcast, and this episode is just the beginning!

https://youtu.be/28hRaMARgnAWatch PDP180 on YoutubeProtrusive Dental Pearl: Tailoring consent to each patient involves discussing only the risks that matter to them, using standard forms for GUIDANCE, not for completeness. It’s about clearly explaining how we’ll minimize these risks, ensuring the patient feels secure and informed about the precautions taken. For example ‘Mrs Smith, your tooth is very badly broken down and this can be a very tricky extraction. The way we are going to make it easier is by carefully dividing the tooth in to 3 roots’

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

01:36 Protrusive Dental Pearl
03:33 Dr. Kathryn Bell Introduction
05:01 Dr. Kathryn Bell’s Journey in Facial Aesthetics
09:08 Perception of Facial Aesthetics
15:34 Discussion on Documentation and Patient Education
20:05 Patient Consent and Managing Risks
25:13 Screening for Body Dysmorphia
33:50 Considerations for Patients with Depression Seeking Aesthetic Treatments
38:06 Learn More with Dr. Kathryn Bell

Join us on Protrusive Guidance, our own platform for dental professionals. No need for Facebook anymore!

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In this episode, we’re launching Protrusive Students, a segment dedicated to dental students while offering valuable insights for young and seasoned dentists. This section provides various resources including exam prep materials, clinical videos, and networking opportunities.

A key highlight of this episode is the introduction of Emma Hutchison, a dental student hailing from Glasgow. Emma shares her revision notes and resources aimed at helping students excel in their exams. Together, we’re bridging the gap between academic dentistry and clinical practice, fostering a collaborative learning community among dental professionals.

https://youtu.be/Dx6xz1RAnSMWatch PS001 on YoutubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

3:32 Introduction of Emma Hutchison
5:49 Emma Hutchison’s Dental Journey and Background
10:54 Collaboration and Protrusive Student Notes
14:19 Protrusive Guidance

Alright, Protrusive Students, listen up! Here’s how you can get involved and access exclusive student spaces, including the coveted ‘Protrusive Vault’, typically a paid feature within our network.

Head over to the protrusive.app on your web browser.
Select the community plan, which is completely free.
Fill out the screening questions to ensure authenticity. We’re serious about keeping our community genuine – no bots or impersonators allowed!
When completing the information, simply indicate that you’re a dental student.

Now, here’s the crucial step:

After filling out the form, shoot an email to student@protrusive.co.uk. Attach proof of your student status, such as your student ID card or a university letter. Also, let us know your expected qualification date.

Once we verify your student status, you’ll gain access to a wealth of resources and opportunities tailored to support your dental journey. Don’t miss out – join the Protrusive Guidance Community today!

If you loved this episode, be sure to check out another episode for students! Occlusion Questions from Students – AJ005

Click below for full episode transcript:Jaz's Introduction: This is the launch of Protrusive Students. Now, the intended audience is students, but it's also suitable for young dentists, and even experienced dentists looking to reconnect with the foundations and the basics. Look, I've been doing this podcasting for a little while now, and the focus is always dentists.Jaz’s Introduction:
And when I speak to students, you guys are so keen for the content, you guys love it, but you guys do admit to me that sometimes the level that we’re speaking at just goes above your head. So I really wanted to create a space just for students. So it’s going to be the PS episodes, the Protrusive Student Episodes.

Now as part of Protrusive Students, I’ve also created a brand new zone within our network, Protrusive Guidance, just for students. But again, anyone can join if they wish. It’s going to have a crush your exam section, student clinical videos, and an opportunity to network and liaise with students all over the world.

As per the values of Protrusive, you probably are the nicest and geekiest students in the world, so we deserve our own little place. Hello Protruserati, I’m Jaz Gulati, and this episode I have the great pleasure of introducing you to THE Protrusive student, Emma Hutchison. Emma’s a dental student in Glasgow, and her chief mission is to provide you with revision notes and resources so you can truly crush your exams.

You see, what I’ve arranged with Emma is for episodes where she gets to ask questions from a student’s perspective. When you’ve been experiencing and practicing for a while, you kind of forget the struggles of when you’re learning something for the first time. I think part of the success of Protrusive is that I’m such an avid learner and learning is one of my highest values, so I always try to reconnect with that.

But I’d like to have this opportunity for Emma, our Protrusive student, to ask me questions, which probably most dentists are too afraid to ask because it perhaps seems too basic, but that is what’s going to be the most valuable. So I don’t know where it’s going to go. Like people ask me all the time, like, Jaz, what’s your goal with Protrusive?

To be honest with you, I’m just really enjoying the journey. As long as I’m learning and sharing, as long as you guys are learning and sharing through Protrusivez Guidance, I’m in a happy place. So I’m not so much outcome centered at the moment, I’m very much process centered. And there’s a magic of that when you’re a learner.

So listen up, this is how you get involved if you’re a dental student and you want to get access to all the student spaces, but also if you verify that you’re a dental student, you will get access to the Protrusive Vault, which is usually a paid space within the network. The way to do it is you go to protrusive. app on your web browser.

You then select the community plan, which is free. Now, when you fill out the screening questions to make sure everyone is legit, I don’t want any bots, I don’t want anyone who’s pretending to be a dentist or a dentist student. When you fill in all the information, just say that I’m a dentist student.

But the next step is, once you fill that in, you need to email student@protrusive.co.uk. That’s student@protrusive.co.Uk and you need to prove to us that you’re a student. I want to see your student ID card or some sort of letter from university and also tell us which date you’re expecting to qualify.

The team will go ahead and match up the application on Protrusive Guidance to your proof, and then you’ll be allowed in the network. And that will also trigger us to add you to the Protrusive Vault space. Now I know what you’re thinking. Why so many steps, Jaz? Because I want to see, I want to see really how badly do you want to be in this.

Well, I think it’s going to be an awesome space. I wish we had this when I was a student. Sometimes to get the best people, you have to make things a little bit difficult because people who really want to be part of it, they’re going to self select themselves. So let me remind you one last time, apply for the community plan, which is free.

And then also email student@protrusive.co.Uk. That’s student, not a plural, singular, student@protrusive.co. uk. Make sure you spell protrusive correctly and give us the proof and also your expected year of qualification. And when you’re using your email, use your personal email. Try not to use your uni email because if you lose access to that, you might lose access to the network. So without further ado, let me introduce you to Emma and I’ll catch you in the outro.

Introduction of Emma HutchisonIt is with great pleasure that I introduce to you all. Emma Hutchison. Emma, welcome for the first time and one of many times to come to the Protrusive Dental Podcast. How are you?

[Emma]
Thank you. I’m good. I’m good, Jaz. How are you? I’m excited to be here.

[Jaz]
I know. I know. Right. And so we’ve got some really, really great stuff in store for dentists and for students. So it’s quite special. So those of you who don’t know yet, we’re going to talk about Emma today. She is a dental student, but we’re going to learn a little bit about her journey because I find it really inspirational, the whole journey element, how someone gets into dentistry.

And your background with nursing. I’m so excited to unpack more about that. But basically, I found Emma because you guys might remember on the Facebook group a little while ago, I posted that Protrusive is growing, it’s expanding, there’s so many ideas and stuff. And I feel is that I wanted to get some students on board a to help them instead of them.

You’re working as a locum nurse. I said, okay, how can we help you in terms of having some sort of income and stuff, but at the same time, how can we work together to help it make it easier for young dentists and students? And so what has come to fruition, which we didn’t know at the time, I didn’t know it would go in this direction at the time, Emma, is Emma’s notes.

Because I feel like I hit the jackpot with you, Emma, when you show me some of your notes, they’re absolutely impeccable. Right. They’re so, so good. So well done. But before we delve deeper into that, Emma, just tell listeners and watchers a little bit about yourself.

[Emma]
Yes. So firstly, I’d just like to say thank you so much for this opportunity, Jaz. I’m glad to be here. So my name’s Emma Hutchison. I’m 24 years old and I live in Glasgow in Scotland. I’m currently in the middle of BDS3 in my third year at Glasgow University in Dentistry. But I’ll say this is actually my fourth year due to COVID, we all had to repeat a year. So I was unfortunately the 2020 baby of dental school. So we all had to repeat our first year.

[Jaz]
But that’s not too bad Emma, because if you think about it, there’s a lot of dental students, right, who were in the peak of their, like, clinical third, fourth year. So I feel as though they had it quite bad. I feel as though if I could do first year again, Emma, don’t get me wrong. I’d have to do first year again.

[Emma]
Absolutely. Absolutely. And to have first year online, that was good, but no, I felt so bad for especially the fourth and the fifth years. Yeah, definitely. I would choose first year again.

[Jaz] Emma Hutchison’s Dental Journey and Background
But what got you into dentistry? Like you’re here at Glasgow. What attracted you to dentistry? And when did you actually do your nursing?

[Emma]
I’m going to go out on a whim here and say, I think a lot of dentists at one point thought they wanted to be doctors. I was one of those. You’re 14 at the time, you don’t really have a clue of what you want to do.

[Jaz]
One thing I’ll say, Emma, is just because it’s the first time recording, is with the international audience that we have, your beautiful Scottish accent, okay, I want you to talk a little bit. I want, it’s beautiful. I just want a little bit slower because the first time we had a Scottish guest, the girls just could not transcribe it at all. They just, for them it was Japanese. All right. You’re doing great. I’m loving it. Just maybe just for the international audience to slow down a bit.

[Emma]
Okay. So I definitely think I was one of those people who saw they wanted to do medicine, but for, at the time, I was 14 at the time, I didn’t really know what I wanted to do. There wasn’t much work experience for me to do, and I went and did a day’s shadowing in an oncology ward down at the hospital in Livingston, and I did not like it.

I really didn’t like it. Looking at it more and more, it really just wasn’t for me. And my mum’s a dental nurse. She’s worked in the NHS as a dental nurse for a long time over 40 years now. And she said, what about dentistry? So I thought about it and then work experience with her for a week. And she got me seeing all sorts of things. I was in GA sessions. I was doing sedation and things like that. I was watching everything and it was amazing. And I loved it.

[Jaz]
And it didn’t gross you out?

[Emma]
No, no, it didn’t. It was really, really interesting. Really interesting. And that sort of, I don’t know, fueled the fire, I suppose.

[Jaz]
And you worked a lot with the implant clinicians as well, right?

[Emma]
Yeah, so that was a wee bit later on, doing implants. I worked at an implant practice when we had our sort of year out due to COVID and things. I worked at a private practice, does a lot of implants and things in Glasgow. So that was really, really interesting.

[Jaz]
Which was amazing for us as a protrusive listeners and watchers because when we had Devang Patel on, about restoring the single implant. Like, you know more about implants than me, Emma, right? And so it was amazing to have you just to finesse those notes. They were absolutely brilliant. And so that came in so much handy. I started to see, wow, Emma’s got a lot of broad experience. That was a stroke of luck, I thought.

[Emma]
Yeah, no, it was really, really good. It’s really interesting, but had a bit of an unconventional route into dental school, I suppose. I think at school in what’s our sixth year or final year, you apply to dentistry before you get your results from what I was sitting at the time, which was my advanced hires, which I think is the equivalent to your A levels, I think.

So I was applying with my results that I got from my hires which was the year before and I think I got three A’s and two B’s. But it just didn’t really cut it for dental school I think they were asking for four A’s at the time So it was a bit of a bummer, but I said, you know what? I’m going to go ahead and I’m going to do really well in my advanced hires especially in chemistry because that was one of the ones that I got a B in, so kind of a biggie.

So I don’t know how some miracle managed to get an A in my advanced higher chemistry. And I thought, right, I’m definitely going to apply again. I take a year out, I’m working at Costa Coffee, and I try again, and the same thing, I just, I didn’t even get a sniff from any dental schools, didn’t get a sniff at all, no interviews, anything. I think my UCAT was also maybe a little bit poor.

[Jaz]
So you had the grades but no interviews?

[Emma]
No interviews, no. I think they were still quite hung up that I got that be in higher chemistry even though I had got my A in advanced higher and also it’s just so competitive to get in. So, so competitive. So fair enough, but I was so disheartened and that’s when my mum said to me, she’s a dental nurse, she said, if you really want to do this, go and do your dental nurse and see if you even like it.

I think a lot of people get to dental school and they’re like, not for me, which is fine. I managed to get a trainee job as an apprentice, where I went to college one day a week, was in the practice, the rest, and I absolutely loved it. I worked in such a good practice, well organized, fully staffed. It was great. And I applied again. I went on a course this time to help with my UCAT test. And here I am really, so yeah, that’s pretty much me.

[Jaz]
Perseverance, resilience, that can do attitude, you display all those. So, so well done. And I’m so glad you did that when you look back, life doesn’t make sense, but whether you believe in destiny or God’s plan or whatever you believe in, right?

Like you had those extra experiences. And I think honestly, Emma, like I know we’re still early, I think, the world’s your oyster, and I think as a dentist, like you’ve already shown me qualities that you’re going to be amazing, honestly, like the foundations that you have and the experience that you had as a dental nursing, that’s really going to set you up, I think.

Collaboration and Protrusive Student NotesI think it definitely, definitely gives you an edge. So well done for persevering. And so it’s great to share that story with everyone. And when I see what we’re going to be, what we’re going to be sharing with the Protruserati and the students, it’s is your notes. And they’re so detailed and methodological.

And I think it’s wonderful that you, we had this thing that Emma, are you sure you’re happy to share in a world where students are hoarding their stuff? I said, Emma, I’m going to put your name on it. I’m going to say Emma’s notes, but how do you feel about sharing it we’re dental students all over the world, and I was just amazed that you said, you know what?

We’re here to look out for each other. Let’s do it. And so we’re embarking on this journey together to make dentistry tangible for students as well. I’m so, so glad to have you part of that. What do you think about that?

[Emma]
Yeah, I’m just, I’m so excited for it. So like, I understand the overwhelm and again, maybe that wee bit of a background in dentistry, it can be a wee bit easier to pick out. I suppose what’s relevant to the real world and what happens in real life, so, we learn about multiple different bonding systems and file sequences, like what do we actually need to know to pass our exams, and then what do we need to know moving forward in our career at dental school and beyond. So just sort of making that a wee bit more tangible and a wee bit more easier to understand, like that’s what I’m excited for. So it’s good. It’s good. I’m excited.

[Jaz]
Well, the way we’re joining forces is like your notes, which I’ll probably just bring up on the screen for those watching, for those listening, just take my word for it because that’s just beautiful. Like the dental material one is like amazing depth and detail, but not overpowering. It’s not too much. It’s just the right bullet point amount of stuff, which I love, but I agree what you’re missing. And I mean that with respect. And we all saw the students do is that real world aspect to it, which is why the theme we’re going for is monthly.

We’re going to record something that’s going to benefit all dentists. Right. But it will be a focus on how can we make your dental notes? How can we add that real world clinical attribute to it to make it more understandable for dentists and students? And be that bridge between dental students and the real world dentistry.

And I think that’s how we’re going to best join forces to benefit everyone. So for example, the episode after this, the one we’re doing is about adhesive dentistry. And so you have some top questions. So we’re going to be sharing your notes on composite, dental composite and amalgam and adhesive dentistry.

So those notes will be out there for all dental students, but you’ve got these real world questions to ask me, which we’re then hopefully we’re going to add that missing element that you hadn’t done school because you just don’t get enough experience at dental school and that’s okay. It’s not dental school’s fault.

So I think that’s how I think we’re going to best merge our unique positions. You as a dental student, who’s so detailed and thorough with her notes, me with my enough experience, real world and making things tangible to bring it together. And I think that’s what’s going to make your notes even more special.

[Emma]
Yeah, absolutely. Absolutely. And like I was saying, I know the overwhelm and dental school, especially the first two, three years. It’s just, what do I need to know to get me through the exams? And then you can sort of, you sort of lose the whole, you know, you don’t even think about it, the whole, what does this actually mean for me as a clinician?

And what does it mean for my career? So I think, especially third year, that’s where it sort of start starts to shift a bit from just theory, theory, theory. And then you’re thinking, wait, how do I actually put that into practice? That’s what I’m finding difficult at the moment anyway, so we’ll navigate it.

[Jaz]
That’s where we’re going to help together. And that’s where the Protruserati, we’re all going to come together on the new platform called Protrusive Guidance. There’s a whole section we have on there called Crush Your Exams. This is where you’re going to shine, Emma. Your notes can be there. We have example questions and stuff, but mostly just the depth and the beauty of your notes.

And then we have student clinical videos that we’re going to have to help students see there’s little things that, when you’re starting out in clinic, how to give local anesthetic, basic things, which I think we’ve really beneficial students have that clinical element to it. And that’s where I think the whole section run by me and you will, I think we’ll do really well to help students everywhere.

And dentists, actually, I think dentists will also be able to back to basics is a nice thing to have. But the other element which I’m really excited about is the community aspect. I think dentists can be an isolating profession. I’m sure you’ve seen it in your time as a nurse. It can be between those four walls.

This is the dentist, the patient and you and it can get a little bit lonely, especially if you don’t interact with anyone getting that mentorship. So what we’ve trying to set up is a safe space for dentists and students. How important do you think it is to have that kind of a safe space as a student? Is this something that you think is demand for out there?

[Emma]
Yeah. I think it’s hugely important for students to have a space to interact, to have that bit of an outlet. Sometimes sticking your hand up in a lecture theatre can feel, it can feel embarrassing. I don’t know, everyone else wants to leave or sticking into a message, into a group chat, asking your peers.

It can actually be quite scary because you don’t want to feel silly and you don’t want to feel like you’re lagging behind your peers, which isn’t the case. And I think that’s just in itself very human nature, you don’t want to feel vulnerable and all the rest of it. Especially in a room with a bunch of other people in their late teens, in their early twenties. So I think providing a space where it is open for students to talk to other students, different universities, different continents, like, it’s such a great idea.

[Jaz]
But Emma, I’d ask your thoughts on actually bringing dentists, like, I was debating whether it should be just for students, like a little space, or is it okay if dentists can also interact on there?

I think we decided actually, it’s a really nice bridge between students and dentists. And the way that we’re going to make sure that it’s a nice, safe environment is very simple. The entire ethos or what I’m trying to set up with Protrusive Guidance is, I want the community and the collection of the nicest and geekiest dentists in the world.

I don’t want all dentists. Okay. I just want the nicest and geekiest ones. And I think when you combine that together, that’s why I think that even our Facebook group, which we’re going to phase out, sorry to say people on Facebook, we’re going to phase it out because I want to go all in on the Protrusive Guidance platform. And I want this to be the place to go to when you want some advice, but you also might need a hug.

[Emma]
Absolutely, you might need a bit of a hug, and even from a student’s perspective, I’ve worked with probably over a hundred dentists, I’ll say, I’ve done a lot of locum nursing, sorry, but you just learn so many tips and tricks from everyone you meet, every new dentist that I work with.

There’s something something else that I’ll pick up and even being on the main clinic and university, I’ll speak to everyone and they’ll say, oh, clinician said to do this and different clinicians said to do this, you just so many opinions and tips and tricks out there. Why not share them especially to the to the younger dentist as well?

[Jaz]
I think of all things I think whoever’s going to be nursing for you in the future when you qualified stuff, they’re going to be so lucky. They’re going to be so lucky because you’ve been in their shoes. You walked a mile, you walked a hundred miles in their shoes, right? So I think whoever your future nurse is going to be is going to be very lucky and knowing that you also worked at Costa, I know you make a really good coffee as well. So your nurse will be well treated.

[Emma]
Yeah, that’s that.

[Jaz]
Emma, thanks so much for introducing yourself to the Protruserati. I’m so excited to go on this journey with you and see where it takes us to make dentistry tangible for young dentist students and dentists in general to try and make that bridge. I think that’s where the magic and the beauty will happen.

Connecting all of dentistry together, not just established dentists, but getting the students on board so that we’re all have this space to connect and thrive.

[Emma]
Yep, perfect. I’m just so excited for it. I can’t wait to see what it evolves into and just for people to take advantage of this and put it to good use.

Jaz’s Outro:
Amazing. Thank you. Well, there we have it guys, the introductory episode to Introduce Emma is completed and the next episode is Adhesive Months. We’ve got some adhesive questions about the longevity of composites that’s coming with Emma and every month we’ll release another episode, another revision notes in the Crush Your Exam section and I’m actually really excited to see where this leads.

So if you’re not a dental student and you know a dental student, please send this to them. And if you’re a student, don’t hoard this. Don’t keep it to yourself. Everyone’s going to find out about it anyway. Go and share, share the love. Let’s all learn and grow together. So I’ll catch you in Protrusive Guidance on protrusive. app.

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LIVE from Chicago AES 2024 + Midwinter!

Fresh off our thrilling journey to the American Equilibration Society (AES) Conference in Chicago, alongside the Midwinter event, this episode is your ‘access all areas’ to relive the highlights of our long-awaited expedition.

Previously focused solely on equilibration, AES now embraces a broader spectrum, encompassing occlusion, comprehensive dentistry and the TMJs. Join me and Dr Mahmoud Ibrahim as we unpack the highlights of this dynamic event.

https://youtu.be/3lQohxbKSig Watch this on YoutubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

1:05 The Journey to AES

3:20 AES Opening Ceremony 2024

3:52 Global View of Diagnosis and Treatment Planning

5:29 Diagnostic Records in the Digital Practice

6:19 Dr. Chuck Fischer

7:57 Dr. Glenn Kidder

12:41 TM Joint Imaging from an Orthopedic Perspective

14:15 Adopting a Top-Down Security and Privacy Strategy

14:45 Lip Esthetics and Maxillary-Mandibular Advancement Surgery

16:30 Indications of TMJ Replacement in Ortho-Surgical Case

17:04 Face First Treatment of the TMJoint

18:11 AES Day 2

19:32 Occlusion – TMD from the Orthodontist’s Perspective

20:53 Occlusion – TMD from the Periodontist’s Perspective

21:39 Catch up with the Protruserati

31:02 Case Study: TMD Panel

32:41 Digital Occlusion: What Works and What Doesn’t Work

33:48 Occlusion – TMD from Prosthodontist’s Perspective

38:54 Insights and Reflections from Dental Giants: Kois, Spear, and More

40:38 ‘Composite Challenge’

42:44 Interview with Dr Alan Mead

45:28 Reflections and Takeaways from the Conference

53:11 Connecting with the Dental Community and Looking Ahead

If you loved this episode, be sure to check out BACD Experience With Pascal Magne

Discover more podcast episodes like this one and earn CPD or CE credits. Join our community to access exclusive content such as ‘Verti Preps for Plonkers’, Sectioning School tutorials, over 30 rubber dam demonstration videos, webinar replays, and clinical videos showcasing various dental procedures. Upgrade to our Ultimate Education Plan for comprehensive learning resources.

Click below for full episode transcript: Jaz's Introduction: A, E, S. It's in the joint. Sorry, had to get that out of my chest, but we're back. We're back from AES TMJ conference in Chicago. I also went to Midwinter, and this episode will summarize mine and Mahmoud's trip to somewhere where we had longed to go for so long, the American Equilibration Society. Now, This society likes to be called AES because we've kind of moved away from the whole equilibration thing.

Jaz’s Introduction:

It’s way more than equilibration. It is occlusion. It is TMJ is the definitive conference sense that brings together all these occlusal camps. And I tell you guys, I was in heaven. I was in education heaven, and I was also in food coma heaven. So join me in Mahmoud on this, like on the field kind of different podcast, gain a sense of the magic of AES 2024 conference.

You’ll kind of feel like your presence was there. And of course I’ll share at least one key lesson per lecture. As well as some interviews from the amazing Protruserati and mentors that I met. Like, I shook hands with John Kois and Frank Spear within an hour, and I didn’t even wash my hands. So how did this trip begin?

Well, it began with what we call level one permission. Now I joke about this level one permission whenever we organize a trip like last year, a few years ago Porto, this year we’re going Sicily in June for Vertipreps and of course for Chicago, I needed level one permission. So people ask me on Facebook, what is level one permission?

Okay, level one permission is when you have to ask your spouse if you can go. I know that sounds really weak, but it’s a reality when you’re a father of two boys, young boys, I had to absolutely beg Sim to let me go to Chicago. I’m so thankful, me and Mahmoud were both thankful to our wives for letting us go.

So Mahmoud’s got three kids, I’ve got two kids, both young families. And we had to beg our families to let us go so that we can follow our passion and attend our first AES conference. I mean, the lineup was just amazing. Like John Kois, Frank Spear on the same day. Are you kidding me? It was absolutely insane to just be in their presence.

And obviously, the president this year was Dr. Jim McKee, who’s been a previous guest on the podcast. And I also got to see Bobby Supple. Now, if you remember from that episode with Bobby Supple, I kind of promised him that I would come to AES and I didn’t know when it would be, but I did promise him that I would come.

I’ve been wanting to come to AES every year and I’ve got a small child, but 2025 is a really cool date that I can earmark to my wife and really just build this, what’s 2021 now I’m going to keep whispering every few nights, every few weeks, okay, 2025 AES so there we are. It finally happened. And also it was really nice to to see an old friend and mentor, Dr. Michael Melkers.

That guy has taught me so much about occlusion and splints. So it was just great to catch up with Michael again. We’ll be hearing a little bit later how Michael made our trip very special when it comes to hot dogs and oysters. I actually had oysters for the first time and they weren’t just any oysters.

They were very fancy oysters. And so thanks so much, Dr. Michael Melkers for allowing me to have oysters for the first time ever and experience the traditional Chicago hot dog. So we arrived to Chicago from London Heathrow and we were just amazed at the architectural beauty of Chicago. It also seemed like a melting pot of different cultures.

So as a city, we loved it. I mean, it was mostly the conference that we attended and we didn’t get to explore as much as we’d like, but from what we saw of Chicago, it was a pretty awesome place. So the theme of the conference this year, AES 2024 was Clinical Excellence through Interdisciplinary Care.

And this was the 69th meeting that they had. So the way the AES actually started was A, with a prayer, which is pretty cool. And then secondly, there was some flag bearers and I got to bear the flag of Mexico, which is pretty cool. And as we’re bearing these flags to represent all of Mexico where all the delegates who’ve attended AES are from.

So loads of different countries attended. I’ve got Mexico flag. We’re walking in and we’ve got bagpipers. So these bagpipers are marching in and way behind with the flags, and everyone’s like standing and clapping as is happening. And this is very different. I’ve never seen a conference start like that. We then had the first lecture.

The first lecture was a global view of diagnosis and treatment planning. This is by Dr. J William Robbins and James F. Otten, this was a fantastic lecture. Now I’m not going to be here and say that every single lecture was fantastic. I’m not going to do that to you. I’ll give you the learning points. And I’ll be honest that some lectures as always in a conference out of the, I don’t know, 12 lectures or how many there were, were sensational and others were maybe not my cup of tea, right?

And that’s how conferences work, right? But this one was right up there. This system that these two lecturers have developed is actually well known. There’s actually a book. It’s called global diagnosis, a new vision of dental diagnosis and treatment plannings by J. William Robbins and Jeff Rouse. And if anyone wants a good resource for treatment planning and having like a global view, then I think this will really fit the bill.

I think the main. takeaway that I could share with you was the following. You know how when we plan a case, we like to start from the incisal edges, like the upper central incisors, where they sit in the face will really determine the rest of the upper aesthetics. And once you determine that you can determine the opposing.

But Dr. Robbins argued, actually, perhaps we give too much emphasis to the incisal edge and we need to give more emphasis to the upper incisor gingival margins. So the gingival margins of the upper incisors. Because this then gives you a periodontal diagnosis. So for example, gummy smile, vertical maxillary excess, or something called altered passive eruption, whereby the gums didn’t mature and they didn’t recede to the CEJ.

So that’s why another cause of a gummy smile. And they had a whole system that they shared about how to diagnose and what are the different options to treat. And I think it’s a really great one for anyone early in their career to really get a landscape of treatment planning and diagnosis. The second lecture was called diagnostic records in the digital practice. This was by Dr. Seth Atkins.

What a clever, clever man. Like at the moment I’m scanning, but that’s as far as digital as I’ve gone. I’d like to do more like, you know, printing and designing, but I haven’t quite gotten to that, but what Dr. Atkins was showing was absolutely brilliant.

At the. cutting edge of digital dentistry. My biggest thing that I enjoy the most from this lecture was just seeing the 3d printed mock up as an overlay that goes in the teeth and how they really can look fantastic and how far the printing has come to allow us to do that. So next time you have a situation where you want to do like a mock up, it can be 3d printed.

So speak to your lab and work alongside your lab to work on the digital design to be able to create some sort of a mock up that you can give your patient like this instant smile to assess. Like traditionally we’d use like LuxaTemp or ProTemp in a putty, but with digital dentistry and printing, there’s a neater and quicker way.

Then it was the break and every break I was able to catch up with colleagues who attended the conference and I went into like interview mode. I just wanted to ask questions and just be a sponge and gain from their wisdom and knowledge. And also hear about the experiences of attending AES all these years.

For example, Dr. Chuck Fisher has been attending AES for 40 years. Let’s hear it from him. Can these conferences perhaps be a bit different dogmatic? That’s what I asked him.

[Chuck] Chuck Fisher, I’m from outside of Denver, Colorado. I’ve been coming to AES for probably 40 plus years, and I find it one of the best meetings I can go to, not only the information that we get, but the experience with colleagues from all over the world. It’s just an amazing time. Thanks.

[Jaz] Why do you think there is perhaps this perception that inclusion conferences can be very dogmatic? What would you say to someone who perhaps has that view?

[Chuck] I’d say you have to come and watch the dialogues that occur with opposing views. And that’s the way we learn is we’re challenged by other people that think I see a different perspective and it makes us stronger on ours or we have to change-

[Jaz] What I’m looking forward to today is the debate that’s going to be happening later, which I think we need more. We need more debate and dialogue about different ways of managing a condition.

[Chuck] You bet. That’s we learn from each other and we have to have dialogue. We have to have confrontation.

[Jaz] It’s very much the case here, in a nice way, and it’s very collaborative, so I’m very stoked to be here, actually.

[Chuck] Me too. We’re on the same boat.

[Jaz] The next person I got to meet was an oral facial pain specialist, Dr. Glenn Kidder. Now, I actually have his photo in some of my slides, with a quote that he says. And I’ll explain what the quote is in a moment, but it was so nice to meet this genuine man. And what I liked the way our discussion went is, when you speak to oral facial pain specialists, they’ll argue that actually, the occlusion isn’t so important, you know?

In terms of pain and TMD, we know that the link between occlusion and TMD isn’t established. And I know that’s going to offend some people. Like one of my mentors, Robert Kirstein, he’s the other way and I respect him. Whereas others will be like, nope, there’s no evidence at all that occlusion and TMD are linked.

Now you’ll see from my discussion, very brief discussion with Dr. Glenn Kidder that he likes to see both sides of the coin. So let’s hear what he has to say.

I just want to say thank you so much for inspiring me. You don’t know this, but I do some talks on occlusion, and one of the slides I put up has your photo on it. And I put the following quote, okay? It’s the way teeth come together, occlusion is important. The way they function is more important. But the most important is for how long, how they function. And I love that quote. So just do you mind spending a minute just explaining just for the younger colleagues out there, just a little bit more about that.

And is that something that you picked up or is that something that you sort of sat down and philosophized over? Where’d that come from?

[Glenn] Oh, I don’t know. I have over 5, 000 hours of CE, so I’m not sure where that came from, but I have an occlusion background through Pankey and Dawson, but on the other hand, I’m a board certified in oral facial pain, so I respect the science and so most people in that field would say occlusion is not particularly important.

And I like to see both sides of that equation. So sometimes I think the side that doesn’t think occlusion is important, thinks more of exactly how the teeth fit. But you can have a perfect occlusion and still have a lot of symptoms if you’re clenching and grinding a lot. On the other hand, you can have a terrible occlusion if you don’t clench and grind a lot, it may not be an issue.

So every case is different. So we have to do individualized treatment plans and we need to come up with a diagnosis, but I think occlusion is important and I do respect that. I think you need to fit right, look right and fit right to work right. However, if you clench and grind, it’s a major factor.

[Jaz] Brilliant. And I saw you earlier with your grand grandchild.

[Glenn] That’s my grandson.

[Jaz] Adorable. And that was real. That was really nice to see that at a dental conference for you to have that. So do you bring family often to the conference?

[Glenn] No, my oldest son and her mother are both dentists. And Michelle Lee, they asked her to come to this meeting and they’ve been here a couple of times before. But, I’m happy that they’re here and they enjoying the course.

[Jaz] Great. I’d like to encourage the listeners and watchers to consider coming to AES one day. And I have been waiting for years for this moment. So to be here, I had to beg my wife to let me, we’ve got two young boys. I had to beg my wife to be here. So Sim, thanks so much.

[Glenn] I’ve been here about 40 times.

[Jaz] And this is the theme.

[Glenn] It’s a great meeting. And I always leave here with a little bit of a knot in my stomach feeling as there’s just so much more to learn. I got to keep learning. So it’s a great meeting to come to.

[Jaz] Just quickly then. Some young colleagues may be concerned, some colleagues may be concerned that perhaps occlusion conferences could be dogmatic. What would you have to say to them about the AES regards to that?

[Glenn] I think we keep a very open mind. I didn’t see any dogma here this morning. In fact, just the opposite. I think we keep very open minds. We look at the whole patient and we look from airway to aesthetics, the occlusion to so many factors that are involved. I think we do a pretty good job of looking at the whole patient.

[Jaz] And you get a great representation from all the big occlusion bodies, you got Kois, Dawson, Pankey, they’re all coming together to discuss such a topic that’s so close to our hearts. Final thing then, what’s your top advice for a new graduate, a young dentist in anything in dentistry? It could be patient relationship. It could be a clinical tip. Anything you think.

[Glenn] Just to keep learning, never feel like, you know it all, again, the more I learned, the more I realized I don’t know, personally, I have a little bias toward the Pankey Institute because I think they teach things in a cool way, a lot of hands on stuff.

[Jaz] The human stuff that you guys cover, which I’ll be just famous there-

[Glenn] To learn more about the technical end up learning more about how to be a better person.

[Jaz] About themselves as well.

[Glenn] And so that’s an important thing as you develop, you’re not just your practice, but your family and your community. So that’s the cool place.

[Jaz] My first exposure to occlusion through my old principal, Hap Gil, who’s a proud Pankey alumni, was a Pankey and some of the things that he passed on to me. So, shout out to the Pankey Institute there. Thanks so much, Dr. Kidder. It was honestly an absolute pleasure to meet you.

[Glenn] Enjoyed.

[Jaz] So after the break, there was a lecture on TM joint imaging from an orthopedic perspective. This was radiologist, Dr. Tom Predey and Dr. Jim McKee presenting together. The main takeaways here was they were going over the Piper classification system and actually had an episode with Dr. Jim McKee, all about the Piper classification. Funny story. I was standing next to Dr. Mark Piper, who had an epic mustache and it was just amazing to be in his presence. This is the magic of conferences just like this.

I was very excited to be standing next to one of the most Eminent TMJ surgeons in the world. Anyway, the main takeaway that I could pass on to you from this TMJ imaging lecture is twofold. One is that maybe centric relation isn’t a thing anymore. Maybe centric relation isn’t the preferred term that we are now preferring FSCP.

Can you think of what FSCP stands for? Okay, full marks if you said fully seated condyla position. Listen, I don’t make the rules, but I’m happy to play along. It makes sense. Let’s go with it. Okay. So FSCP is in, centric relation is out. And the other main overarching theme of this was that we need to be wary of the occlusion that develops because of a change at the joint level.

So as Dr. Jim McKee said in our episode, actually think not about how the occlusion influences the joints. Think how the joints influence the occlusion. So for example, the loss of the disc over the joint may mean that you develop an anterior open bite. So as the condyles potentially seat further and they go superior and posterior maybe, this would manifest as a change in the dental occlusion.

And so to keep in mind when you experience a change in the occlusion, that perhaps the joint imaging will help to validate your diagnosis. The lecture after that was adopting a top down security and privacy strategy. So basically this was by someone called Rex Lee. And the long and short of it is that we’re all royally screwed.

Whether you’re on iOS, Android, they’re all selling our data all the time. And we’re constantly at risk of being hacked. And if you have a smartphone, like we all do, then we’re in a pretty crap situation. And to be honest with you, I got a little bit depressed and I didn’t know what the conclusions were.

So, I think the guy was doing a great job in raising awareness, but it was very, very sad to know that we’re all screwed. So after a lunch break, we had a phenomenal lecture by Dr. Michael Gunson, who’s a California based oral surgeon. Now in the UK, we have a speciality called oral surgery. And we have a separate speciality called oral and maxillofacial surgery.

For the latter, you need to do dentistry and medicine. Now, I learned that in the States, they just have oral surgeon and oral surgeons, like they are like max, max, they’re all encompassing. And so this chap was a very charismatic oral surgeon. I loved his lecture. And basically the top takeaway here is the importance of a lip seal.

Now, firstly, he started his lecture by saying that it’s absolutely that occlusion is not linked to TMD. He strongly believes that there is a link. And then he went on to say about assessing the inter labial gap, i. e. the gap between your upper lip and lower lip, i. e. it just shouldn’t exist. When we close our mouth together, our lips should come together first and then our teeth should come together.

And he really emphasized that lips being apart is very pathological, and if we think about breathing, eating, and communicating, these are all vital for survival, and all need to achieve some sort of a lip seal at certain points. And what he said was that the brain will sacrifice all other things to achieve this.

So as long as the brain can continue to breathe, eat, and communicate, then everything else is relevant. So sometimes if you think about how much effort the patient who’s got incompetent lips is doing, how much extra work the facial musculature must be putting in to allow the lips to form a seal could be a significant player in temporomandibular disorder.

So that was a fantastic lecture about the lips, which are the way our smiles are framed. And it really gave me a heightened importance when I’m assessing smiles and taking that lip in repose photo to really make sure that this is not overlooked. Now, following Dr. Michael Gunson, oral surgeon, it was followed by two more oral surgeons.

So remember, the interdisciplinary element of the conference is now in full force. Now, we had Dr. Reza Movahed and also Dr. Brian Shah, also, very talented surgeons. Now, a lot of the stuff they were saying was surgery based, and it was like, wow, this is really fascinating, and you guys are amazing for the surgery that you do.

But it wasn’t applicable on Monday morning for me, but it was really, really interesting. It was interesting, especially some of the like general takeaways. Well, I look at this guy, Dr. Reza Movahed, and this guy is like a phenomenal artist. He’s a musician, he’s an oral surgeon. So really, if you want it all, you can have it all.

And then we had Dr. Brian Shah talk about all these algorithms of when to do a total joint replacement versus discectomy. But the most tangible thing I can pass on to you from these lectures is who is the most susceptible, which patient is most susceptible to perhaps needing surgery in the future? And it’s that patient with the small condyles.

It was a common theme amongst surgeons that if you’ve got small condyles, that automatically puts you at further risk of having a breakdown and potentially needing surgery in the future for a TMD issue. And they all had these scenarios they were describing the patient with a bag of nine different splints and eventually they come and see the surgeon and they need the total joint replacement.

But I know one thing that was perhaps missing was some key guidelines for us dentists, some key guidelines of at what point should we stop bothering with occlusal appliances and conservative care, and perhaps where early intervention, early surgery may have benefited the patient.

So I think that element maybe could have been discussed, but I was in awe of the amazing surgeries they were doing and what is possible out there. Always important to get exposure of this kind of stuff. So that marked the end of day one. And so day two, I interviewed Mahmoud in the morning. We were super, super excited. Today was a big day.

Mahmoud, it is the big day. John Kois, Frank Spear. What are you thinking, man?

[Mahmoud] So let me tell you a little story. When I was younger, Planet Hollywood opened in Dubai in the early 90s. Do you know, you’ve heard of Planet Hollywood, right? So it’s like a restaurant.

It’s sponsored by a lot of A list celebrities, usually, and they come to the opening. We were standing there outside and one of my friends managed to grab and hug Sylvester Stallone. Like he was giggling like a little girl when that happened. And I just looked at him. I was like, calm down, dude.

You’re going to have to control me today and stop me doing that. When I see one of those two, I’m going to fanboy so hard. I’m really, really, really excited.

[Jaz] Tough question. Team Spear or Team Kois?

[Mahmoud] I think I’ve probably had a lot more influence on me by Spear’s teachings? So I’ll have to go team Spear.

[Jaz] Shame on you.

[Mahmoud] I know, I know. Well, you weren’t going to let me get away with that giving you an answer, were you?

[Jaz] So day two of AES. Absolute superstars today, John Kois, Frank Spear to name a few. But one thing I’m actually really excited for today is the panel discussion. The theme is like, how would you treat this on Monday morning?

And they’re talking about disc displacement. It’s something we see all the time. We can all diagnose it in a way, but actually the management of it, TMD is like the Wild West, right? And So yesterday we saw some surgery and stuff, but today is real applicable stuff. Let’s go check some people out.

So the 8. 15am lecture was by Dr. Domingo Martin. I think he’s part of the face group, this is from memory, which is like this group of orthodontists who are very knowledgeable on occlusion. I know what you’re thinking, what, orthodontists? Occlusion? It can’t be, it can’t be true. Well, these guys are actually working in the fully seated condylar position, which is a great point.

Right? Like if you’re doing a full mouth rehab in enamel, which is essentially what orthodontics is, perhaps we should be choosing to work to a fully seated condylar position. And this was exactly what this lecture was about. And he showed some cases and in a high percentage of cases, Dr. Martin would actually give these patients a splint, an orthotic to wear 24/7 for some time to completely deprogram them and find their first point of contact in the fully seated condylar position.

And they can repeatedly bite that and then do the orthodontics in that position. So really now what you’ve done is you’ve built the teeth around where the joints are the most stable. So that was really cool to see. I’d heard a lot about Domingo Martin, but it’s first time to see his lecture and he was hilarious.

There’s one thing he said, right? He was talking about relapse and he was saying about the importance of the interincisal angle and actually getting the joints in the right place, getting the teeth in the right place that relapse may be mitigated. And what he says to his patient is, look, relapse will happen.

Now, one to two millimeters, just be grateful that you’re still alive. And honestly, that got the biggest laugh for the conference and it just really put everything into perspective, I guess. We then had a periodontist lecturing. So the occlusion was a occlusion TMD from the periodontist perspective.

This was Dr. George Mandelaris. And the key takeaway, the key notes I have from his lecture is a takeaway, no recession, no problem. This theory needs to change, right? So just because you don’t have recession doesn’t mean there isn’t a problem. If you’ve got a thin biotype and thin bone and the teeth are being pushed orthodontically out of the bony envelope, just because you don’t see recession doesn’t mean there’s a big problem.

The teeth are essentially walking off a cliff and so in the susceptible individual before orthodontics, it’s important to liaise with your periodontist. And he was showing some really advanced perio things, which I am not familiar with, but he seemed very intelligent and it was really cool surgery, what he was doing. So more power to you.

God bless you, sir. And he also echoed a saying, he said, small condyles, big problems. Then at the break, I was able to catch up with some more Protruserati. I was able to catch up with committee member, Dr. Matt Standridge, and I presented a hoodie to Dr. Colleen Scheive. Now she’s on the Protrusive Guidance app.

It’s great to have her there. And funny story about Colleen, right? She found me because she basically went on YouTube and she typed in occlusion and she found me, right? And then she found the episode I did with Dr. Koray Feran on equilibration. And then she came to London to do Koray’s course.

Obviously it was brilliant. And so she went back and I saw a message saying, Hey, Colleen, you live in Chicago. Are you coming to the AES? And bless her. She was so honest with me. She said, she was like, I had to go away and Google what AES was. And it was great that actually that led to her coming to AES.

And it was great to meet Colleen there. I wanted to give her a hoodie. And also, she was just a lovely, lovely person. She really embodies everything, Protrusive is about. She’s nice and geeky. And actually she gave me some great parenting tips. And so you’ll hear how I give her a hoodie to celebrate her.

So Matt, we just met. It’s great to meet you. Do you come every year to your committee? Okay, your committee. Okay, amazing. Okay. So how long have you been involved with AES for?

[Matt] For AES, my first meeting was about eight years ago. And I’ve made most of them since. It’s been a great organization to get involved with. And then just this year they asked me to get involved as industry relations chair. And so this is my first year doing that.

[Jaz] And so you’re responsible for all this?

[Matt] Well, I will be next year.

[Jaz] Okay. Okay. Yeah. Okay. Yeah. The vibe is brilliant. I’m absolutely loving it so far.

[Matt] Thank you.

[Jaz] What message could you give to Protruserati and then those who are always maybe considering it but haven’t never made the plunge?

[Matt] If I had to give an elevator pitch, I would say it’s the best two day clinical comprehensive meeting in the world. I mean, you have all of these thought leaders from all of the great occlusion camps and world leader worldwide, and they bring them together and they may have some disagreements, but we have a central philosophy around function and stability. And I think that’s just something that’s not talked about enough. So you won’t find another two day meeting like this.

[Jaz] Do you think there’s an element of dogma involved?

[Matt] I would say a lot less than probably it used to be now. I’m fairly a young blood with this so I’m sure it was a lot more dogmatic before but I would say things have been opened up a lot more within the last 10 years, I would say and incorporating multiple different thought processes and from different camps and stuff and it’s amalgamated a lot more than probably what it used to be.

[Jaz] Amazing. Well, thanks for for being part of this. I look forward to seeing you next year. Hopefully. Last question and this may not make the podcast because I’m debating whether this is kosher or not. Team Spear or team Kois?

[Matt] What’s that?

[Jaz] Team Spear or team Kois?

[Matt] Oh, I love both. I’ve been through a lot of Spear and I’m currently going through Kois.

[Jaz] Okay, I love that. I love that answer.

[Matt] So yeah, yeah, I love both, but yeah.

[Jaz] If you had to pick one.

[Matt] So right now, what I will say this, I will say Kois’ treatment planning way of doing things and how structured it is, and almost like systematic how it is, I would say that really put some light bulbs off in my head. Like it really connected some things.

[Jaz] I love it. I feel, I agree. His stuff is amazing. so much. I’m going to hand the mic over to Colleen now. Okay, Colleen.

[Colleen] Yeah, it’s been so make me look more professional. If you’re sitting next to me, it’s been so nice.

[Jaz] As a Protruserati, it was great to have you here, right? And so I wanted to just give you this hoodie. I wanted to make sure you have a protrusive hoodie basically. So while you open the hoodie, I’m going to tell the Protruserati a little bit about you. Colleen, just having met you and stuff and on the podcast. And I asked you on the old app on the forum, are you coming? And you had to look into it. It’s actually, it was just down the road from me.

[Colleen] So I’m going to come really easy.

[Jaz] I love how you’re getting stuck in. I love you getting stuck in. Amazing. Okay, good. It’s been so nice to meet you here. And I had a really nice conversation yesterday. And I’m just inspired by you as a learner. But also, you got three kids, three kids. And then we discussed about how there’s a season of learning and season of life.

And sometimes there are other priorities and learning is not number one priority. And then now your kids are ageable, perhaps, but you can go back into it and stuff. You look great. So amazing. So good. Okay. I love my discuss. Okay. You do us at 12. Do us 12 now. Okay. But, it was just great to learn about you as a business owner, a practice owner, dentist, a parent. What advice would you give to women in dentistry who are mums who are aspiring practice owners. How, and those who aspire to go to CE classes and stuff, what advice would you give to them?

[Colleen] I think, what I am learning and coming to grips with is that there is no balance. So stop searching for it, right? Their life is always a lot. And so, you try to find the good parts in each part that you are. And what I am coming back to is finding Colleen. I had lost Colleen for a while, right? So, your doctor, and your boss, and your wife, and your mom, and your daughter, and I had lost a sense of self.

So, it was a very purposeful kind of chat in your own head of like, who you are, and what things make you happy, and then you bring that part of you into all of those other relationships, and I don’t, I mean, I feel better all the time, so I’m going to call that successful, right?

And so I think we all have a different sense of what success is, certainly in the U. S., right? Monetary is usually at the top of that list, but that’s not necessarily true, right? I have a lot of friends who are incredibly successful. financially successful. But then they’ll talk about these simple things like, oh, I played catch with my kids and this is the beauty of life.

And I’m thinking, oh, okay. Well, I like my kids and they don’t drive me insane. And I like my patients and I like my team. So to that, so that’s successful for me.

[Jaz] Amazing. I was really nice to get some parenting tips from you last night. Well, the story you told me last night, I will never forget that. So I thank you for making me a better parent after the essay.

[Colleen] So it’s by far my favorite job. It is. I mean, just, yeah, raising tiny people is amazing. They teach me as well.

[Jaz] So anything you want to say while you’re on the podcast to the Protruserati?

[Colleen] Oh my gosh, keep watching, learn about the joint and how to create everything into that proper function. But yeah, I mean, I will definitely keep watching.

[Jaz] Where has your occlusion journey taken you? Cause you’ve done a bit training with Lukas Lassman, you’ve done Pankey. You’re here now. Do you ever feel, because you’ve been exposed to a few different teachings, that perhaps it’s got confusing for you, and it says you made the topic less tangible?

Unknown Speaker: Occlusion’s kind of a mystique of its own, isn’t it? And it’s like it’s perceived to be a dark art. Particularly, I think, the main reason because it gets confused in dental schools between departments. And we always think in a very departmentalized way, don’t we? So you have surgeons who are talking about anatomy and they typically within their department will tell you about the physiology of how the joint works and all the rest of it.

But truthfully, do they know how the dysfunction of the joint works when it relates to the occlusion and the teeth when they meet in the middle? Well, usually because of their training, less than you might imagine. And you remember back in university as an undergrad in Sheffield, we have the restorative tutors teaching us about occlusion. Did they know anything about joints? Probably not realistically.

[Jaz] I mean, yesterday was a testament to that. We had a whole lecture about joint based occlusion. So the occlusion as a consequence of the joint. So the disc lip and then that changes the occlusion.

Unknown Speaker: Yeah.

[Jaz] And actually what we see is a class two, but actually they were a class one. 12-year-old. But it’s because of the disc injury.

Unknown Speaker: And as a result of that journey of just discovery of all of these pieces of the puzzle fitting together. I don’t think you can ever know enough. And so my journey of why I bolted on the things that I did at the time was almost by accident.

Pankey became a kind of an extension of the work that I did when I lived out in Australia and worked out there for a couple of years and the dentists out there were comprehensively minded dentists and that was the work they were doing and they went well you can’t go anywhere without having the bedrock of occlusion underneath you. So go to Pankey or go to Spear or go to Dawson or something and to be honest with you a lot of it was to do with I was just exploring and following the world and following my nose and seeing where life took me and then it can get confusing when you then bolt other things onto it but when you really like people like Lukas Lassman for example.

You listen to his stuff and he’s brilliant at formulating his patchwork quote and explaining why he ascribes is quite a strong word, but kind of like why he’s taught, he’s tied these aspects of Dawson ology into it. And why he uses up a Kois deprogrammer, as opposed to a Pankey deprogrammer and things like that.

When you go, okay, fair play. I kind of get where he’s coming from.

[Jaz] Just a quick one, Team Spear or Team Kois?

Unknown Speaker: Should we make this like a big old, I think on one side of the audience there’s going to be half and then on the other side of it’s still be half. And then I think they’ll split down the middle and they’ll me, I’m hoping there’s going to be a fight at some point today, so I’ll probably sit right on the fences.

Coward. Make coward. Do I have to wear any of their like devices? Is that what we have to do today? I have to wear a Kois programmer all day.

[Jaz] You can arrange that.

Unknown Speaker: To be fair. I do have a little take Kois.

[Jaz] Okay, there we go. So after the break, having spoken to Matt and given the hoodie to Colleen, there’s really cool panel, like it was a case study, three perspectives on a patient who had basically a disc displacement. It was Dr. Lynn Lipskis, Dr. Lee Ann Brady, who I adore. Absolutely adore. What a wonderful woman, I’ve been following her blog for years, fantastic educator.

And Dr. Peter Lemieux. I probably said that really wrong, I’m so sorry Dr. Peter Lemieux. [trying to pronounce ‘Lemieux’ correctly]. God damn, I wish I was listening to when they pronounce his surname. Anyway, really cool guy. Very cool headed. Anyway, fantastic panel discussion. I wish we went more into treatment. I wish, I mean, that thing could have been a whole, that panel discussion could have been a whole day.

I would have loved to delve deeper into treatment strategies, but it was basically about how they assess and diagnose such a patient. My biggest takeaway I want to give you from that lecture is of course, DrLee Ann Brady, right? Her saying is, Talk your think. Just a wonderful thing. I’m a big fan of showing your working out.

Like when I’ve got a tough case, I’m very happy to show my working out and my patient. I’m saying, hmm, you know what? So here’s where it could be because X, Y, and Z, but also we must also consider A, B, and C. And obviously stay away from jargon. I make it in patient friendly terms, but just talking your think and, saying what you see and just having that open and honest relationship with your patient is fantastic.

And so that was a real communication gem to highlight. So after this lecture, Dr. Michael Melkers surprised us with the Chicago style hot dogs, which are amazing. I almost said donuts there, Chicago style hot dogs, which are absolutely fantastic, better than five guys. And I just want to say, thank you again, Michael, for being here.

Oysters, the hot dogs, everything. It was a real culinary experience. So now, what you’ve been waiting for, right? So it was next up was John Kois and Frank Spear. Not together, separately, okay? So first was Dr. John Kois with his colleague, Dr. Marta Revilla-Leon. Now, this lady. Gosh, she’s so clever. So she is like the authority on like face scanning and digital dentistry and how precise these digital articulator systems and motion trackers are basically.

And so she’s the authority on that. So basically what they were talking about is the old facebow, traditional facebow and articulator and how in John Coyce’s own words, the days of the articulator are numbered. Why? Because now with the advent of face scanning and digital articulators and different ways to transfer that information digitally now is so good.

And the way it’s heading is that articulators are going to be dead. Right. I mean, of course there’ll always be niche uses of them, but a bit like the digital scanners that we have today, your TRIOS, your iteros, et cetera, your medits, year by year, the number of impressions being taken are less and less.

And it’s going to be the same with articulators and facebows. And so that was the main taker of that. Their articulators are going to get phased down. He didn’t say exactly when, but me and Mahmoud are having a chat and he had some cool things to say. In fact, let’s listen to what Mahmoud had to say about that lecture.

So before I share Mahmoud’s reflections on this, I’m going to just tell you about Frank Spears lecture. Again, if It was so great to see these two giants one after the other, and I was just starstruck. I was in awe. These guys have taught me so much. And so just like from John’s lecture about articulators being phased out, the takeaway from Frank Spear’s lecture, which was basically about TMD and the prosthodontist perspective.

A good reflection to share from Frank Spear’s lecture is that most patients are not in centric relation. We know this already. Most patients have some degree of slide. And so maybe it’s not the presence of the slide. That’s an issue. It’s perhaps the degree of the slide. So if someone’s got a severe slide, we know in the literature that that is correlated with TMD and facial pain.

Now we don’t know whether that’s because perhaps the joints change and that’s what caused a slide, and that could be like a confining factor here, but essentially I like his common sense approach and the quote he said was having a patient know where to close is more important than the pin point CR position.

Let me say that again. Having a patient know where to close is more important than a pinpoint centric relation position. So I like the fact that Frank Spear is not so bogged down like some clinicians are, but it has to be fully seated condylar position. And we had some of that at the conference and that there’s a degree of a biological variability or a bit of fudge in the system.

Okay, we are in Chicago. Midwinter, waiting for the midwinter shuttle. How awesome was yesterday?

[Mahmoud] Absolutely incredible.

[Jaz] John Kois, Frank Spear, at the same place.

[Mahmoud] Yeah, it was so eye opening. I also loved the contrast between the two.

[Jaz] Go on, tell us more. Firstly, we totally fangirled them both. Haven’t washed my hands since.

[Mahmoud] Yeah.

[Jaz] We got to take both our hands, which is pretty special.

[Mahmoud] Yeah, selfies.

[Jaz] And we got the selfies. And we squirted chilli in, you squirted chilli in Mike’s face.

[Mahmoud] Mike’s face.

[Jaz] Yeah. Michael Melkers massive shout out to him. He’s looked after us so well. He helped us through and through. So it’s all these superstars that we’re just, so a huge shout out to someone who’s taught us so much and inspired us, actually.

[Mahmoud] Yeah, you made this really, really unforgettable. So thanks so much.

[Jaz] Entire committee, actually, we were in this meeting room with all the AES members and the amount of hard work that goes into it was super obvious. So for next year, guys, AES 2025, please do show your support to help a society like this that really, it’s like the main one for comprehensive care.

[Mahmoud] Yeah. I mean, it’s doing all the right things. Isn’t it? It puts you in an environment where you can really meet people from all sorts. They’re all interested in the same thing of doing like absolutely amazing high quality dentistry. And I mean, the quality of the content was mind blowing.

[Jaz] So tell us about some of the younger colleagues, this thing, sometimes I get this question, like Jaz. What do you mean? What is comprehensive care? What does that mean? What does that mean to you?

[Mahmoud] Comprehensive care really, kind of means you’ve got to look at the patient as a whole. So, a patient might present to you complaining that they’ve got a broken tooth or some pain, but you’ve got to step back and to take a look at the bigger picture because things aren’t always obvious. And the best way to serve that patient isn’t always necessarily just fix that one tooth and off they go.

Step back, have a look at, they’re always talking about, I mean, the heavy focus was on. So looking at the joints because there might be a bit of a I don’t want to say paradigm shift, but we are starting to learn and really appreciate the effect the joint has on the rest of the occlusion, how things come together.

[Jaz] As Jim McKee said on the podcast, when he came on my podcast, it was just great to see him. He hosted so well. He said that we used to think how the occlusion affects a TMJ. But really what we should be thinking is how is a TMJ and the mal health of it, the maladaptation of it affect the occlusion, which is really my eye opening once you think of it that way.

Now, back to the thing about comprehensive care, I just want to say, the way I see comprehensive care very simply is there used to be a time where dentists would just treat caries only, right? Hundreds of years ago, caries, take teeth out. That was it. Then it was like, okay, we need to now look at caries and perio.

Then I was like, okay, caries, perio, mouth cancer. And now really the next level is okay. Look at their diet, look at their joint health, look at their masticatory system, their breathing. That is a comprehensive dentist and that doesn’t happen like a shortcut overnight because dental school doesn’t prepare us for that. So this is where societies like the AES really come into play.

[Mahmoud] They open your eyes and then they help you, guide you through the process of acquiring the knowledge you need to be able to implement it and honestly implement it. I mean, they’re always there to help you figure out a way to put it into your own working environment, we know that everybody can dedicate 90 minutes to their first patient exam or whatever it is.

[Jaz] Especially when you’re younger, maybe don’t own your own clinic, but if you just tweak one thing at a time, like, for example, like if you’re at the moment, if you don’t palpate the masseters, but I know we bang on about this, right?

Yeah, just one thing that you do, for example, at the moment, if you don’t make a diagnosis list. A simple thing, like how many dentists you know who just don’t make a list of diagnoses? Right? Just make a diagnosis list and go for it and keep adding to your sort of comprehensive exam. Eventually you get comfortable in your shoes to be able to make better diagnoses, better diagnoses and better care.

[Mahmoud] And every time you add something, you get good at it. It frees up a little bit more of your mind to add the next thing. And then it all becomes routine.

[Jaz] It can’t just be done in one day. So, it’s a beautiful thing. Now, just before the shuttle comes, what was your top takeaway from John Kois? I can’t pronounce that lady’s name. She was brilliant, Spanish lady. John Kois’.

[Mahmoud] Marta?

[Jaz] Marta. Well, her surname, I forgot, but yeah, Marta, she was brilliant. John Kois, the way you introduced her, she’s a force of nature, I think that’s what she said. How much she’s done in this field of digital dentistry already is fantastic. What was your main, just describe to those who weren’t there, what it was about and what your main takeaway was.

[Mahmoud] So it was about where digital was going, or where it is, really, and-

[Jaz] articulators are dead. Of course, make that clear.

[Mahmoud] Anyone who’s heard me speak knows how much I love the traditional articulators, face bows, etc. And the reason I love them is because they were there to do a job, right? They were making our work more predictable. I think they’ll still have a place in certain areas, but the way to get more accurate records and do this in a more predictable way is certainly digital. And that’s here. And she’s doing all the hard work behind the scenes of testing.

[Jaz] Okay. So the rest of this show today is basically me and Mahmoud at the Chicago midwinter conference, which was cool. Like it was a downer compared to the magic of the AES. Like how could something compete with what we just seen. Yeah. But it was nice. It was nice to be in Chicago and good vibes and good food.

And some of the cool things I’m going to highlight you in this podcast is the coolest thing that I saw at midwinter, which is called a halo. This is a mirror that I think is releasing next month. No financial interest here, but apparently it’s like a mirror, a mouth mirror and an intraoral camera at the same time.

I mean, this is genius and apparently it heats up so it doesn’t steam up. So take my money kind of thing, right? It sounds amazing. So I kind of interviewed those guys as the most innovative thing I saw at the conference. We also caught up with Dr. Alan Mead. And finally, Mahmoud set me a challenge. He set me a challenge, say composite as the Americans do.

He sent me a chance to say composite at 10 times. So let’s count if I was able to achieve this challenge. Thanks to our good friends at Cosmodent.

[Mahmoud] Okay. So, we’re setting a challenge for Jaz. He has to interview the guys at Cosmodent. And he has to say the word composite at least five times. You ready?

[Jaz] All right. Wish me luck. Okay. So, we’re talking about your composite range. What makes your composite really exceptional compared to the other composite brands out there?

[Cosmodent] First of all, we’re the only company that makes a microfilm. Better polishability. Better. There’s one company where there’s one other company that makes a microfilm. They don’t sell a lot of it, but we’re basically, we’re the only company Fizzly has it and shows renamable microfilter. Best polishability-

[Jaz] This composite, I’ve used it before. Really fantastic shine. I mean, I go on a Dipesh Parmar course in the UK, but their payment, they distribute it to good friends of payment. So I’ve tried this composite firsthand, really lovely sheen and shine.

[Cosmodent] Gives you better, possibly better trans, better reflexibility for class fives. Give you better wearability, Give you better depth of color. It matches the Vita Shade Guide exactly on the button once it’s cured. So it doesn’t go darker or lighter.

Our hybrids are stronger than anything else on the market. A little bit more opacious. So they block out underlying color better. They also match-

[Jaz] Do you guys make pink opaque composite as well?

[Cosmodent] Pink opaque is designed, it’s a microfill based composite. It’s designed to block out dark grey, dark brown metal. And it brings the value up on, like, white, which brings the value up. It brings the, it makes things brighter, but brings the value down. The pink keeps the value up. So when you put your composite over the top, it gives you the-

[Jaz] Keeps the chroma gives some warmth as well.

[Cosmodent] Gives it warmth. We also have our pink composite called Gingafill, which is three different colors, light, medium, and dark. It’s the only microfilm based composite there is, so it has better flex again, so you don’t lose it when you’re putting it in margins. It holds its polish so it looks wet, like gingival tissue, unlike the other ones that actually lose their polish and become opaque. Same thing with our microfilter, we’re talking about re enamel microfilter, better flex so you don’t lose your margins. It doesn’t lose its polish like a hybrid or nanofilter, so it doesn’t become opaque, that’s why you can’t see where the composite stops and the dew starts.

[Jaz] I’m a fan of this composite, so if you haven’t used a re enamel composite before, please do give it a go. Nice to meet you.

[Cosmodent] Nice to meet you as well.

[Jaz] I’ve been on podcasting, okay, Alan Mead, how was your day?

[Alan] It was good, it was long. Exhausting because we were doing it in here.

[Jaz] How many guests did you end up speaking to today?

[Alan] Seven or eight. And that’s a lot considering I didn’t really have any, I only had two of them scheduled when I got here and I had to turn some away. I feel bad about it. So that’s great. It was good.

[Jaz] Two months worth of content right there.

[Alan] It kind of is. Yeah. Like it’s every podcaster that does this goes, Ooh, this is good. I gotta, I can put my feet up in a little while, but not that that ever really happens. But yeah. So that was good.

[Jaz] Highlight of the day, what was one thing that you learned today from speaking to a guest that you want to pass on to the people of Protrusive, who I’m hoping will also tune in to a Very Dental Podcast as well?

[Alan] It’s a good question.

[Jaz] What was my resounding thing?

[Alan] Well, I talked with a hygienist about prevention and how I think some dentists, a lot of dentists have kind of given up on prevention. And by saying that going, I think we’ve given up on a lot of people, maybe dentists care more than people do. Hygienists are more into prevention than dentists. It was an interesting conversation. I think. Maybe dentists put prevention off to the hygienist so we can do it. And when in reality it needs to be the whole team, it really does.

And that was a real, I talked to a couple of people about that. Honestly, that was one good thing. Also, I got to sit down with David Hornbrook, which I mean, I’ve podcasted with him before, but it’s so in person, he’s just the best. I could talk to him for hours. So yeah, it was very good.

[Jaz] Well, we look forward to checking that one out. It’s just great to see you in the person. Really good to see you, it was really cool. But hopefully not the last time.

[Alan] How have you liked this meeting? Is this your first midwinter?

[Jaz] Yeah. The first midwinter. I mean, the main reason I came was for AES. Frank Spear, John Kois, Gunson.

[Alan] So they didn’t speak together. They spoke at the same meeting. How about that?

[Jaz] I know. I know. We never thought it would happen. But me and Mahmoud thought if we don’t come this year. With that lineup. So hoping to encourage lots of younger blood all around the world. To consider coming to meetings like that basically, is AES one that you ever been to?

[Alan] Man, I’ve been AES adjacent for a long time. I should probably go. Cause I know, I mean, I know a lot of the Spear guys that go there and I mean, Jason, the new president is, I’ve been friends with him since dental for 20 years.

[Jaz] He seems like a really cool guy, and so we’re excited he’s the new president.

[Alan] He’s a good leader. He’ll be great.

[Jaz] Do you know what he did for his acceptance speech?

[Alan] I don’t. I don’t. What is it?

[Jaz] It was a rap. It was a rap. He basically rapped for five minutes.

[Alan] Of course, of course he did. I’m not surprised by that at all.

[Jaz] So hopefully, again, I’ll come again next year for AES, but it was nice to experience Midwinter. It’s much, just like everything in America, it’s much bigger than everything we have in the UK. Yeah.

[Alan] Well, and the weather has been pretty mild considering. Midwinter is one of those things where it could be 70 and sunny or 20 below. So you hit a pretty good time, I think.

[Jaz] Yeah. Very lucky. John Kois, Frank Spear, the weather. And then now we got to meet you as well.

[Alan] Nice to meet you.

[Jaz] Thank you so much. Thank you. Okay, guys, we’ve just arrived at Heathrow from a fantastic trip. I’ve lost my voice still, major jet lag once again. But just want to sign off with a couple of things. Firstly about John Kois’s lecture. We didn’t get to reflect on that because I posted on Instagram about the death of articulators.

I was at the WIPMIC stand at the Chicago Midwinter. I posted a story and you guys were like, whoa, what the hell? Like, what’s going on? Our articulator is really dead. And I don’t care the fact that I’m in a tunnel and you can’t see me. You guys can hear me, right? So that’s the most important thing.

Our articulator is dead. Then I also want to just sign off by just the experience that we’ve had in Chicago. So firstly, Mahmoud, you were paying more attention in that lecture than I was. This is your bag, right? Like I was mesmerized by John Kois. But as soon as they were talking about all the mud jaw and the face scanning, I’ll apply this Monday morning because you love your articulator.

You stroke your articulator to bed. So for you, this was like a big deal. So, what were the main summaries or takeaways from that lesson that led me to say on Instagram? This could be, I mean, as John Kois says, the days of the articulator are numbered.

[Mahmoud] So, I mean, hi everybody, so we’ve just got off of like an hour of flight, so excuse me if I’m a little bit incoherent, but I would like to, first of all, say that I slightly disagree with John Kois, which is a big statement for me, because I still think analogue will always, at least for me, have a slight advantage, and that is the feel. Now, once, some of you may have heard me.

[Jaz] I told you guys he strokes his articulator.

[Mahmoud] I do. So, we can talk about that another time. However, what they were talking about essentially with digital, right? We can all scan arches, right? You can get the arches scanned and digitized and then you can put them into a digital articulator on whatever software you want.

The problem’s always been how do you orient or orientate the arches on the articulator so they best represent how they are in the patient.

[Jaz] Essentially the problem just for the younger colleagues is how can we replicate the patient and their movements, whichever way we do it, whether it’s traditional or digital, how can we make the patient’s head on a plate?

[Mahmoud] When you do an analog, a facebow is a good way to do it, right? It relates to the upper arch to the condyles. But the problem is there was no digital facebow. Getting the digital scans onto the digital articulator usually is just random, but then some people started using photographs, right? You take a digital photograph, make sure you can see the entire so approach where they’re, you know, use retractors or not.

And then you rely on the technician’s ability to orientate a 3d digital scan using a 2d photo and trying to get AP position, the anterior position, anterior posterior position, the lateral, line everything up. So the beautiful, the beautiful thing was that the Kois group, they did a lot of research and they compared using a photo versus using a 3D face scan.

And what they found was overall using the face scan was more accurate, although it depended a lot on the quality of your scan. So if you had a crappy face scanner, you’re going to get crappy results at a good face scanner. You’ll get better results than using just a photo and the results could vary in terms of error between like half a millimeter to up to six millimeters, which is insane. But obviously what she kept on sort of getting back to is the gold standard seems to be the the jaw trackers. The jaw trackers are going to be the gold standard like the MODJAW and there’s a few other ones out there and competition will always breed better results and bring the hopefully the prices down eventually for people like us to be able to use them.

However,

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Managing black triangles with composite resin – often these are periodontal patients. Doesn’t that mean you’ll be bonding to root dentine?!

Continuing our Adhesive Month series in to March (oops!), we’re excited to bring you Part Two of our journey into the Bioclear Adhesive Philosophy. Building on the rich discussion from Part One (PDP 178), we’re joined once again by Dr. David Carroll and Diana McKenna as we shift our attention to anterior restorations. We focus specifically on the intricacies and challenges of closing black triangles.

https://youtu.be/AFlhZXTm32wWatch PDP179 on YoutubeProtrusive Dental Pearl: Protect the unrestored teeth and restorations from air particle abrasion! Using a soft steel matrix strip, similar but softer than a matrix band, protects the adjacent tooth’s enamel when air abrading the tooth.

Example one I found on the market: Polydentia soft matrix strip (no financial interest)

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

1:33 Dental Pearl – Protect from Air Abrasion
04:19 Ceramic vs Composite Debate
11:17 Informed Decision Between Ceramic and Resin
19:22 Bonding to Root Dentine
22:33 Anterior Restoration Protocol – Heated Composite
29:57 BT Matrix System of Choice
34:35 Guidelines for Anterior Bioclear Composites
39:55 The Importance of Proper Set-up
41:46 Learn more from David and Diana

Take advantage of our upcoming Documentation Month this March!

If you want CPD or CE credits from this episode, just take the quiz. For premium app users, scroll down to download the notes. You’ll also get access to our special content like ‘Verti Preps for Plonkers’, Sectioning School, over 30 rubber dam videos, webinar replays, and clinical videos on various dental procedures. All these are available with our Ultimate Education Plan.

If you liked this episode, you will also like PDP178 – The Bioclear Philosophy of Adhesive Dentistry – Part 1 (Posterior)

Click below for full episode transcript:Jaz's Introduction: Hello Protruserati, I'm Jaz Gulati and welcome to PDP 179. Now I know we are well into March at the time of publishing and we're still stuck on adhesive month, which was February. March is supposed to be documentation month, but don't worry. I've got some cool stuff coming to catch up in March, including what software I'm using at the moment to write my notes for me.Jaz’s Introduction:
I know it sounds crazy. I have two, I have two dreams in my life. One is to never have to wash dishes ever again. And no, I don’t have a dishwasher. My kitchen is not big enough at the moment. And number two is to never have to write my notes again. So, you know, dishwasher can wait, but number two is actually almost happening.

And I’ve been on this crazy journey to discover the best software or the best way. So as part of documentation month, I’ll make it up to you by the end of this month to reveal which softwares I’ve tried and tested and which one I’ve decided was the best. This episode, of course, is the part two following the discussion that we had on the Bioclare Adhesive Philosophy.

Like, I don’t want this two part episode to be about the Matrix. Like, the Matrix is awesome. Like, we know that Bioclare matrices, they do very well, but I’m not here to shine a light on, on just the Matrix. I’m here to shine light on a philosophy like sometimes when we’re closing black triangles the nature of the beast is that we’re now bonding composite to root dentine that’s the kind of stuff i want to uncover that’s the geeky kind of stuff i want to discuss with dr david carroll and diana mckenna who did such a great job in the part one if you haven’t listened to it already PDP 178 discussing the posterior Bioclear protocol on this one we’re shifting our focus to Anteriors, think black triangle closures for example. We’ll discuss the nuances of the Bioclear technique and understand a few more nuances about black triangle closures.

Dental Pearl:
Now, every PDP episode, I give you a Protrusive Dental Pearl, and I’ll be honest with you guys, I’m not the best in remembering exactly which pearls I’ve given. Now, like now we are on PDP 179 hereafter, which means I’ve given you 178 Pearls already.

And you know what? Maybe I might have repeated myself once or twice. So let’s go with this one. It’s relevant to adhesive dentistry, and even if it is a repeat, I think it’s well worth it. Right. So air abrasion, you know I’m a fan of air abrasion and I’ve got a really cool episode all about air particle abrasion coming up with someone who’s on a PhD on this topic, basically.

So those of us who crave the geeky details about air particle abrasion. Should you use 27 microns or 50 microns? Blah, blah, blah. We’re going to cover that soon. Now, as we covered already in the previous episode, one of the reasons we use air particle abrasion is to really remove the biofilm, really effectively remove biofilm so that you can get bonding to the actual substrate that you want to bond to.

If you are bonding to biofilm, if you’re bonding to plaque, you’re going to get stain and you’re going to get early bond failure. Now imagine you’re doing a class 3 restoration, let’s say it’s a upper lateral incisor and you want to air abrade that mesial cavity. The issue is with most air abrasion units, you’re going to get it everywhere and you might even abrade the central incisor distal by accident.

The problem with air abrading that surface is that you make it rough and then you make it prone to staining. And that’s not cool. So what can we do at the time of air abrasion to prevent this? Well, I like to use this soft, really dead soft metal band. It’s kind of like a matrix band, but it’s like way softer.

It’s called Conform. And honestly, I don’t even know where to buy it from. By the time this gets published, I’ll put some links out there in terms of where you could buy this from or alternative materials that you could buy. But you don’t want to use a matrix band because matrix bands can be expensive and you want to use it for this purpose.

And also matrix bands can be, it can be thick and rigid, whereas you want something really soft, but you still want it to be metal. You don’t want to use PTFE. because when you air abrade PTFE, it perforates. So, by using this dead, soft metal band called Conform, I am able to now shield that central incisor against the effects of the air abrasion, and therefore, I air abrade the area that I want to air abrade, i. e. the lateral incisor mesial cavity, and I don’t damage the enamel surface of that central in this example.

And then we don’t get the disadvantage of the staining. Yes. I know it’s one more thing in your protocol, but I feel good about it. I feel good when I protect your adjacent teeth. Like I remember just being a little bit gung ho with it and seeing staining sometime later and thinking, hmm, I could have done something to prevent this.

And so I feel better when I’m using some sort of a metal barrier to protect the areas I don’t want to air abrade. Hope you enjoyed that Pearl. If you’re listening on Spotify or Apple, please don’t forget to rate the podcast. It means a lot to me. And if you’re watching on YouTube, hit that like button, hit subscribe.

This is how Protrusive grows and I’m able to make these cool episodes. So thanks so much. And let’s join the main episode.

Main Episode:
So it was very refreshing to see that. And I hope I have not offended everyone. It’s just a perception that we have across the pond that if you’re going to need a filling, we don’t believe in filling, let’s just crown it. Okay. That’s the kind of an in joke that we have in the world about the Americans, but I know that’s all changing.

Listen, I know that’s all changing. And so I hope that offended no one. I come from a place of respect. So tell me about your shift as a prosthodontist. And, you know, the whole term prosthodontist, impressions, making impressions, the lab work, seating with ears and stuff. What did it feel like to you shifting a lot of your work to, towards composite and away from ceramic?

[David]
Yeah. You know, Jaz, when I first started becoming involved with BioClear, they nicknamed me because I’m a prosthodontist. They nicknamed me the enamel assassin. Okay. And that was my nickname. And let me tell you, if you’re going to hang out with David Clark, you have to have a very thick skin.

[Jaz]
Because he’s a mad scientist kind of guy. I just love it. I’ve seen him. He’s just a funny, mad scientist, quirky, just legend.

[David]
Oh, he is. He is. So I’ve been called a lot of things. And so at our last summit, I retained the title of enamel assassin and Marco became the cost killer. So he, cause Marco gave a presentation and he said, I’m going, I’m the cost killer.

I’m the killer of the cost. So because he was basically showing his presentation where he’s overlaying everything to, to get everything into compression, you know, so yeah, so it was, it’s a, it’s a big shift, you know, getting away from prepping and stuff like that, but, you know BioClear is very patient driven, so patients get very educated today.

So we have patients that drive from hours and hours. We just finished a full mouth rehab, all direct, and I’ll tell you, Jaz, the American College of Prosthodontists, they would take me out back and they would find a tall tree and a short piece of rope, and they would haul me from that tree, just to tell you what we were doing on this lady, I mean, open vertical dimension, I opened her twice, okay, opened her three millimeters on a lower arch and another three on an upper arch, And entire full mouth, no articulator, no diagnostic wax up.

It’s insane. It’s insane, okay? And I hope that I don’t do too many cases like that because it goes against everything in my prosthodontic background. However, you know, this lady was, that’s it. She was determined that she was going to find somebody who was going to rehab her mouth without cutting down her teeth further.

And without prepping her teeth and, you know, so, the reality is we have to look at emphasis on different teeth. Okay, so if you have a large molar, that’s a heavy tooth, a big heavy molar. If you want to do a crown on that tooth because it’s got an MOD and a buccal cusp cracks off, I don’t have any problem with that at all. Now, I know David Clark may not like that recording, but I’m telling you from, this is from me, right?

[Jaz]
It’s just your reputation of enamel assassin just gets maintained. The next conference is fine.

[David]
Exactly. I’ve got to maintain that, right? I have no problem going full coverage on that tooth because first of all, it’s a big heavy tooth. You can still way away from the pulp. Alright, you’ve got plenty of tooth to work with, and if you put a good crown on that tooth, it’s going to last many, many, many, many years, okay? On a second molar, we still try to do gold crowns, because if the patient will accept a full gold crown on a second molar, I will go for that every single time, because that is the, one of the finest restorations in dentistry and I’m looking at my dad’s gold crowns that are 40 years old, okay?

50 years old, okay? You’re not going to see too many things in dentistry that are going to go that long, alright? So that’s the, that’s the pinnacle restoration. But when you get to anterior teeth, let’s look at maxillary first bicuspid with that furcation and the mesial and all that stuff like that. You cut that tooth for a full crown, a traditional crown, on somebody that’s had a little bit of bone loss, some recession in the root exposure.

And before you know it, you have this little figure eight thing that looks sort of like a tiny little, you know, and the lower anteriors are worse or they’re worse. They’re the worst. So when you get to the lower anterior part of the mouth, I honestly feel like at this point, if you have a lower anterior case, black triangles on a patient with lower anteriors, honestly, I think the BioClear method at this point is basically becoming like standard of care.

Because to take a burr and just start cutting those teeth for ceramics. I won’t do it. I will present the options. We have a video we present to patients, but I won’t do it. My dad taught me a long time ago, do not let your patients dictate your treatment plans. Okay? That’s words of wisdom from a guy who’s been down the road and been down the bumpy road many, many times.

And so, we inform the patient, it’s today’s a different world. My dad used to go in there and just start prepping teeth. You know, there was no discussion about A, B, C. He just go treatment plan number one. Your whole, you know, your full mouth reconstruction is going to be 30, 000. Go pay at the front. Boom, boom, boom.

Start cutting, cutting, cutting, cutting, cutting, cutting. Today’s a different world. It’s a different world. I think you could get in trouble for practicing like that today. I really do. Because I think if that patient leaves your office and goes and finds out that, Hey, I didn’t have to cut these teeth for crowns.

There was another method and this doctor did not inform me of that method. I think you’re opening yourself up So I think for that reason alone if people want to learn BioClear only to do black triangle closure. I have no problem with that at all. Go to learn just that just learn how to take care of lower anterior teeth without cutting them all down. You’ll be so happy you did you’re going to have patients driving from all over to see you, to find you and find you because we know we love doing adult ortho.

I know you love doing ortho I love doing some ortho too. I’m a little lazier than you so I probably do a little less ortho But, but, you know, when we do the adult ortho, I would hear I was fixing all these black triangles for patients. And, you know, I did an ortho case and I forgot to tell my patient that they could end up with black triangles. You know how stupid I felt, Jaz?

[Jaz]
Happens to us all.

[David]
Right? I thought to myself, Oh my God, what in the world? I mean, I have people driving hours to come see me and for some reason I thought I could do ortho without making black triangles. I mean, what is, you know, and I had to explain to the patient. After the fact, you know, I’m sorry, we’re going to have to do another procedure.

And guess what Jaz, I had to do most of that for free because I couldn’t bring myself to tell them, you know, so I had, that was a giveaway black triangle closure.

[Jaz]
When I first got exposed to the BioClear anterior technique, it was for the magic of black triangles. I think that’s really when the initial. Videos I’ve seen and David Clark talking about it, you know, it was like, this is, this should be the standard of care, but I’ve seen that evolve so much now, obviously with posteriors, which we’ve discussed in depth now, but when it comes to resin veneers, or just generally that decision making process that you have, what percentage of the time are you opting for ceramic and what percentage of the time are you opting for resin?

Now obviously the matrix of choice is the Bioclear for you. What are the distinctive features that you’re sort of looking at to sort of sway yourself to one direction or to another basically? Essentially, what are the, also the shortcomings perhaps? At which point you think actually this is a tipping point that perhaps we should still go to ceramic and maybe is beyond something like BioClear or just resin in general.

[David]
Yeah. So we were talking about before, before this program started, I was asking Diana, what does she think is the biggest advantage of BioClear over ceramics? And then what is the biggest advantage that ceramics has over BioClear? Because remember we stay neutral.

We stay neutral and we are trying to educate the patient to make the best decision for themselves. We will guide them on the decision, but in a lot of cases you can go either way. A lot of cases can go either way. So we try to educate the patient. So Diana, what do you think is from your perspective as a hygienist and a dentist, what do you think is the biggest advantage that BioClear has overdoing porcelain.

[Diana]
I think the biggest or what I noticed is why patients come to us. When they come to us, they said, I don’t want my teeth prepped. I don’t want that my teeth being cut for the material. So I think the biggest advantage of BioClear, what I noticed is that, that we don’t have to prep their tooth. We do certain preparations, but never like a crown or So, I, in my opinion, is that and porcelain color stability, even though BioClear has great cosmetics, I think the color stability in porcelain is a bigger advantage than that.

And as a hygienist, something that I see, I love BioClear margins. The gingival margins when I clean that, because we like to feel the smooth, we like to feel that smooth when we clean. And with BioClear you cannot feel the margin. So it’s something that-

[Jaz]
It’s a very smooth emergence. So you, it’s undiscernible with the probe. I mean, I, I know what you mean, or-

[Diana]
Right, like when you clean, you cannot feel that, like the margin, the difference between the tooth. And the restoration.

[Jaz]
Infinity blend. I don’t know if that’s an official term you guys use, but it’s a, it’s a, it’s a good way to describe it.

[Diana]
Infinity margin, right?

[David]
Yeah. The infinity margin. Yeah. It’s, yeah. When you get it right and you do it right and you nail the result, we don’t even know where it’s at. So that part, that’s a big advantage of, of BioClear is that infinity margin. And another thing we would distinguish between color stability at, on a patient who has stable gingival levels and patients who have unstable gingival levels.

So in other words, let’s say you have a patient that’s prone to recession and you see all their teeth, they have recession, recession, recession. I would prefer BioClear on that patient because that tissue is going to keep moving. More the likely. All right, and then so the color, the porcelain itself has wonderful color stability in the veneer itself.

However, that margin is going to become more and more exposed over time. And that margin there does not have very good color stability. It tends to pick up stain. And you see patients coming in with 20 year old veneers, you can see every margin, you know, every single one. And it’s hard to refinish that margin.

It’s a little, you know, you can try to do certain things, but that glass is unforgiving to try to get in there and try to polish that and try to make it blend. Where with BioClear, you can really go back and re, we had one of our cases was our oldest black triangle case is about eight years old now.

And she was just in a week or two ago. And I felt around and I felt like in the mid facial areas a little bit of overhang and I was able to go in there and just spend like, you know, 20 minutes and I just kind of refine, refine, refine, refine. And now I like it much better. Okay. Now, and her case is already like eight years old.

So she’s going to go and trust me, Jaz, I was awful when I did that case. I was so bad. Okay. I was sweating and sweating. You want to see a process on a sweat, right? So, you know, what’s funny is here I am trained my whole career cutting full arches, right? I’m in there cutting, cutting, cutting, cutting, right?

And I’m humming along buzzing enamel off, right? But for some reason that first black triangle case where I cut nothing, I was sweating. I was sweating. I mean I was just dying, right? I’m dying in there and the matrices were not as good as they are now, so the matrices were kind of floating a little, you know, and I’m kind of pushing them back down.

And by the way, Jaz, I had no experience with rubber dams, but Diana has been the goddess of the rubber dam because prosthodontists are allergic to all latex, including rubber dams. Okay. So, you know, so she was like, I was just telling her, go in there and do the rubber dam, call me when you’re done. Right.

So, you know, and just the little intricacies of all that stuff. So there was, so it’s a testament to the method, the fact that my first case, which I wasn’t good at, it’s still there. You know, does it look perfect on the x ray? No, it’s not perfect. But here’s another thing that’s interesting, Jaz. You do crowns, right, on teeth, especially small teeth, since we’re talking about anterior teeth.

You do crowns, let’s say you crown a maxillary lateral incisor. And you cut away 60%, 70 percent of the volume of that tooth in order to do a traditional crown, right? Now you take an x ray and it’s got an open margin. You know, you see a little opening, a little gap there, you know? You have to cut that crown off.

There is no options because the bacteria has a direct pathway into the dentin that the patient cannot do anything about that. Okay. Now on BioClear, the composite, I don’t want to tell anybody that they can be sloppy because we’re not sloppy. You have a chance to come back and correct it. You can correct it.

You can fix it. Okay. And the body, you have not cut the tooth. So even though you might have a little ledge or a little overhang or something like that, the bacteria does not have a direct path to the pole. Okay. And you have time, you have time, you could, a patient can go home and they can come back two weeks later and you say, you know, I’m going to just rework this a little bit. You can’t do that with Crown and Bridge.

[Jaz]
It’s a bit more forgiving with composite in general and that’s why it’s a beautiful material. A really great saying, Dr. James Baker in the UK, he said composite is a bit like being married to a supermodel. You sometimes forget how good looking they can be. I just love that saying, I heard him say it once and I thought, this is amazing.

And so you’ve got these other advantages as well, obviously with compositing, like, like you mentioned, so, so it seems really great that we have such a great versatile material. It’s like, you know, it’s changed the game in density in the last 20 years, how much we’re doing in resin. Just describe any, obviously, in the, in the, this will be a two part episode, as in the previous one, you talked about posterior protocol, anteriors where we have more enamel, we mentioned that you will be using the technique whereby once you’ve done the cleaning, which is still important, you know, the, the bioblasting, getting a nice clean surface, the matrix selection, which I’m going to ask you some tips for, once you’ve got that all secured, and you’re doing the bond, and you’re rubbing it in, massaging it in, but you’re not curing, because it’s the whole injection molding protocol.

You’re going to go with the flowable, you’re going to go with the heated paste, and I’ll ask you shortly which is what, why that’s different, which type of paste you would prefer anteriorly, I’ll ask you that shortly. But once you do all that, I’m just thinking about that scenario you mentioned about the recession, right?

Are we concerned about bonding to the root dentine? And, and, and, and therefore, are you then treating that differently, basically? So this is a higher level question, it’s a geekier question, I guess. But, but how can we get a higher level of stability in those less forgiving areas? Which I, I, I totally agree that if you put a veneer margin there, then you’re equally as screwed, because there’s no enamel.

If you’re doing a veneer, you want, you know, you can get screwed there. But I guess just some top tips that I’m seeking. So I don’t know how you want to approach that crappy question. I didn’t apologize. Not my best question I’ve asked, but in terms of just the differences between posterior and anterior workflow, did I get it all right when I mentioned that? And then how do you feel about finishing on the root dentine, I guess?

[David]
Yeah. So that is a great question. And so I’ll usually discuss with the patient. I inform them. I tell them, you know, the bonding is not as good down on the root. And because you have black triangles because you lost bone around those teeth and then the gum tissue went down and followed the bone.

So now you have these, these open spaces that you don’t like the way they look. We get very predictable bond to all the enamel. However, we know that the bonding that goes to the cementum or dentine, we know that that is going to be compromised long term. You know, we know that we can get great in vitro results bonding to dentine in a lab.

But in, in the world, what we see, we see something else. We see that those interfaces don’t hold up as well, right? Now, the good thing that we have with the BioClear is that we are shrink wrapping on lower anteriors. We’re shrink wrapping the whole tooth. So, lower anteriors, because they’re such small teeth, We’re not doing one eighties, almost never, very rare.

Okay. Most of the time we’re going to shrink wrap that entire tooth. And now we have a cervical cuff where, when we light cure, the shrinkage of the composite, most composites shrink 2%, two and a half, something like that. That shrink is, it is actually in a way it’s, it’s even better. We’re like locking in on this, on this thing, strangle it, right.

It’s locking in on it, right. And now at least we have a continuous bulk of material that we haven’t layered. Completely ensconcing. That’s a David Clark word that I didn’t know. Ensconcing. Wow. What a word. The entire, what a word. Okay. Yeah. David uses a lot of words like that. We, I, I had a dictionary I was going to look up on my phone.

This is not a real word. He’s making this up. And then I would look up the word that he uses. And it is a word, and I think, I guess, I don’t know.

[Jaz]
Very intelligent man.

[David]
Very intelligent man. It’s my first and only.

It’s, it is a monoblock. Essentially, you’re making this beautiful monoblock, which is, which, which is why you get a, a, a strong restoration. And, and I know Marco and everyone talks about the, the strength. because of the fact that you’re not layering and you have them on a block, that gives you added strength and less risk of chipping at the contact areas posteriorly, for example.

Correct. And maybe we give up 20 percent on the cosmetics, but we gain, we gain a lot of strength and we gain a lot of integrity to that restoration.

[Jaz]
So what’s your concept of choice anteriorly where, where aesthetics is more important. You’re in a posteriorly, you said you’re using the bulk fill paste. Is it a different protocol anteriorly? And then also I want to know. Because Protruserati starting to be thinking this all over the world. How many degrees Celsius, and Fahrenheit if you want, are we heating that composite to?

[David]
So the BioClear heater I think is set to 155, 153 or 155 Fahrenheit. So I don’t know what that is in Celsius.

[Jaz]
It is 68. 3 Celsius.

[David]
Okay, okay. So that’s the heater now and we get questions all the time. Can I use another heater? Can I don’t have a problem with other heaters as long as you can get what you want out of that heater. So, you know the bowl of water in the microwave and all that. I don’t know That’s, that’s stretching it a little bit, right?

[Jaz]
So, the old keeping the local anesthetic in your pockets as you walk around and when you need it, it’s already warm. Have you heard of that one?

[David]
Yeah, I didn’t know about that. I didn’t know about that.

[Jaz]
That’s a real thing. I’ve never done it. Never will, but all I know is that some dentists are very noisy when they’re walking up the stairs and now you know why.

[David]
Laughter Yeah, so, I think. The heating is critical that the heater be reliable, and the one thing I will say, the heaters from BioClear, they are expensive, however, they are very durable.

So, we have the original heater that we bought 8 years ago, we still are using that same heater. And, so, a question we get, which you bring up very good is when do we put the composite in the heater? When do we take it out of the heater? Do you know? So we leave the heaters on pretty much all day, but we only put the composite in about 8 or 10 minutes ahead of the procedure.

So when I’m giving anesthesia, Diana asked me, which composite do you want, right? And then we put it in the heater then the reason is, is I feel like if the heater is sitting in there, if the composites in the heater all day, all day, all day, I think it has a tendency is going to dry it out and it’s going to have a tendency to possibly dry it out now with Filtek, Filtek Supreme, one of the Filtek’s, which actually the one that I don’t use, that was the one that was tested and FDA approved in the United States for heating, multiple heatings, multiple, because 3M, in order to, for 3M to really back BioClear, they were very, very strict on the science. Okay, because it’s a huge, huge company, and they don’t like, you know, trouble.

[Jaz]
That’s very respectable.

[David]
Yeah, it’s very, yeah. So they went into the, they went for full FDA clearance on heating and, and multiple cycles of heating the composite, okay? So, what’s interesting is the composite that they went through, I don’t know if they ever went through it on the blue colored Filtek Supreme, the one with the blue label.

But they did it on the one with the pink label, which was like Filtek Universal or something like that. So the problem that I, I didn’t like Filtek Universal heated, it became too runny. So this is a key thing with dentists who are going to play with materials in the heaters. You need to know how the heating is going to affect the body composite.

Okay, we use all body shade. So if we’re using with Filtek Supreme, we might say, okay, A1 flow, A1B or A1 flow, B1B. Okay, so we’re going to go the flowable and the body composite, very compatible. They can be one shade off, but not more than that. Because if you try to get too fancy. You get a swirling effect of, you might get a little, like a little candy cane too.

[Jaz]
Streaky, yeah, yeah. I can imagine that.

[David]
Streaky looking tooth, right? I have some cases like that because I thought I was going to get real cute, and I was going to put, oh, I’ll put a little A3 in the gingival, and then I’ll, and then I’ll paint the A1. Yeah, you get a nice candy cane. Okay, that does. Don’t do that.

Don’t do that. Okay. So make sure they’re at least the same shade or maybe they can be one shade apart. That’s it. So we do a lot of Filtek Supreme on our routine restorations. However, being a Tif Qureshi fan, I found myself going to Venus and trying Venus because I know he had already vetted, he had already vetted Venus and you know, Tif has been the, my idol as far as record keeping, the way he documents his cases, six-year recall, nine year recall.

You know, and so, we’ll have cases where we mix BioClear and Edge Bonding. And so, we’ll do Venus, I used to do Venus Diamond, now I’ve kind of shifted over to Venus Pearl. So I’m using Venus Pearl in the anterior quite a bit.

[Jaz]
But a lot sTifer. I mean, you obviously, it sounds like you’d like the sTifer composite based on what you said about the previous comment about the Filtek. And I’m at the moment, I’m using Estelite and Estelite heated is very nice and soft. I quite like it, but having used a Venus before, yeah, I found it a bit sTifer when I’m doing heated composite technique to bond my lithium disilicate overlays and stuff. I found that perhaps that was too sTif, but maybe for, maybe because you got enough of the bond and the flowable in there, that for BioClear, you’re saying that it works well in your hands, right? And that’s one of the certified ones?

[David]
Yeah, well, I say Venus Pearl works good in the heater. I don’t think it’s certified, I don’t think it’s tested for multiple heating, so it’s not cleared as far as that, as far as FDA goes. But if you’re going to, Venus Diamond is too thick. Venus Diamond is nice on edge bonding if you like a heavy, heavy composite.

Yeah, and Venus Diamond is very strong and Venus Diamond appears to be quite color stable. But for Venus Diamond, you have to take time because that material is very heavy. And you have to take the time to really blend it and blend it and blend it. And it’s a little tougher on the polishing sequence. So BioClear has a polishing sequence which is really fast and furious and you and you get a luster real quick.

However, that polishing sequence is not as effective on Venus Diamond. On Venus Diamond, you have to kind of go with the Venus polishing, you know, their sequence, because it takes a little bit more time. Venus Pearl is more like Filtek Supreme. When it heats, it heats exactly like Filtek Supreme Universal.

Almost same consistency, same flow, which is what you want. When you’re going injection molding around anterior teeth, you don’t want it too thick and you don’t want it too thin. You want it just right. You know, you want it so that it’s heavy enough to push the flowable, but not so thick that it’s not traveling and needs to travel and conform.

It needs to conform inside that matrices. You know, yeah, venus diamond was just kind of heavy and kind of displacing the matrices too much-

[Jaz]
Which is one of the edge bonding scenarios, like you said.

[David]
Yeah, I like venus diamond for edge bonding. And although I have played around with the pearl now for edge bonding, and it’s actually nice as well.

It’s nice. And I’ve also done edge bonding with Filtek Supreme and Filtek Supreme handles good for edge bonding to not heated for the edge bonding. I don’t do the edge bonding heated. I do edge bonding, not heated. and injection molding heated. So the, basically, that’s a question I get. Which bonding do I do that’s not heated? Edge bonding.

[Jaz]
Got it.

[David]
Pretty much everything else I do is heated.

[Jaz]
Yeah, I’m very much the same. Final few questions as we’re going to wrap up is, when you’re doing your anterior cases, any tips on, I know with the upgrade in the system, it might become easier now, but before there was a bit of guesswork involved in terms of, okay, which matrix should I use in terms of the different colors, different curvatures that you have at the cervical, how has the system evolved to simplify the process so that when you’re selecting, you know, the distal central, you know exactly which one to go for. I see a really cool gauge that that is around. Tell us about when you’re picking the matrix itself.

[David]
Okay. So one of besides becoming an enamel assassin, I also have a reputation as being the lazy BioClear dentist. Okay. So I’m either assassinating enamel or being, or being lazy. So, I use black triangle matrices a lot.

They are a bit more expensive. But I use them for class threes, class four composites, and stuff like that. On the black triangle series of matrices, they have a kit. That comes large and small matrices, okay? And then the gauge tells you the curvature. And then literally there’s a thing in there like a cookbook, right?

So you can follow the cookbook. So what I would recommend for all your listeners is try to find an intro class where you are, okay? Because we teach remote intro class. And so we are online for about now, we call it an intro class, but it’s, you know, David Clark style, which is there’s no such thing as intro at David Clark.

You’re either in or you’re out. Right? So our intro class is about eight hours long on Zoom. And then BioClear mails you all the stuff and you follow along. Now, however, on your side of the pond. They can only mail it one way. So if you take our intro class from over where you are, you’re going to have to buy the heater and the instruments and stuff that goes with it.

And that’s going to be roughly about 2, 000 US in order to take that class. However, I will say I think it’s the best intro class there is. I can’t imagine an intro class like this. And even people that are happy with some of their composite, they always tell me, you know, I like my class two system, but I learned like three or four things that I’m going to start doing right away.

Because, you know, like I didn’t know about the diamond wedges. I didn’t know the diamond wedges came in two lengths because you could have short and long now for like big teeth. That’s, you know, I didn’t know how you use the disc to finish. I didn’t know this. So, because we’re doing, we’re demoing and they have all their hands on stuff.

So if you can get an intro class on your side, then by all means go for it. And there’s learning centers. You have a learning center in the UK. You have one in Sweden. You have Marco in Egypt, Abdul Rahman in Egypt. You have Marco in Italy. So you have a reason to take a vacation to Italy and try to go take, right?

Okay, you have a reason there and everyone wants to go to Italy anyway. So, right. Everyone wants to go. I want to go. I want to go. I’m going to go take Marco’s class for sure because I got to go to Italy.

[Jaz]
Come with us in June. Come with us in June. We’re doing Vertical 3. 0 in Sicily. You should come.

[David]
I should. I should. No, I really should. I’m going to talk, I should talk to Marco about that because I do want to take his course. So once you take the intro class, you have some hands on experience. Now you at least have a feel for it. Now what I would do is go on to YouTube and watch every black triangle video you can find on YouTube.

All right and order the black triangle kit. Okay, so the black triangle kit will come with the different sizes. It comes with the measuring gauge to measure the size of the triangles and all that kind of stuff. And then I want your listeners to follow about five criteria because I want them to slam dunk their first cases, all right?

I don’t want them to go astray, all right? And one of the keys is case selection. Just like you’re starting to learn ortho, you’re not taking the deep bite, you know? You’re not taking the, you know, the cross bites. You want to learn ortho one step at a time, right? So with BioClear, black triangles is not a bad way to start.

It’s not a bad way. You have to use rubber dam. You have to. This is one of the things that we learned. The infinity margin comes much easier with the rubber dam because the rubber dam is helping to form that seal around the matrices. The matrices goes into the gingival attachment. Okay. So it’s kind of tucking in there, but that rubber dam is acting like a gasket, like a turtleneck sweater around that matrices and keeping, keeping things stable.

Okay. Okay. Cool. So you have to use rubber dam. You have to bio blast the case. There’s no option there because you cannot clean between lower anterior teeth with a scaler and think that you’re going to be okay because you’re not going to be okay.

[Jaz]
How about in those tighter contacts? To, to use like an interproximal IPR kind of strip to remove some calculus or biofilm where even the sand might not reach. Is that, is that a part of the protocol?

[David]
100%. That’s part of the protocol. We do have to alter those contacts if they’re tight. So, first criteria I say, Jaz, is I want the teeth to have contacts. So, on your early cases, don’t try diastema closures on lower anteriors and things like that. Got it. Okay, there’s a way.

[Jaz]
So go for black triangle, but not for black triangle and diastemas, obviously, or just diastemas, basically, because it’s a there’s a lower hanging fruit in black triangles.

[David]
Correct. Correct. We’re going to go for the lower hanging fruit right away. So we’re going to have contacts on the teeth, alright? The teeth should have a decent color, alright? Don’t try to color shift too far. So if you have to bleach the teeth, bleach the teeth, but the teeth should have a nice color. Okay? Another thing is good tissue health. They can have black triangles, but we have learned that if the tissues look angry Don’t do bio clear.

[Jaz]
No, that’s a bloody mess waiting to happen.

[David]
Don’t do, don’t try it. Don’t do it. We had a couple cases. We thought you know, hey, we know what we’re doing. We’re good. We’re above all that. No, no, no don’t, don’t do it.

Okay. So what we see in our cases is that if the tissue health is good and you do bioclear, if anything, when you nail the results and the infinity edge looks beautiful on x ray, the tissues, if anything, look better. Maybe it’s an illusion because the papilla is filled in. Whatever it is, but it seems like the tissues even look better, and the patients say, I don’t get as much tartar as I used to, I don’t collect as much food in there, you know, I don’t have to kill myself with a water pick every night, and I have less sensitivity, and all the great things happen. When the tissues look angry, the opposite happens. When the tissues look angry and you do BioClear, the tissues get more angry.

[Jaz]
Mm hmm. Mm hmm.

[David]
They were unhappy before and now they’re really mad. Okay? The patient bleeds like crazy, so don’t do that. So, stable tissue health is good, or get the tissue health. Good. You know? If the tissue health looks bad, sometimes I just send them to the periodontist and I say, when the periodontist tells you that you’re okay to come back, you come back and I will do it, but right now I can’t do it, alright? And the patient knows that you’re not desperate for money, you’re not starving to death.

Right? Now, mentally stable patient, that’s hard to judge on a brand new patient, but you would like to try, for those who are learning this, try it on a patient of a record who has been in your practice for a while. Like Tif Qureshi says, he says, he gets more nervous on a new patient. Everyone wants new patients. He says he would rather work on an old patient because he knows them. And he knows their behavior. He’s a hundred percent correct. A thousand percent correct.

[Jaz]
He’s a lie. It’s all about the lifetime patient, which is why we, we love Tif so much. Absolutely.

[David]
Yeah. He’s a hundred percent correct. And by the way, if you’re, if your listeners haven’t learned from Tif Qureshi in the UK, you have, you have a BioClear Learning Center there and you have Tif Qureshi and ISA Ortho, and now you have you. And you have Jaz. You guys are getting spoiled over there. You guys are really getting spoiled.

[Jaz]
That’s crazy.

[David]
So don’t be lazy like me. You have to go after everything you have to go take a BioClear course and then go take an ISA Ortho and then take another BioClear and then take an ISA Ortho.

And trust me, you will never regret either one of those learning experiences because you’re going to grow and grow and grow and you’re going to grow faster and that’s going to lower your stress level. I tell people if you could learn 80 percent of what’s in David Clark’s head and 80 percent of what’s in Tif Qureshi’s head, you would be one of the best dentists in the world.

If you could just get 80%. Which I’m not sure you can, but if you can go, if that’s set your goal and say I’m going to get 80 percent of what David Clark has and I’m going to get 80 percent of what Tif Qureshi has. And sure, I’m going to go learn from John Kois and Frank Spear and, and all these other people, but I’m going to go after these, these people, right? And so let’s go back. I did, I digress.

[Jaz]
I loved it. That’s fine.

[David]
All right. Mentally stable patient, contacts are good, good tissue health, good color on the teeth and generally good alignment. So if the patient needs ortho, do the ortho because The BioClear matrices, the black triangle matrices, they don’t line up so good on teeth that are misaligned.

And that’s more advanced. If you’re going to handle teeth that are all crooked, then the matrices are not going to because what happens is these matrices have a nice area that they butt up against each other, and they kind of stabilize each other. We call it like matrices stabilization. And we like matrices that are stable.

I don’t like matrices that are swimming around. My, my criteria is I need to be able to go have a cup of coffee and come back and everything should be sitting right where I left it. That’s a stable matrices and that’s a stable patient. And we spend, Jaz, we will spend on a lower anterior case all morning. If we have four anterior teeth, we book all morning long. And sometimes on some patients, I have not even injected my first tooth. Until I’m two hours into it.

[Jaz]
There’s the preparation, the cleaning, the isolation. That’s the foundation, isn’t it, really? The actual injection molding from the videos I’ve seen is very seamless and the cutting back is quite rapid. I’ve seen that. But it’s the setup, the setting yourself up for success.

[David]
The setup. If you’re doing indirect cases, you’re setting up your technician, you’re trying to set up your technician for a slam dunk and you’re doing everything you can to make it as good as you can for the technician. When you’re doing direct cases, you’re setting yourself up and you have to take the time to set that case up.

So to win, it’s got to look like a winner before you inject your first tooth. And if it looks like a winner, it’s going to be a winner. If you’ve got a good feeling about it, it’s going to go the way you think. Mind you, the size of the triangles is not that critical that if it’s a big triangle, small triangle, that doesn’t make any much difference.

Okay, so just try to follow those five criteria of just trying to have a stable patient, stable periodontium. Okay, decent color, good contacts, and good alignment, and follow the cookbook and you’ll be, you’ll be okay. Good isolation, rubber dam is going to happen, you know.

[Jaz]
I wish Diana can clone herself and start doing rubber dam for, for all the doctors. You’re very lucky, David. You’re very spoiled. Okay. So that’s great. It’s been absolutely amazing. We’ve got a two part episode. I’m just so excited to share this with all the Protruserati. I think we’ve covered this is exactly what I wanted. I didn’t want to become too much about the product, I wanted to become about the science, the engineering, the philosophy, and I think we covered that.

But I also want to shed light on a fantastic product that does exist, that makes our life easier. And it’s a system, it’s a philosophy, and it’s about being exposed to everything wonderful that’s out there in dentistry and finding your own path. And this is where part of the path, part of what we did today was exactly that.

For those that would like to learn more from you guys, can you please tell you, obviously, I’m going to put in the show notes, the QR code and the link. I would love for everyone to follow you as well. Both of you but how, what’s the quickest and best way for them to, to reach out and find your stuff.

By the way, if you’re on Protrusive Guidance, David is on there. We’re on Protrusive Guidance. There’s a, we’ve got, we’ve invested a lot of time and money and energy into. Now creating the ability that you could actually DM me. You can DM David. You can DM anyone on there. And it’s so seamless. It’s way better than Facebook.

So join Protrusive Guidance, protrusive.app. Then go and message David and tell David what an epic job he did. And what your favorite part was about this episode. I would love for you guys to do that. So reach out to David on the DMs on protrusive guidance, but how can we reach out to you? How can we learn more from you?

[David]
So Diana, how did they find you for, or they’re definitely not asking me rubber damn tips. I can tell you that they’re definitely not asking me that question. So how did they find you?

[Diana]
I have my instagram account. That is rdhdianamckenna and always there. So I’m happy to answer any questions.

[David]
So Diana McKenna, how do you spell McKenna?

[Diana]
M C K E N N A Irish last name.

[Jaz]
I’ll put that, very nice, I’ll put that in the show notes as well so people can just click onto it.

[David]
Yeah, she doesn’t look Irish, but she’s got some Irish blood.

[Jaz]
How about you, David? How can we follow? I’ve seen your wonderful work before. How can we follow you? And then what’s the official website to learn more about training with you guys?

[David]
Anybody that wants to learn more in general about BioClear is bioclearmatrix. com, bioclearmatrix. com. And then that brings up the front page of the site. And then you can go to resources there and that’s how you can get in touch with, and it should be international. You should be able to find the learning centers in Sweden or UK, or you and I are going to go to Italy.

Go visit Marco. So, but if you want to reach me on Instagram, it’s carrolldentistry, C A R R O L L, two R’s, two L’s, caroldentistry, F L, like Florida. Yeah. Okay, because we’re here in Miami.

[Jaz]
What a wonderful life decision you made to, to, to live in Miami. you always think about, we don’t spend enough time in our lives deciding where you want to actually spend the rest of your life.

Where do you actually want to live? And I feel like if you’re someone who resides in Miami, you, you picked well, so amazing. It’s great to host you guys today. I had a lot of fun, lots of geeky discussions that were had, and I just really want to thank you for your time and enlightening us and sharing some, some really cool things.

And also making yourself vulnerable, talking about the things like failures and the tough cases you had, your first case. And sometimes when things didn’t go to plan. That’s what makes our community of dentists special. The fact that we’re not all perfect, we’re happy to have a little bit of a laugh, happy to learn from our failures, and happy to just expose ourselves a bit.

One thing, this is the first time I’m revealing this. One thing I’d like to do, family willing and, and stuff, we’ve got two young boys and stuff. I’d love to host a conference on where, where we have people just like you, David, just amazing dentists that we respect. Just do an hour each, just show your failures and what you learn.

It’s just, it’s, it’s, it’s, it’s no humble brag, just show all your cock ups. And that’s one thing that it will probably happen this year or next year. I would love for that to happen, basically.

[David]
Yeah, I would be honored, Jaz. And, and, and Diana and I are honored to be on this show. I’ve seen the quality of the clinicians that you interview all the time, and we are very honored to be here, and we would love to help the Protruserati any way we can.

[Jaz]
Amazing. Well, we’ll be sure to DM you what we learned and engage with you on the Protrusive Guidance. Thank you so much.

[David]
Thank you, Jaz.

Now, as you know, I’ve been recently giving you the CPD questions and I give you one as a teaser, but I’m actually really late because I need to go to work. And also I’ve got the flight tomorrow and I’ve got some family time to catch up with. So just to let you know, there is 45 minutes of CPD available from protrusive. app, aka Protrusive Guidance.

I just want to thank David and Diana again, but again, they’ll be back next week to finish off the part two, which we focus more. on anteriors, how do you bond to root dentine? Like if you’re closing black triangles, you’re going to be a root dentine, right? So that’s one of the themes that we cover.

As ever, I want to thank my team, Erika, Gian, Krissel, and Mari were involved in this one. And if there’s one action you take by the end of this episode, if you’re enjoying the last episode in this episode, and you enjoy and enjoy it adhesive month, please could you share it with a friend, I’d really appreciate if you could spread the word of Protrusive.

Thanks so much for listening all the way to the end. Once again, I’ll catch you same time, same place next week. Bye for now.

View Details

This episode aims to shine light NOT on the matrix itself, but the adhesive philosophy followed by those that use Bioclear matrices.

Everything you wanted to know about the Bioclear system (but never asked!)

As we continue to celebrate Adhesive Month (now spilling over into March!), we’re thrilled to bring you insights into the principles of cavity preparation and adhesion a la Bioclear.

In this first part of our series, we’ll uncover the ‘unconventional’ yet highly effective techniques employed by practitioners like Dr. David Carroll and his colleague, Diana McKenna. One of the key highlights we’ll explore is the Bioclear approach, which challenges traditional norms by utilizing a single large increment, diverging from the conventional use of small increments.

https://youtu.be/mn_FRhSIGCkWatch PDP178 on YoutubeProtrusive Dental Pearl: If there’s a disagreement between you and your principal or associate about practice philosophies, arrange a face-to-face meeting. Work together to find common ground and reach a win-win solution that benefits both parties and aligns with the practice’s goals. Effective communication is key, whether it’s with our patients or our colleagues.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:
0:00 Introduction
7:22 Journey into Bioclear
15:30 Bioclear Philosophy
19:19 Posterior Bioclear Matrices and Wedges
20:58 Clinical Protocol for PosteriorInjection Molding
25:08 Alternative Cleaning Methods
26:38 Advantages of Bioblaster Over Aluminum Oxide
28:14 Addressing Concerns about Shrinkage Stress
31:15 Technique for Deep Restorations
32:44 The Hip
33:29 Bonding Protocol
37:31 Posterior Composite Selection
39:56 Bulk Fill Composite Application
41:05 Posterior Overmolding and Tidying Up
43:33 Evolution of Dental Education and Bioclear
46:33 Stress-Reduced Direct Composite and Finding a Repeatable System
50:53 Outro

Struggling with rubber dam placement? Check out my Quick and Slick Rubber Dam series! It includes a one-hour walkthrough for isolating quadrants AND 30+ clinical videos showing procedures in full detail (POV). Access it on Ultimate Education Plan via Protrusive Guidance

If you loved this episode, make sure to check out PDP177 – Fast Modelling Composite Technique.

Click below for full episode transcript:Jaz's Introduction: So you might have come across the BioClear matrices. They've been kind of taken dentistry by storm over the last few years. I was first exposed to them maybe about, gosh, nine, ten years ago. And this mad scientist type figure came on the scene, Dr. David Clark. And I just loved his quirkiness, his humour and just the way his brain worked.Jaz’s Introduction:Now, fast forward some years, I used their anterior matrices for black triangle closure. I had some good success. And as an associate, I never got to purchase the posterior matrices, although I did do a hands on workshop and I was quite impressed. But today, this episode is not about any matrix system. It’s not a sponsored episode.

It is just to shine a light on some really important principles that we can learn from the bioclear philosophy. We’re just about still in adhesive month, it’s February, so we’re focusing on adhesive dentistry and maybe part two will fall into early March. Now in this part one we focus on posterior. What are the principles of cavity preparation and the BioClear approach?

I mean how do they do it with just one big increment, very different to the small increments that we’re used to using. In fact they’re very similar themes to the last episode we discussed with Dr. Ahmed Tadfi on the fast modeling composite technique. And so there are a few crossovers. So we’re really spoiling you this month with these really cool episodes about posterior bread and butter at adhesive dentistry, and it was great to host a Protruserati Dr. David Carroll and his colleague, Diana McKenna. Look, David has been a Protruserati for over a year. I used to love seeing his very kind comments on YouTube, and then he joined Protrusive Guidance and we’ve been DMing each other, just a great guy and I love his cases on social media. And it’s a privilege to host him as a BioClear instructor on our episode.

I’m gonna give you a little spoiler for later in the episode. Dr. David Caroll is very lucky, you see. He’s good at what he does, but sometimes with the rubber dam, he says, you know what, I’m not fussed for the rubber dam. So he’ll walk out and then Diana will do his complete isolation on the rubber dam for him.

We all need a Diana in our lives. Now if you are someone who aspires to do your own rubber dam isolation, I’m just kidding with you David obviously, but seriously if you’re struggling with rubber dam, check out my quick and slick rubber dam series. It’s got a one hour complete walkthrough of how I isolate quadrants and then 30 plus clinical videos for anterior and posterior uncut, like the entire two minute, five minute, seven minute sequence of how I isolate these quadrants through my OxoCam point of view film.

It’s like a point of view that you see through my loops, and that’s included in the Ultimate Education Plan of protrusive. The website for that is protrusive.App and the platform is called Protrusive Guidance.

Hello Protruserati. I’m Jaz Gulati and welcome back. It’s your favorite dental podcast. I’m actually super excited tomorrow I’m flying to Chicago for the AES, American Equilibration Society for most favorite things, occlusion, TMD, and of course I’ll be there for the midwinter as well. Obviously, by time this comes out, this message would’ve not reached you, so I’m hoping I’ll be able to meet some of the Protruserati in Chicago.

Protrusive Dental Pearl
The Protrusive Dental Pearl I have for you for this episode is a non-clinical one. You see, one of the Protruserati reached out to me and asked if I would anonymously post on Protrusive Guidance. Now, the whole Anon posting on Facebook is a bit too much, but I’m hoping to breed a culture in Protrusive Guidance whereby we can share our failures and challenges and not having to feel like we go Anon.

However, there are some sensitive issues that we discuss sometimes that I feel is the reason why Anonymous was actually designed in the first place. So I was happy to do this particular Anon post. It was about a Protruserati having some friction as an associate with their principal. And I don’t want to delve too many details away.

I don’t want to give any identities away. But sometimes, I mean, the lesson here is sometimes we don’t fully see eye to eye with our principal. Now, whether the issue is about how much annual leave you get or how the rota system is working for your nurses or DAs, it could be so many things that you have some sort of a friction over.

But the Protrusive Pearl here is dialogue. Always, always, always be willing to engage in dialogue. I think there’s so much behind the scenes where people are grumbling and they’re getting upset and they’re exchanging emails and Whatsapps and voice notes and stuff maybe. But what we really need is face to face dialogue.

There’s a magic and beauty of face to face. So if you’re in a situation where you’re not really seeing eye to eye with your principal, I would. And if you’re a principal, if you think your associates really not following the philosophies of your practice, you both need to arrange a face to face meeting and try to seek a win win.

There is always a win win. If you can’t find a win win, you’re not searching hard enough. So I’m hoping just by this gentle reminder of the importance of dialogue and face to face interaction that may help some relationships between principals and associates out there. Thank you so much and let’s join the main episode.

Main Episode:
Dr. David Carroll and Diana McKenna, thank you so much for joining us on today’s podcast on BioClear. How are you guys?

[David]
We’re doing great, Jaz.

[Diana]
Good, excited.

[Jaz]
It’s so nice to have you and for those who are listening on Spotify and Apple, there’s a giant fish behind you guys. All right. So this obviously is a reflective of David. Can I call you David?

[David]
Absolutely.

[Jaz]
David’s passion for fishing, which I recently discovered as you joined Protrusive Guidance and then I read your bio, second generation dentist, prosthodontist. And I just have to say, when I see people like you. People I look at like, wow, this guy’s a specialist and I see your cases, stuff like, how did he end up in the, the Protrusiveverse?

It is absolutely so humbling to find clinicians like you, who I just admire and you’re so brilliant, to come and just listen and learn and be open to hearing new ideas. And I’ve been seeing, you’ve been commenting on the YouTube channel for the last six months. You’ve been so supportive.

You’ve been sending lovely things on Instagram to our team. Just thank you so much. It really does a lot for our enthusiasm, our confidence as a small, but mighty team producing content. So thanks for supporting young dentists. I just really want to just get that out of my system now.

[David]
Well, Jaz, I think your educational channel that you’ve built is so awesome and so needed in dentistry. And when I started in dentistry, the only way that we could really learn is we had to go to meetings. We would have to travel. We would have to book airplane tickets and hotel and everything. It was really expensive to learn from clinicians that were much further ahead than we were. And we all wanted to go hear our mentors and the people that we looked up to and the people that we knew were much further ahead than we were.

And it was just so taxing. You had to take time out of the practice. My dad, I’m a second generation dentist. So my dad and I would travel together and we would go to these meetings and see these things. And but today thanks to your platform and the content that you’re bringing is so valuable.

And I really think that it’s a, just a great service. So I’m learning from you and I’m learning a lot from you. I need, there’s no doubt in my mind way more about occlusion and TMJ than I do. No doubt. I’m totally iron billet ball.

[Jaz]
You’re very sweet.

[David]
And I’m going to take your, I’ll absolutely going to take your every course that you put out, but I love all the people that you interview and here we’re on this side of the Atlantic, so I’m not so familiar with some of your mentors over there, so I’m learning the talented people over on that side. I mean, we have one person in common that one of my mentors is Tif Qureshi, all right, and totally he’s one of my biggest mentors. But other than Tif, I wasn’t too familiar with all the names and people that you’ve interviewed. So I’m learning from you guys all the time.

[Jaz]
Well, what I love doing is bringing Protruserati on the show, right? People who just embody the values of Protrusive, which is the nicest and geekiest. And I just, I definitely see that in you. I want to learn a bit more about Diana as well and how you guys work together. Before we delve into that about BioClear stuff, that’s going to come later. But I always like to spend just a couple minutes to explore an individual’s journey. So in the context of everything you do or the smile makeovers, I see that you post on Instagram David.

How did you get into the BioClear? How did you get into this pathway? And maybe a little bit before then, why prosthodontist is this something that maybe your dad inspired you? Or how did you fall into this?

[David]
So, my dad and I were both doing a lot of ceramic rehabs. And so, I became a prosthodontist because I knew my dad was doing a lot of that type of work. And so, I wanted to come in knowing a little bit more than average, and I didn’t want to become just a clone of my father. I wanted to become my own individual. And I also didn’t, at the time I took prosth training, there was no implant training in undergrad level, and we didn’t even touch an implant as a dental student.

So the grad prosth program had, everyone was touching all the implants. So I went up there to learn implant dentistry. So when I came in with my dad, we were doing a lot of ceramic rehabs, and one day my dad says, Meena, he says, you got to figure out something to do with these lower anterior teeth, because when they’re a little crowded and things don’t work out well, he says, the ceramics is really not a good modality.

He says, it’s just, it’s not right. He says, so why don’t you learn to straighten out the teeth? So I went in and started going into ortho and I started, that’s how I found Tif. Tif was in the United States teaching a course over here and I learned from him and then I started doing Inman Aligner, which you may be familiar with, right?

And I started straightening teeth. And then, of course, we started to end up cases with black triangles, right? And we get them straight, but now they’ve got black triangles. So I started researching black triangle and I come across David Clark. I see him in Orlando. I watch him do a case live in front of like 70 dentists and nothing is working right as you can imagine, Jaz, he’s going to go live and do a clinical case, right?

And we’re in a hotel. He’s got a crappy little compressor that’s not generating enough power. The suction system is not right. Everything is off. Right. And and at the same time he’s speaking and lecturing and I’m thinking this guy is crazy. There’s something not right. And at the end, he actually got a very respectable clinical result in that circumstance.

And I was just like, wow, I was blown away. And without cutting the teeth, everything turned out pretty good. And I said, this is a game changer and you don’t see a lot of game changers in dentistry. I’ve been out of prosth for 30 years, and it’s something comes along like implants, that’s a game changer.

Clear aligner ortho, that’s a game changer. BioClear is a game changer, and you just don’t get a lot of those. So when they come along when you’re a young dentist, you see something like that, you need to jump on it. Full steam ahead. Don’t think about it. Just go and learn and try. And that’s what I did.

So I started taking trips out to Seattle, which is a long way from Miami. I started taking trips out there and learning and learning and and just back again, like Abdul Rahman. I know you have, I’ve saw him on one of your programs, same thing. Once you go out there, you realize, all right, there’s a lot of nuances to the technique.

There’s a lot of technique to it, a lot of little things. It’s not necessarily hard, but it’s very detailed. So I kept going and learning and learning and the method has evolved a lot since, since I started. The matrices are much better. The system’s much more refined. So it’s gotten better and better.

[Jaz]
It definitely has a luxury feel to it. And I’ve been using BioClear myself. Haven’t done so for a little while now, but I previously, I’ve still got the kind of older generation, new generations with the color tab and the gauge, very sophisticated, very clever. And I’m sure we’ll talk about that actually.

But what I like about what you said there is how under difficult circumstances, Dr. David Clark was able to produce a respectful result. And that’s what we need because when you have any technique, If it’s overly technique sensitive, and if it’s overly difficult to use, how can the average dentist, average hands, reproduce it?

And a lot of the listeners and watchers here are international. They’re in Bangladesh, they’re in Philippines, they’re in countries where perhaps they don’t have access to even the best light cures. I know there’s a research in India showing how poor quality light curing can be. And so in those tough scenarios, how can we help clinicians all over the world to get good results?

And that’s what it’s about. In fact, in England, other than I feel familiar with soccer or football, there’s a saying, can they do it on a cold Tuesday night in Stoke? So yes, this team is really good, but can they do it in these kinds of scenarios, basically? And that’s what it always reminds me of. So we’ll definitely unpack that. Diana McKenna, please tell us about how you have been working alongside David into sort of his programs.

[Diana]
Well, I started working for Dr. David about eight years ago. And I was pretty much assisting him. And I think he has started with this journey about 8 to 10 years. And it has been really great because we have seen how from the beginning, how the results were not the most amazing. Like we saw some like ledges here and there.

[Jaz]
I love how brutally honest you are. This is good. We need to hear it. This this is why I got you on today because I saw that you guys are about this. This is really good to hear.

[Diana]
It’s a, no, it’s because it’s very difficult, not very difficult, but people can, or dentists cannot think that they’re going to master this technique from the first case.

[Jaz]
Especially if they’re learning from Facebook or something, right? Because the temptation sometimes is to see some photo in a magazine. Or someone’s using BioClear, and then you go to your reputable supplier, you buy it, and then you start just making up and winging it. That’s not when you get the best results, I think, and I’m sure you’re going to cover that as well.

It’s a bit like when you read the papers, the scientific journals, and then you’re trying to extrapolate the data from the journals. But if you’re using the different materials that were used in the journal in a different way, and if you’re etching for the wrong number of seconds compared to what they did in that journal to get that result, you can’t expect to get the same result.

And I learned that as myself, actually, various tools, products, techniques, philosophies. And when I tried to wing it, it was some good results and some hiccups. But when I went on a course to actually learn, just like David said, the nuances, and then you come away with a, a real enlightened moment. So I think that’s exactly what you’re saying as well.

[Diana]
Yes, that’s correct. Like, you need one, you need experience. You need to keep trying. Because BioClear is a technique that, one, you need to go to the courses. Like, we have an intro course that we teach once a month, and it’s a great point to like, okay, the dentists can see, they can see the basics of the technique, but if they want to do more or they want to learn more, ideally they should go to the different learning centers.

And also practice. I think it’s a technique that you have to keep practicing. Because it’s a learning curve that you learn from your mistakes. You learn from what you’re doing. Like we have been learning. I don’t know, at the beginning we had problems with the light cure. So we learned that we needed a light cure that was stronger. So it’s a process, but it’s kind of fun. I think it has been a really fun journey for us.

[Jaz]
It looks very rewarding, and I mean, all of the cases that you post, and not only just black triangle closures, but all sorts of resin cases, and I think what we owe it now is what this episode is about is, I don’t want this episode to be about like, this is not like a sponsored episode about a product.

What I’d like to really tune into is the science and philosophy. Right? Because there are some, let’s say, some naysayers who think, hmm, but how could this work if that’s the case? And we need to address those concerns, but also we need to understand, okay, what are the philosophies? What are the quick wins that you can share?

So that when someone does after going on the course, for example, come on to their first case, what are the little things to remember to that you can actually improve? The success of that dentist. So the first question I’m going to start with is, can you just describe what actually is the method and and how I know there’s the anterior BioClear, there’s also posterior matrices. Can you just briefly describe what this entails?

[David]
Yeah. So BioClear is basically a form of injection molding dentistry. And basically you’re using anatomic matrices and anatomic forms to either surround part of the tooth. Or potentially surround the whole tooth and inside those forms, which are anatomic to wherever you’re at.

So if you’re on a distal of a central, there’s a matrices for that. If you’re doing class twos, there’s a matrices for that. And basically then you’re surrounding either a portion of that tooth. Or the whole tooth. So if it’s an anterior tooth, we might say it’s a 180 or it’s a 360. You either wrapped half of the tooth or you wrap the whole tooth.

And that’s a big designation between conventional bonding, let’s say traditional bonding and BioClear. So we say in BioClear, it doesn’t go in the tooth. It goes around the tooth or on the tooth and that’s changes. Then the sort of the dynamics of how you work with the material and trying to get away from the disadvantages of composite and turn them into advantages for us.

[Jaz]
Well just about that actually, I asked Dr Abdul Rahman as well actually, but I want to hear from you and your perspective and those who perhaps haven’t heard that because that one was more visual and did actually make it to the Spotify listeners so it’d be good to cover it now, is you say 180, 360 and I like that way of thinking, is there a scope?

Maybe there isn’t, I don’t think there is, but is there a scope to do 90 degrees? What I mean by that is, if you’re trying to close a diastema, can you do just the distal portion? Or do you really need to cover facially as well with the technique? What, when, how do you get the best results? Are there any disadvantages of doing just one side only or one proximal surface only?

[David]
Yeah, so you can definitely do the diastema closure by just doing half a tooth and half a tooth. However, over time, composite is going to change color different than the tooth. The tooth is going to change color also. And then the composite is going to change color. So the patient has to understand that that’s going to need to be replaced.

More often than if you were to cover the whole tooth, depending on their habits, whether they’re drink a lot of coffee, a lot of red wine, a lot of dark tea. That’s what we talked to them about and we have not been able to predict which patient is going to color shift more than some other patients.

Some patients we bring them back five, six, seven years later, there’s no change at all. We just see the material looks exactly the same. Other people, the color does migrate. So that’s something that’s one of in the list of advantages and disadvantages between ceramic and composite. We cover that with the patient. So that the patient understands when they’re choosing composite and choosing BioClear, that is one of the potential disadvantages, is that long term color stability.

[Jaz]
But really, by wrapping onto the labial and veneering the entire surface, you are helping to mitigate that risk, right? Because if you’ve got a nice smooth veneer layer and no transition mid facial between the composite and the tooth, I can now see why, when I have seen, Marco Maiolino, Abdul Rahman, yourself post these cases quite often going in the labial.

Initially I used to think, hmm, because you might have seen a video I made recently actually about my preference for after orthodontics. Respecting that beautiful enamel, but sometimes when you have got black triangles and you’re trying to close diastema using the via clear way, I understand why just a thin bit of composite to create that uniformity in the color.

It makes sense to me. If I was to shift my focus now to posteriors, and for those who aren’t familiar, these are these, you know, very beautifully curved anatomical matrices posteriorly that you can put in, you’ve got these, the diamond wedges of via clear are the best. I use them for when I’m doing a non via clear case. These are just. Fantastic wedges. Can you just say in your own words what makes the BioClear diamond wedges unique and special?

[David]
Well, the wedges are like the matrices, they’re anatomic, so you can select the wedge. There’s even one for the furcation and the molars, so that you can select a wedge with the furcation and either use that side or use the other side.

The other thing is that if you’re going to use anatomic matrices in the posterior, your wedge has to be very low profile. Because if the wedge comes up too high, now it’s starting to distort that matrices. And that’s one thing you always have to keep in mind with BioClear is that you’re not trying to do anything that will distort that matrices. Because it’s anatomic the way it is, but if you use something that crushes it or bends it, or inverts it, then you’re going to end up with not such a nice result.

[Jaz]
I mean, the superpower is the shape, isn’t it? The power is in the shape that it gives you. And just like you said, if you wedge too aggressively, you create a convexity into the matrix, and which would actually show up as a concavity in the restoration, right?

And that’s not going to be hygienic and stuff. So, but the wedges, when I’ve got a deep case, and most wedges in that scenario would actually not be able to get down low enough. The diamond wedge has been brilliant. So I just wanted to give that point for those who aren’t familiar, even just with the wedges, they’re absolutely fantastic, beautifully designed.

When you’re using the protocol for posterior, let’s say you’ve got the matrix in place. Let’s say you’ve got the wedge in there. Let’s say you’ve got the ring in there. And you’re happy that you’re going to get a nice profile. Can you just describe the clinical protocol in terms of the whole etching, bonding, curing? Just so we can understand what a typical injection molding looks like posteriorly. And then based on that, I want to just ask a few more questions on just technique, just geeky stuff.

[David]
Okay. Yeah. We love all that. We love all the geeky stuff, right? We can geek out all day. No problem there. Yeah. So the first thing is when you have to think when you are going to bioblast the tooth or clean that tooth.

And when does that come in? So my preference is to bioblast after I prep. So I will very commonly clean up the tooth first. And take the old restorative material out. I will do my anatomic changes to the shape of the prep because commonly we’re cutting out amalgam and the amalgam has parallel walls and a GV black design and composite should not go into that same shape.

Okay. That’s one of the key things engineering wise that Dr. Clark has taught us all is that composite bonding is not going to make up for bad engineering. You have to re-engineer that tooth. Okay. And we’ll talk about how you have to flare it out. You have to actually sacrifice some enamel so that you can get this tooth more into compression.

Okay. If you just stick composite into a GV black prep, it’s going to function like white amalgam. You’re not going to get cuspal splinting. You’re not going to get the benefits of the composite and you’re working against the material. Okay. You’re working against it. So we take the old material out, refine the shape.

Now we’re going to bioblast or clean the area. So I use the bioblaster from BioClear. Abdul Rahman is using a different device. And I’m not sure what Marco is using, but everyone is cleaning something with something like that. All right.

[Jaz]
So I remember just, I didn’t know the bioblaster existed firstly. So thanks for sharing. I didn’t know existed as a product. So that’s good to know. I remember David Plunk just proving a really good point. And then you would probably imagine as well that no matter how much he scaled the tooth, no matter how much pumice, et cetera, he used, there was always, when he disclosed, there was always plaque until you aerated, until you introduce air particle abrasion.

It was dirty. And that’s what causes the staining. That’s what causes the bond failures and all the issues with it that we have in at least dentistry is not having a clean enough surface. So the bioblast, is there anything unique? is it sand and water together?

[David]
It is with water and it’s aluminum trihydroxide, which is a little bit different than aluminum oxide. Aluminum oxide is a much harder particle and a smaller particle. So, it’s more for cutting. So, when you blast the inside, the intaglio, one of your favorite words, the intaglio surface of a zirconium crown, when you hit that with aluminum oxide, that’s, you’re really going at it with a hard sand and you’re really going at it to alter the surface, right?

So, that will cut a tooth and that will cut into a tooth pretty rapidly. So, instead we’re using a softer powder, which is a larger particle size and it’s designed to clean a tooth. Kind of like a Prophy-Jet and you disclose, you disclose it so you see everywhere the plaque is and now you blast all of that off because remember with BioClear, your margin is not really your traditional margin.

So your interface, what we call the tooth restorative interface, is going to end up on uncut enamel, enamel that you never cut with a bur. And if that enamel hasn’t been cleaned, plaque free, blast off the pellicle, and all that, you’re not going to get adhesion, and it’s going to stain, and it’s going to leak. So that’s where that protocol comes in, is to that sequence of events that you have to blast, you have to blast.

[Jaz]
Beautiful. Well, before you move on from after you cleaned it and aerated and blasted it, which I’m a big fan of, the top question I get, David, the number one question I get, guys, is, A dentist will email me and say, Jaz, I don’t have an aerobrasion unit.

Can I use the Prophy-Jet? Can I use those sort of cleaning powders? Will that be adequate? And I don’t know. I feel as though for what we’re trying to achieve, like especially on dentine, I don’t think it’ll be aggressive enough on dentine is my viewpoint. To remove biofilm, maybe you’ll be good enough on enamel.

But I don’t know if you guys got any science on this or any bioclear opinion on is the the Prophy-Jet kind of stuff, does it do anything?

[David]
Have you worked with a Prophy-Jet? No, so I haven’t worked with-

[Jaz]
Polishing powder rather than a slightly more bracer powder.

[David]
Correct. So what I tell my students that from all over every month is I tell them test it, disclose a tooth, take your Prophy-Jet and go after it and see if you can blast every bit of that disclosing solution off of that tooth. If you’re successful with that, I have a feeling you’re going to probably be okay. I mean, it’s definitely going to be much better than nothing. Absolutely. Much better.

[Jaz]
But it goes back to what I said earlier, to get the best results, you’ve got to follow the recipe book. And the recipe book says bioblast or air particle abrasion, and I’m a big believer in that.

So for all those dentists out there who are not using an abrasion moment, really save up. That’s the next big investment. You can use it for all sorts of dentistry, even for your zirconia, just like you mentioned. So amazing. So now bioblasted before we put the matrix on, which makes sense because I guess If you put the matrix on, you get like a matte surface of the matrix if you were to do it with it on.

[David]Yeah. And another point is that one of the reasons why we like the bioblaster as opposed to aluminum oxide is that when you use aluminum oxide, it’s a very, very fine particle. So you have to be careful how much of that you end up breathing and inhaling.

[Jaz]
Absolutely.

[David]
Right? So when we do the intaglio surface of zirconium, we are in a little vent, a laboratory thing, which we bought them from Danville Engineering. And they’re little, just sit in the operatory. So two of our operatories have those things. We always go inside there and do the air particle in there. Because when you do aluminum oxide, you see the particles just in your light. Your loops and your light, you see that stuff floating around you.

[Jaz]
David, that stuff is in my beard right now. Literally, I could just dust off my beard. There’d probably be aluminum oxide flying all over my microphone. I’m just being real, real, real with you here. It’s everywhere.

[David]
I thought you were just getting a little gray and aging, maybe.

[Jaz]
Yeah, it’s definitely not that. It’s definitely the aluminum oxide. Let’s say that.

[David]
Yeah, so in aluminum trihydroxide, what goes in the bioblaster, it’s a heavy, heavy particle, so it’s messy. Like we have to drape the patient because the stuff will go around and so we cover the patient up and we cover them and cover their face and everything. And when that stuff hits you, you feel it. If it bounces off and hits you, it feels like you got hit with a little rock.

[Jaz]
Oh wow.

[David]
So the good part of that is there’s some plus to that. The plus of that is that it doesn’t float. Okay, cool. It just, boom, it just sinks. So, and if you’re going to be doing a lot of this kind of dentistry, you don’t want to be breathing this stuff all the time. So, you want something that’s just going to drop and hit the floor, and then you can sweep up and clean up, and you don’t want this stuff floating around you.

[Jaz]
Very valuable insight. Brilliant. So, after the cleaning, let’s say you’ve done the matrix, and what I’m really interested in is, the whole bit about some dentists being concerned about the shrinkage stress if you’re going to do an injection molding posteriorly. That’s really the main myth I want you to bust. So can you just describe the protocol and then how the protocol lends itself to perhaps not being conforming to this myth?

[David]
Okay, well, I know that, like Diana asked me, that was one of the first things that she talked to me about when she came in with me. And we started doing BioClear. She started saying, what about the C factor? What about the C factor? Because you’re doing like these huge volumes, right? And in the beginning, I was a little worried myself because that’s what we’re taught. That’s what we learned. We should layer.

We should layer and layer because otherwise the c factor. Yeah, it’s gonna get the c factor is this monster that’s gonna get us, right? And we’re all gonna go to dental hell and so, but then what happened is, you know, what’s weird, Jaz, is that it never happened. You know, we started doing, we followed the protocol, and I don’t want to say that the c factor is meaningless, but let’s just say that it was really over blown.

Like it’s not the monster that it was made out to be. If you get the engineering, right. And you do the protocol, right, then. The C factor is largely mitigated and you don’t have to worry so much about the C factor, okay? And there’s some advantages to layering, but there’s disadvantages to layering too.

There’s disadvantages. We know when you try to layer, the layers don’t go together seamless. We can cut those, cross section those. And we see that even with the best clinicians, there’s gaps and there’s things that are not desirable about layering. Now, we have to layer sometimes on deep restorations with BioClear because, not because of C factor, but because of the light.

Because the light is only going to penetrate so far, right? And so when we look at these restorations, we’re not thinking, oh my god, there’s too much shrinkage. We’re thinking, is the light going to get there or not? And that’s the change, how you have to change how you think. It’s all about the light. So you have to have the high powered light, but then you, that high powered light on bulk Filtek is only going to go maximum five millimeters, really maximum.

Okay. So if we’re working on a bicuspid, it’s a relatively small tooth. We know we can come from buccal and lingual, we can do three point curing and we can get to that restoration. But if we’re working on a big molar. And it’s a big tooth and you have a great big guy and he’s got these big teeth. Okay, four millimeters, I’m thinking is max because I can’t come from buccal and lingual is not going to help a whole lot. That tooth is huge. So that’s where you’re thinking about it.

[Jaz]
So that’s why you’re doing the cervical portion first, getting it fully cured and then do more traditional injection molding as per the BioClear technique to resume the rest, yeah?

[David]
Correct. And since you can’t really wedge that deep one without bending the matrices, That’s where your friend Maciek came up with that floss wedge. Yes. All right. We use that a lot. Love it. Okay, because what that’ll do is it’ll tighten that matrices up just a little bit. Just a little bit. Just to keep it there for you to build that first layer.

Now you light cure that. Now you can go back and take out and do the diamond wedge. Pick your favorite diamond wedge and wedge it and the purpose of that wedge is not separation power we have a ring that will give us enough separation power. The purpose of that wedge is to anchor that matrices so that matrices does not lift up when you drop that ring on because that’s how you get in trouble which we learned I learned the hard way.

[Jaz]
Of course.

[David]
All right when that ring goes on if that matrices lifts up a little bit and is not fully seated and then you injection mold and you pressurize this system, you get something that you don’t want.

[Jaz]
Absolutely.

[David]
You get something that you’re going to have to go in there and drill it out and start over because you’re going to get what we call a blowout and we don’t like blowouts.

[Jaz]
That’s a bad, messy day at the office. I can totally imagine that. I’m trying to think. The cervical part, I see Marco, who I’m seeing in June actually in Sicily, I’m excited to go visit him, but that cervical portion, he calls it the hip. Is that bioclear terminology philosophy or is that something that he’s, he’s made up of?

[David]
Well, we used to call it the, David used to call it The Hip, and he used to compare different hips based on and he kind of got away from that because he got away from that because some people were offended by The Hip. Okay. Yeah. Well, we won’t go in. It used to be a Kardashian or or Aniston or something like that. So we got away from that. We got away from that.

[Jaz]
Well, the hips don’t lie. We know that the hips don’t lie as Shakira said. Just briefly describe the protocol. Let’s say you’ve got the Bioblaze, so the Bioblasting, got the Matrix on. Let’s say you’ve secured it. Can you just tell me exactly which bonds you’re using? Now, how many seconds you’re etching for? Are you doing a total etch or selected etch? Which bond you’re using at this in 2024? Obviously these things change. Someone’s listening in 2027. It might be different because it’s denser, it’s dynamic. But what’s your current protocol for like a standard DO using the Bioclear system?

[David]
Okay, so we’ll do a total etch. We don’t do selective etch. And we’ll do, basically, I’ll do 30 seconds on the etch, which I know is a little bit more than some people might do, but I do 30 seconds and then what makes it easy is I also do we rinse out dry, get everything cleaned up and now we’ll do 30 seconds on the bonding agent.

So we’re using scotch bond universal plus alright, so it’s a basically. It has the potential to self etch dentine, but it will really not self-etch enamel very well. I don’t know that any of them will self-etch enamel very well, which is why we do total etch technique, okay?

[Jaz]
So, are you etching the dentine as well?

[David]
Yes. Okay, fine, fine, okay.

[Jaz]
So, etch, definitely etch enamel and also dentine, got it.

[David]
Correct, correct. And now we go in with the bonding agent and one of the keys to not getting sensitivity is to not rush that step. That bonding agent, whatever you are using, you need to massage that in there and give the dentine time to really absorb that.

Okay? And the modern bonding agents, if you give them enough time and you massage it in there, we set a timer. 30 seconds. The company says 20 seconds. We go for 30. And if you massage that in there for 30 seconds, and then let that soak up, if dentine is exposed, we always light cure that coat, that first coat of adhesive.

Okay. And that is shown to have benefit to doing that. So, we will end up going with another layer of adhesive that we do not light cure. As part of the protocol. So the second layer of adhesive becomes a wetting agent. That’s our wetting agent.

[Jaz]
This is exactly the doubt I had that you’ve just completely just cleared out which I thought that okay if you’re not curing that first one because I thought the whole protocol was you don’t cure the bond and then you go straight to flowable and then the heat to composite and just make mix it all together and that’s the beauty of it but you really helped me understand that that. If you’re an enamel anteriorly that perhaps you don’t need to cure that bond you keep it uncured is that correct?

[David]
That’s correct.

[Jaz]
Okay super.

[David]
That’s correct.

[Jaz]
Going back to the posterior you’ve now cured that first layer after a generous massaging and just a little geeky point right I’ve seen these scanning electron microsoft images all these micro brushes and essentially what you have is very hairy dentine.

Okay. I imagine my dentine looks like this. Okay. Very hairy dentine. Okay. So some dentists, I know they use more like the paintbrush, like the black bristles, like a long strands. Is there a bio clear approved way of doing it?

[David]
I don’t think there’s a BioClear approved way, but what I prefer to do is I like the little sponges on the deep dentine because I feel like I can massage that better. And I know that I’m getting the adhesive on that area. Okay, so that my first coat that I’ve gone on dentine massage, massage, massage. Okay, 20, 30 seconds. We time it. Okay, air thin, air thin. Now, light cure. All right. Now, the second layer of adhesive that I will not cure that I will apply with the brush because the brush I can go around the corners.

All right, because the matrices is going around that tooth. And it’s wrapping and it’s going into areas that are uncut. So I’d like that brush to kind of tease it around, tease it around, and tease it around. Same thing when I’m doing black triangle closure in the anterior, the brushes can tease around the adhesive and make sure that adhesive is getting everywhere that you want. Then you’re gonna air thin which is going to also disperse the adhesive. But now you already got it there. You’re already good to go.

[Jaz]
Perfect. And then at that point, just finish off by saying exactly which flow we’re using and which composite system you’re using. Obviously it’s a heated composite system. Just tell us a bit more about the finalized posterior protocol so we can just understand about it a bit more.

[David]
Okay. So in the anterior system, we like to play with some different composites because I’m geeky like you. I’m super geeky. And I get bored if I’m using the same composite on everything because I want to see different cosmetic effects of different composites, okay?

But, in the posterior game, we strictly go Bulk Fill 3M. Because, I’m not trying to win any cosmetic competition on a second molar. And I think that in the back of the mouth, it’s all about function and being good contact, painless, chew on it, doesn’t break. So it’s all about the engineering.

And the restorations come out cosmetically pleasing, but we only have maybe two or three shades of bulk fill tech. Okay. And that’s just what’s worked for us in our hands using the 3M system. And we know that if we follow the protocol from BioClear, we know we do the bulk fill, then we know we have very, very low incidence of post op sensitivity.

Especially if you practice selective carries retention, which is another discussion, but you have to practice that correctly and just keep the deepest portion right before you think you’re going to hit the pole. Don’t take that out.

[Jaz]
The best liner is dentine. Even if it’s slightly carries in, that’s the best liner, isn’t it?

[David]
100%. You will avoid so many root canals if you do not go after that last portion. But remember that your CEJ, your DEJ, those junctions there where the carries tends to run along those areas there, you have to make sure that that is clean, clean, completely clean. And so you have a very good seal.

You have to seal, everything has to be sealed up tight. It only works, selective caries retention only works if you keep the bugs out and you’re letting the bugs in, you’re going to get a root canal for sure. So, yeah.

[Jaz]
I remember Dr. David Plunk referring to it as the modified haul technique, which I really liked, actually. So, for those in the UK, especially, very familiar about the haul technique and stuff. I don’t want to go into it too much, but it’s a great point you raised there. I’m not familiar, excuse my ignorance, I’m not familiar with the bulk fill is it a paste or is it all flow?

[David]
It’s a paste. So, we’re gonna go with a flow and a paste. There’s flowable and paste. So, we’re gonna go on that last layer where we didn’t cure the adhesive. Now we’re gonna bulk fill. So we do an uncured adhesive, then the flow, and then the paste. So the paste is basically gonna disperse and displace most of that flowable.

So, probably 80, 90 percent of our restoration is gonna be paste. And maybe only 10 percent is gonna end up flow. So it’s basically like taking an impression with the old polyvinyl impression that we like to do so you’re gonna be light body, heavy body you’re dispersing it you’re spreading. So, you’re filling in all the nooks and crannies and that the paste is also giving you that wrap it’s making the material travel and giving you that wrap around the tooth.

[Jaz]
The pace is like a putty. Compressing away, pushing away the light body. And I can definitely visualize that. I like that. I love those photos on social media of dentists doing posterior BioClear and they’ve just overmolding you guys call it, right? You overmold it, and then when you remove the matrix.

You just see the beautiful, strong, solid contact, right? And then obviously it’s messy, but I know having done this technique myself, that it looks really scary the first time you do it, but it’s so quick to just adjust it, right? And so a common concern someone may have who’s not familiar with the system is, whoa, this looks like really messy, but when you actually take your carbides to it, it’s very simple to tidy up. Any comments on the tidy up?

[David]
Yeah, you can’t be afraid of the bulk. You can’t be afraid. When you make mistakes with BioClear is because you under inject. When you under inject, then you get voids, then you get bubbles in areas that you’re not supposed to get them, right? You have to go full on on the system, and you have to pressurize that system, and then the magic happens.

And then you, when you have the bulk, we will go at it with coarse diamonds, and then disc. Also, even in the posterior. We’ll use the disc the soflex disc with, we take it facing towards the head of the handpiece, like not the traditional way.

[Jaz]
On the backhand, on the backhand.

[David]
Yes, exactly. And then pull. You use that disc to pull your restoration back into the proper shape, so that, so where you have the buccal and the lingual excess, use that disc and pull that restoration in and it will go quick. And another point Jaz, I like to emphasize is that let the occlusion dictate your anatomy.

Okay. In the back of the mouth on molars, all right, do not carve in detailed anatomy. Okay. You have to stop yourself. You have to stop what you were taught and don’t go for all this fancy stuff because what you’re doing is you’re really potentially weakening that restoration. You’re putting deep trenches and deep fossas in there.

And then you’re going to make it look all day. And what you’re doing, you’re taking away material, you’re taking away bulk, you’re taking away coverage over dentine, and you’re not benefiting the patient. The patient is not going to perish from lack of chewing efficiency. So let the opposing arch dictate your anatomy.

And that’s it. If you want to round the marginal ridges with the disc a little bit, you pull that disc over the marginal ridges, you’ll round them, they’ll look nice and thick and heavy, and you’re going to make a restoration that’s going to be there for a long time. That’s what you’re looking for.

Because remember, we have the reason why dental schools are going after BioClear now is because the stuff that we were taught, that I was taught, and probably that you were taught, it doesn’t work. It doesn’t work. Right? It’s not working out. Because these professors in the dental school knew that they were seeing amalgams that were 20, 25 years old, 30 years old.

They put composite in a tooth with a student trying to do the work that, the way that they’re being taught. And then there’s another student taking it back out in three years. Because it’s leaking, it’s got decay, and it’s not working. Because for too long we tried to say, okay, well, we’re going to take a GV Black Prep and we’re just going to do a little bit of this and a little bit of that.

But we’re basically gonna pretend it’s amalgam and that it didn’t work. It just didn’t work. So that’s why the dental schools is, it’s a huge leap for a dental school to try to implement any part of BioClear. It’s a huge undertasking. I mean, it’s like crazy, like they would, so David Clark and I and Diana, the three of us were just introducing it to a dental school here in Florida. And David tells me, he says, it’s easier to move heaven and earth than to move a dental school curriculum.

Yes. Absolutely. You know? So for them to want to go this, to try to implement any part of it, even if they’re not taking the whole package, if they’re just going to try to take something like class twos, it’s a massive undertaking.

Huge step. Huge, huge step. And they’re motivated because they see that the stuff that we were largely taught in school. It didn’t work out. You have to recreate a different system. Is there a composite resin has nothing to do with gold or amalgam? And if GV black were alive today, he would say what are you doing?

Why were you put that composite in my prep? Well, he was smart a super smart guy and he would say that come that composite does not go in parallel walls. Okay, stop with the mechanical retention get over that you know, you have to change the mind, it’s so much easier to teach it to students because they don’t know anything. They don’t have to unlearn.

[Jaz]
The mind hasn’t been perverted. By the all the things that we see and get exposed to. I’ve just got a reflection and a praise because everything you’re saying is going back to engineering, right? The whole thing about not putting in delicate fissures. I think it goes back to the underpinning philosophy of engineering, which is great.

And I’m a big believer in young dentists students messages me saying. Jaz, I’m a little bit confused because I’m doing all these beautiful composites, but as soon as I take the rubber dam off, I have to then spend ages adjusting it, and it ends up looking flat. And then the clue is, well, if the patient’s 62 years old, and you’re gonna give them what the textbook says is a six year old’s tooth, right, it’s not gonna work, right?

Because the opposing tooth, you’ve got to look at it. And so I love that you underpinned that philosophy as well. It’s got to be age appropriate. It’s got to conform, not only to what the textbook says, it’s got to conform to the opposing tooth. And the rest is dentition in that mount. So totally agreed.

And then my last question, therefore, on the basis of engineering is this whole concept of the stress reduced direct composite, which the biometic folk are talking about the use of rib bond and fibers and that kind of stuff. Does that have a place in the biocare philosophy? Have you guys experimented with it? And then once you answer this and you give your views on this, we’ll then pivot towards

[David]
Yeah. So we have not experimented with rebond and those kinds of things and fiber reinforcing and stuff like that. I mean, to be honest, Jaz, we haven’t had a motivation to try to go that route. So, class twos are such an underappreciated restoration.

Both for dentists, like we are, it’s stressful, doing good class twos is stressful, right? And we are undercompensated, terribly undercompensated for something that is challenging to do. So once we found, and I did not go to BioClear to learn class twos at all. I didn’t even know that that was part of their protocol.

I went to learn black triangles. I had no idea. That I was going to be restructuring how I work but once you develop the protocol and you develop the system and everything like that, you will routinely, routinely, routinely just nail class twos one after the other, after the other, after the other, after the other, and there will be the one that kicks your butt. Okay. Because that’s just how life is. There’s going to be the one that’s.

[Jaz]
Extractions happens with everything, you know.

[David]
Everything, everything. There’s going to be the one that gets away from you and you’re going to sit there and you’re going to say, well, okay, but I know the system works. So something, it’s something me, I’m the problem.

And you know what? There’s a joy in that almost. Because before you don’t know if it’s the system, is it the material? Is it my matrices? Is it the, I’m using the wrong stuff? You don’t know what the problem is now you have a system that works in your hands and you routinely bum bum bum bum you one after the other one up and that lowers your stress level and practice. And you feel happier, like oh my god. Look here comes another one not that I love doing class twos because honestly Jaz I don’t.

I mean, I’m going to be honest. I don’t love, I don’t love doing class 2s. I don’t love chasing, right? Okay. But if I get a good result and I get another one, I sometimes I’m very proud of that. You take a post op x ray and you see a nice, nice result. And you say, wow, that was tough.

That was challenging. And look, we nailed it. We nailed it. So because of that, it’s the recipe is there. I don’t want to go off on some tangent trying to introduce something new that I don’t know. And I don’t have the science that I’m going to get any benefit from this. So that’s why we haven’t experimented with the protocol, you know?

[Jaz] I appreciate that and it just good to know what you guys are doing at the moment in your training centers. I love everything you said in terms of having a system that works in your hands. I feel as though when you’re a new grad and you are finding your feet and you haven’t even discover in yourself ’cause you haven’t had enough experience, what works and what doesn’t.

You’re in this constant battle in your mind, like, wait, should I do this now? You’re constantly doubting yourself. So the sooner you find a system, it could be any system. It could be the bioclear way. It could be another way. I think just try out some systems, see what works, makes the most sense in the sense of science in your mind, apply that.

And then once you find a system that’s repeatable, predictable like me personally, I love just being in the zone, I’ve got some music on, I’ve got the rubber dam on, I’m doing my class twos, I’m in a happy place because I’ve got my protocols, I’m looking for that clean surface, I’m using my air abrasion, my beard is getting stuffed, I’m happy in that place and there’s a beauty in finding and actually fighting to find the system that works in your hands, in your practice, for your patients to best serve wherever your patients are in the world.

So with that reflection, If it’s okay with you guys, shall we now just switch the conversation a little bit about anteriors? So let’s talk about anteriors. David, I don’t want to offend my American guests, okay? You, the U. S. is now, the second biggest group of British society is U. S. Okay, used to be Australia and then the U.

So overtook them. So I’m always indebted to the listenership from the States, especially them students. So great to have you, anyone who’s listening right now to this. But it’s very, I have to be, I’m actually laughing saying this, it’s very un American of you to be opting to do these beautiful composites and not doing ceramic and crowns on the anterior teeth.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end. I’ve hopefully whet your appetite for the anterior segment of this episode that we’ll cover next week. Now, as you know, I’ve been recently giving you the CPD questions, and I give you one as a teaser, but I’m actually really late because I need to go to work, and also I’ve got the flight tomorrow, and I’ve got some family time to catch up with, so just to let you know, there is 45 minutes of CPD available from protrusive.app, aka Protrusive Guidance.

I just want to thank David and Diana again, but again, they’ll be back next week to finish off the part two, which we focus more on anteriors, how do you bond to root dentine? Like, if you’re closing black triangles, you’re going to be on root dentine, right?

So that’s one of the themes that we cover. As ever, I want to thank my team, Erika, Gian, Krissel, and Mari were involved in this one. And if there’s one action you take by the end of this episode, if you’re enjoying the last episode and this episode, and you enjoy it, at the month. Please could you share it with a friend? I’d really appreciate if you could spread the word of protrusive. Thanks so much for listening all the way to the end once again. I’ll catch you same time, same place next week. Bye for now.

View Details

Is this the death of composite layering and the tedious cusp-by-cusp build up? This episode might just change how you place posterior composites for good!

I know so many of us have reservations about bulk fill composites – when I was exposed to the Fast Modelling technique in 2016 I had too many doubts. All those doubts were cleared in this 90 minute episode – grab your onions Protruserati!

Joined by Dr. Ahmed Tadfi, we explored this innovative approach that promises increased efficiency without compromising on quality. We delve into the details of the fast modeling or the ‘Espresso’ technique, its benefits, and how it can transform your practice. Whether you’re seeking greater efficiency or curious about new techniques, this is your guide to elevating your posterior composite restorations

https://youtu.be/YXJ6oW6qUKU Watch PDP177 on YouTubeProtrusive Dental Pearl: Composite does not like to be dragged – consider using composite brushes or a cutting action, as opposed to a dragging action, especially if using the Fast Modelling Bulk Technique.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

04:26 Protrusive Dental Pearl – Composite Handling

06:07 Protrusive Guidance Platform

09:24 The Journey of Dr. Ahmed Tadfi

17:44 Ahmed’s Struggle with Posterior Composites

27:46 Help Save Nafisa’s Life

30:03 Evolution of Espresso Technique

31:30 Importance of Proper Cavity Design

33:01 Step 1 – Pre-Operative and Caries Removal

40:03 Step 2 – Pre-Wedging, Matrixing, and Final Clean

46:04 Step 3 – Etch and Bond

58:51 Step 4 – Final Adhesive Layer

01:01:21 Step 5 – Managing Marginal Ridge

01:08:18 Step 6 – Restoration Process

01:15:00 Clarifying Use of Microbrush to close the fissures

01:16:02 Step 7 – Restoration Process Continued

01:19:03 Step 8 – Glycerine Application and Polishing

01:21:07 Step 9 – Occlusion Check

01:24:56 Learn more from Ahmed Tadfi

01:28:02 Ahmed’s Advice about Implementing the Technique

Check out Dr Tadfi’s Composite Artistry courses

Join the Nicest and Geekiest Community of Dentists in the World: Protrusive Guidance – we will be able to comment and discuss on this episode and share more with each other that way. The clinical papers and Composite recommendations have been shared there.

Please do donate to Smiles for Nafisa – we are almost there to saving her life – this will be HUGE for our community to help one of our own!

If you loved this episode be sure to check out Composite Veneers vs Edge Bonding – Biomimetic Dentistry with George The Dentist – PDP075

Click below for full episode transcript: Jaz's Introduction: How are you placing your posterior composites? Are you doing like me? Are you doing cusp by cusp? Or have you discovered another technique? Well, I'm going to start by giving you a warning, Protruserati. This episode may completely change the way you place your posterior composites. I'm talking here bread and butter daily restorative dentistry.

Jaz’s Introduction

It might just completely foundationally change it to the core. And of course it’s got to be for the better. So the technique that we talk about today, the fast modeling technique or the fast modeling bulk technique, this could be an absolute game changer for you in your practice. I know I have internalized it and thanks to our chat with Ahmed Tadfi today, even now I myself am changing the way I place my posterior composites.

Because although I enjoy the cusp to cusp and getting the nice anatomy, it’s something I was taught on course many, many years ago, and I’ve just been doing it, and I’m in a good flow. I just feel that the efficiency can be a bit lacking. Doing two millimeter increments, use something called the snow plow technique, which Ahmed also uses, so I’ll let him explain that in the middle of the episode.

And whilst I’m happy with how my composites look, and thankfully post op sensitivity is not an issue in my hands. So for me to change, I’m resistant because when you have a winning formula, why should you change? But the number one reason I will be changing to this fast modeling technique, also known as the espresso technique, which you’ll hear about.

I just love it. The whole one shot concept, which will go into full detail, but the lure of it, the attractiveness of this technique is the efficiency part. And that’s what I really crave now. Look, for many of us general dentists, this is how we feed our families. This is like bread and butter, daily stuff that we do.

So there’s always a risk involved when you’re changing something foundational, such as this. And I’ve got a feeling that after listening to Dr. Ahmed Tadfi today, if you’re not already using this technique, then you’re probably going to consider changing, but if you’re already using this technique, the step by step way that we approach this episode, and how meticulous, that’s a great word to describe Dr. Ahmed Tadfi. Absolutely meticulous, man.

And the meticulous detail that we go into is really going to make it tangible. So if you’re already using this technique, it’ll give you good validation. And I’m sure you’re going to pick up a pearl or two from Ahmed. I actually remember visiting this technique hands on in a workshop in Singapore, like seven, eight years ago.

But I left that workshop, although it seemed like a good idea to me. I left with too many questions and I didn’t get the clarity I needed. So when I visited this technique again with Ahmed for this episode, it cleared those doubts I had. I just had some doubts about sealing the dentine and the c factor issue and all these things were going on my mind back then, but now they’ve truly been answered.

So now I’m ready to change this very foundational part of my dentistry. But it’s changes like these, things like these that we pick up and it actually makes our day to day dentistry more exciting. I do have to say that just because Uncle Jaz said it and Ahmed said it and he’s making a good argument, if it doesn’t make sense to you, please don’t switch this technique, okay?

And in dentistry, never change to a technique just because you read it once or you came across it through a podcast. It really has to make sense to you. So what I’ll be doing is on Protrusive Guidance, our free platform, our community platform, which also has some pay plans, but essentially the platform, the community element of it is absolutely free on there.

I’ll put together which composites you can use for this technique. Cause you can actually be doing your patient a massive disservice if you’re using the wrong type of composite for this technique. It has to be a specific composite and a clinical trial that was posted using this technique, comparing it to the cusp by cusp buildup.

So if you still need to carry out some due diligence before you change your technique. I think that’s a great thing, but I’ll make those available to you all on Protrusive Guidance. The website for that as always is protrusive.app. For this episode, which will be worth 1. 5 hours of CPE or CDE credits. So it might take a couple of commutes to digest this one, but I tell you, this is really important.

Now, if you really want to skip the foreplay and you want to go to around about halfway mark when he actually gets into the details of the step by step posterior composite part, then be my guest. But by doing that, you’re going to miss something really foundational. You’re going to miss some really important journey stuff.

How Ahmed faced a few setbacks and failures across his career, which is actually quite inspirational. But then also, if you’re going through a bad patch, then trust me, you want to hear the first half. It’ll help us to tap back into our motives and why we got into dentistry and how we’re in this wonderful profession, no matter what people say, all the doom and gloom, just to keep remembering.

We are in a really great artistic profession. I’m hoping that episodes like these ones will rekindle your passion. The entire ethos of the community and Protrusive Guidance is falling in love with dentistry again, and the nicest and geekiest dentists in the world.

Protrusive Dental Pearl

The Protrusive Dental Pearl is actually taken from this episode, but it’s so good. It needs to be emphasized again. When we’re handling composite, composite does not like to be dragged. you might remember dragging it with a probe and as you’re dragging it, kind of leaving like this thin trail of composite as you’re dragging it and it starts to look a little bit messy and maybe that increment of composite is slumping in the wrong direction and and so it’s well known that actually we shouldn’t be dragging composite which is why you see so many people using those brushes right?

I’m a big fan of the brush when I’m working anteriorly one I use by gc you get this autoclavable handle and then you get these little brush tips that you put on I know cosmodent also do some brushes so these brushes are widely available and they overcome this dragging issue, but the other way for this technique, the fast modeling technique, what you want to do, and it’ll make more sense when you get to the middle, to the end of the episode is when you’re actually doing the cut of your composite.

And when you’re listening at the end, I actually thought he meant cutting back the composite once you cured it. So I completely misinterpreted that. And then that’s why we revisited it and just made a lot more sense when you have your uncured soft composite mass and you’re making your cuts with the probe or the fissure instrument as he uses you are not to drag. Do not drag. You’re doing like this up and down cutting motion. See cutting is much kinder and nicer to the composite than dragging do not drag composite.

That’s the pearl right there. This is to be applied anteriorly posturally no dragging guys use some brushes if you need to avoid dragging anteriorly. And you’ll end up with a better result.

Hello, Protruserati. I’m Jaz Gulati. I’m forgetting to introduce myself nowadays. I know you guys are all family. Most of you are returning viewers, but if you’re new to the podcast, welcome. You picked a bloody good one to join us on. Before we join it, I just want to give an announcement about the offer that’s ending on 3rd of March. So, Protrusive Guidance is a free platform, right? If you want to come for the love of the community and a place to discuss your cases and just be a sponge and absorb and grow and learn together, then come and join us.

The website is protrusive. app. We do have a human process of approving each person. So if we have any doubt that you are not a dental professional, you ain’t coming in. So if you’re still waiting for an approval, chances are you haven’t checked an email that Mari has sent you to just validate, maybe asking for a certificate for those we found it difficult to verify.

Now, some of you will want to take advantage of the Ultimate Educational Plan. That plan is 39 a month or US$ 49 a month. There’s also a plan in Euros and Aussie Dollars for my Aussie fans out there. If you take advantage of the annual plan, you get 27 percent off. And that generous 27 percent off expires on 3rd of March.

So if you’re on the fence, you need to make up your mind by 3rd of March. If you want to go all in on Protrusive, all the education that we have to offer, do it before 3rd of March to get 27 percent off on the annual plan. And listen, if you get the plan and if all you do or if it’s just one thing that you do is that you watch Vertipreps for Plonkers, the five videos approximately just over an hour each, and you’ll be able to then prepare your first vertical crown for a pre molar using something called the shoulderless technique.

That’s the mission, then you will have got your money’s worth, like way, way more than your money’s worth. Just by doing that one mini course. We’ve also got Sectioning School launching. Just by the time when this one comes out. So by the time this come out, sectioning school, 4K, high quality videos of me sectioning teeth for extraction.

So this is probably be the best clinical footage of extractions you’ve ever seen. I’m no oral surgeon, but I’m a generous general, and you got my classic commentary as I go through each bit. So 3rd of March, the date. If you are interested in the ultimate educational plan, it’s a good time to upgrade to an annual plan.

Take advantage of that 27% off. Oh, and by the way, if you are in Ireland. If you’re one of my Irish Protruserati, I’m so sorry for some reason the bank’s having issues authenticating, so some of you having to pay by Apple and various other ways. I have no control of this. I’m so sorry. It’s been a surprise.

I’ve got dentists from Estonia, India, UAE all joining in the fun. But for some reason, if you’re in Ireland, the banks are not liking Protrusive at the moment. I don’t know what it is. Which is a real shame, because my top three Protruserati it’s like choosing your children, like who are my top three sets of fans?

I would say it’s the Irish, because over the years, the Irish have been the ones that have kept me going with their emails. Their generosity with their kind words and encouragement, I’ll never forget the Irish Protruserati for that. The second group that are going to get a shout out is the Ghanaians.

If you’re a Protruserati in Ghana, I love you. God bless you. You guys are always there on my live webinars and all the courses we do. So thank you so much. And the third group are from Birmingham in the UK. I don’t know what it is, but there’s a hotspot in Birmingham, which has the most protrusive per square meter of the world in that place.

So shout out to all the Brummies. Anyway, enough of my ramblings. Let’s join this epic episode with Dr. Ahmed Tadfi. You can thank me later. We’ll catch you in the mid roll and in the outro.

Main Episode:

Welcome to the Protrusive Dental Podcast. I’ve been admiring your work from afar, I guess, on social media and your journey and stuff. So it’s great to have you here as part of adhesive month. So February is adhesive month and we’re talking about bread and butter composites. And I’m really excited just to break down your protocols about how we can make our posterior composites faster, more predictable, efficient, hopefully sexier, all those things, basically, before we get to that.

Ahmed, tell us about you. Tell us about your career aspirations. How about your journey? I always want to spend a bit of time to unpack each individual’s journey.

[Ahmed]

Thank you very much, Jaz. I’m super excited to be on your podcast. I’ve been seeing a few of them in the past, but it feels quite surreal to be part of it. So actually I had a very long journey to dentistry. When I was 12 or 13, my dream was to be an architect, actually. I remember in year 10, we had an opportunity to do a work experience in the field of choice that we were aspiring to go into, and I remember feeling quite disappointed with that career choice because it wasn’t what I thought.

So I really like art. I really like sitting and precision and things like that. And I realized no offense to the architects at the time, but all we were doing was making cups of tea and doing nothing really. So I didn’t feel that it was applicable to me because I also wanted the science part of what we do.

So having that like patient communication or people communication as well as the artistic side of like making people’s smiles better and changing their life actually. So, I mean, although our medic counterparts have banter with us. We actually do change people’s lives in many ways just by doing simple things or more complex things.

So yeah, I then was walking by my own dentist and I just thought, I just saw a before and after picture and I thought, wow, this is really incredible, like the difference. So I remember walking upstairs and saying to the dentist, is it possible to do work experience again? I’ve just done work experience, but I wasn’t really satisfied, so I just feel like this is my career choice.

And he said, okay, let’s see how I can put you off this. And as they say, the rest is history. I started doing every Saturday is just going and watching and learning from different specialties. And I got really attached to it. And I kept saying to my friends, I want to be an endodontist. I want to be an endodontist.

I was like, oh, that’s a root canal specialist and I mean, weirdly, I still enjoy root canal treatment. Like it’s one of my favorite things to do, not a specialist at it, but I really still enjoy it and didn’t get my grades went to quite a rough school, so it wasn’t very easy to get grades, had a supply teacher.

Every other week we had fights in exams and people, Central London. Yeah. So it was, it was quite a rough place, but I guess it built my character a little bit and it made me really push through. So I had to do biomedical science and then again, I was really lucky because I’ve just about scraped a 2 1.

But fortunately I had a conditional offer from Birmingham. And yeah, then I started to realize the dream. And even to this moment, 10 years post grad almost, I still I can’t believe that I’m a dentist, which is quite weird.

[Jaz]

That’s beautiful. And then it’s a bit like when you pass your driving test a second time around, just remember and you appreciate and you appreciate the struggle. A lot of our colleagues, they kind of fell into it by accident. You had this determination and I hear this story on a podcast where I really wanted it, but I didn’t get first time and I had to go around. And then it’s a bit like when you pass your driving test a second time around, just tastes a bit sweeter and you really appreciate it a little bit more sometimes.

And I’ve heard this again, the same story again and again, and I think it’s so nice to reflect that and tap into that feeling, that desire you had at one stage. I mean, I want to be a dentist since I was 14 and I really remember just praying that I get the offers and I got the offers and praying.

I got the grades and routes being so desperate. I want you to do before going to the profession. And it’s so easy once you’re there to not appreciate it for all the doom and gloom. And so I love that you said that it’s really important reminder to main reminders from reflections on Ahmed’s message there, guys, is number one, that doesn’t matter what grade you get, that will not determine the quality of your work is success.

The grades does not equal success even at dental school and before whatever. So forget about grades. Okay. I think still to apply yourself, do your best, but just because you didn’t get the top mark doesn’t mean you can’t be a fantastic dentist and have a fulfilling career full of enjoyment. And the other one is just remember why you came into the profession and tap into that energy when you’re feeling a bit down.

[Ahmed]

Absolutely. I just add to that, actually you mentioned about dental school, even dental school. I wasn’t really a lectured person. I liked to listen to a lecture, but I wasn’t one of those people that would take notes down and go over things. I was more practical, hands on, wet fingered. So even in third year, I had to repeat third year, which for me worked out the best thing ever because it was the easiest year, ironically, for one subject.

But it was the one subject in biomaterials. But it made me do all the other subjects again, without having to do any exams for them. But in addition to that, I have an extra year of clinics. So at the end of fifth year, I managed to pick up like a couple of awards from dental school, which even I wouldn’t have imagined that I would be sort of in the position to.

So what I want to say about that is that the time I felt horrible, I felt sad. I felt like I let down my parents, my friends were moving up and I was like making new friends or had to be making new friends. So if anyone’s in that position, I really believe that God always works in ways that we don’t understand.

So everything that happens, yeah, it just happens for the best for you. Like, I always tell the story to Ibn Tanzim, even patients, about the king and his apprentice who would always go out and about and his apprentice, whatever happens, would say to him, oh, this is God knows best. God knows best. So one day the king cuts his arm and the apprentice says, Oh, don’t worry.

God knows best. And the king says, How dare you say that? I’ve just lost my arm. How can you say God knows best? Go to prison. And the next day, the king goes out without his apprentice, gets caught by a tribe, and the tribe take him to sort of give him to their gods or their spirits as a gift. And they realize his hands dropped off.

So they said, oh, we cannot give this to our gods with the hands chopped off, release him. So the king goes back. He pulls his apprentice from prison and tells him. Oh, look, this is what happened to me. You were right. God does know best but tell me one thing what happened to you you ended up in prison. So that was a bad thing for you surely he said well if I was with you they would have let you go, but they would have taken me because I had nothing. So God does know best. So just like a funny story, but it really does In the grand scheme of things, it doesn’t change a lot if you have to do another year. I know a lot of great clinicians that had to do another year. But just think of it in that way.

[Jaz]

I appreciate you sharing that parable. Very good. And just to, different learning styles, like you were not into lectures. I mean, I was massively into my lectures. I used to be there front row. Most of the time I was happy to be sitting by myself, front row, had my iPad out, I was recording the audios, I was typing notes, there’s a really cool app at the time called SoundNote, I was in love with it and stuff, so I was, I was always really, really into it in that way, but everyone’s got different learning styles and stuff, but regardless, if I hadn’t done as well academically, I don’t think that’s what determines your success in the future, that a theme that I’ve covered, to add on to a parable you mentioned so many times on podcast four is, the whole Steve Jobs quote.

You can’t connect the dots looking forward. You can only connect them looking back. And so that’s always a good thing to revisit. Now, the main topic for today, I mean, that was brilliant. The main topic for today is the espresso technique, which I really want to just see, we in there before we hit record, but you’re telling me about it and then how you used to be known as a fast modeling technique for composites.

And so I’m really excited because I don’t use this at the moment, but I know that I’m going to give it a go after our chat today. So my job is to make it tangible enough for myself. And then to also through that energy, make it tangible for the Protruserati, so that we can actually have all the benefits of it.

So I think the best way to approach this would be is why don’t we just look into how you were taught to place a posterior composite and maybe as a new grad, the techniques you were doing, like my anatomy in the past when you’re a new grad, it’s hit and miss, you spend a lot of time doing clues adjustment, you kind of lost, you don’t know the sequence and eventually you pick up, okay, let’s turn it into a class one first through the marginal ridge first and you figure that out, but then you’re always developing your style.

You go on courses, you experiment, you always think about how can I minimize that shrinkage stress? So I want to hear the warts and all story of your own progression, your own approach, your own recipe for your posterior composites and what happened, how that led to, and then we’ll break down the espresso technique. So please, Ahmed, over to you.

[Ahmed]

So again, very interesting one for the first three years post grad, I must admit they were probably the most difficult years of my career because I qualified thinking, wow, this is the dreams come true. And then going into practice thinking, Oh my God, what the hell have I done?

Like, from numbers of patients to not knowing everything, or not being able to find the right materials, the right instruments, not working with the same staff members, and I thought, gosh, this is really tough back to the clinical part of things the way I was placing composites was kind of similar to what we were taught at university.

So try to get some isolation, whether it’s rubber dam or not. Again, this was a struggle in the beginning because we didn’t really know what rubber dam was in the practice I did, but no one else did and it was like-

[Jaz]

As a new grad we’re using just interesting everyone’s different and you probably aren’t using I’m not using rubber dam and they fall into bad habits and they fall out of habit of using it. Even though they were taught in school as a new grad were you quite pro rubber dam from the start?

[Ahmed]

Yeah. So I had a really OCD picky thing about rubber dam and auditing all my endos. So for the first two years of my career, I remember walking around with like two USBs and putting every single endo x ray that I did. Good, bad, long, short, exposed, perforated, you name it, it was all on there.

And I said to myself, this would be my kind of self critique, because for me, you’re your worst critique, you’re your worst sort of analyst, if you like. And that was what I was using to improve. Now with regards to composites, I mean, I was very fortunate to be taught by the late Louis Mackenzie. Rest is in peace and his soul.

He was like instrumental to everything I do now. He was the guy that made me fall in love with the artistic part of dentistry and being interested in how to make them look beautiful, but functional and all of that, but once you qualify, you don’t have the time that you had at dental school to be able to afford to do that.

But there was me trying to push the boundaries and trying to do what I thought was the best thing to do for the patients and spend 1, 2, 2. 5, 3 hours on one tooth. And in the end, I would find that, once I took the rubber dam off, got the patient to buy, I’d spend another half an hour cutting it all back.

And again, on the course, I always share a story about seeing some of the archive pictures on my hard disk. And there was a tooth with like eight cusps on it. And I was thinking, what on earth was I like doing? So making things up, and I got to a point where at the third year post grad. I was feeling the financial pressures.

I was feeling drained. I was feeling mentally like challenged. It was all becoming too much because I was in debt. I was running late every single time for no reason. My work wasn’t good.

[Jaz]

Especially if it was maybe an endo or a composite because you’re trying to exert yourself and then you try to do all your wonderful anatomy level up portfolio building, that kind of stuff. And then it ends up being running late. It happens.

[Ahmed]

Exactly. And it was just catching up. And at the time I thought, you know what, I’m going to call it a day. There was one instrument that we used with Louis Mackenzie in fifth year, which was the StyleItaliano Fissura made by LM-Arte. And it was this like fluorescent green with a really nice pointy edge.

And I was fascinated by this instrument, believe it or not. And that was the sole reason why I googled StyleItaliano. And I thought, you know what? This looks like a nice course. It’s in a beautiful setting in Italy on the coast. Can’t go wrong. Let’s go for a holiday and then I’ll come back, hand in my notice and do cheffing or something like that. I was ready to quit dentistry actually.

[Jaz]

So this was like the last supper for you. This was like, okay, let me just go out with Bash. Let me just do a tax deductible course somewhere and then maybe I won’t have to look at teeth ever again.

[Ahmed]

Yeah, exactly that. Seriously, like it’s amazing how things work. I got there day one. I was like, you know what? It doesn’t really matter, but I just want to see how amazing, like why are these guys so amazing and stuff. And I sat through the talks and then I did the hands on and every day it was a four day course. And I was thinking, my God, like my work looks really good and it hasn’t taken as much time as I thought it would.

And they’re showing me 10 year, 20 year, 30 year follow ups like, okay, this is the recipe to success because it doesn’t have to be over complicated. It doesn’t have to have every single detail that God created because no matter what we do, we will never be God and actually it looks 99. 9 percent better than anything I’ve ever done.

Let’s give it a go. So I thought, you know what? I’ll give it a go. The first month I was practicing the techniques and I was thinking, my God, this is so crazy. I was becoming proficient, efficient, profitable, and I just thought this can’t be true. Because this isn’t what we were taught at university, but somehow it works.

And it was that phrase, there was a phrase they used in the lecture, which was simplicity is the ultimate sophistication, which is something that da Vinci quoted. And it blew my mind. It really is. Simplicity is the ultimate sophistication because instead of using everything that you know, and trying to put everything that you know, in one thing, and just taking everything that works from those steps and applying it, you’ve not only cut out the steps, but you’ve cut out the mistakes, you’ve cut out the voids, you’ve cut out the risk of making a mistake because the more steps you add, the higher the chances you make a mistake and the confusion with your team.

Because again, if you don’t have the same staff member, or they’re sick, or they’re away, or you work in a different site, you have to be able to relay that information very easily, very proficiently, without confusion to your partner, essentially in work. And it just made everything so much easier. And with that ease, all the other things fell into place.

Efficiency, proficiency, profitability, and they have this really nice motto, industry should be feasible, teachable, and repeatable, and then profitable, because you need to make a living, but those three things. Feasible, teachable, repeatable. And if you can get those three things with anything you do, you’ll be successful. With your patients, with your staff, with yourself.

[Jaz]

I see where they all come from. But the teachable one, I’ve been reflecting on this because you’re in education, I’m in education, right? We know, I’ve been reflecting a lot about this. And I think that maybe even that teachable one, we should change that word. I know where it comes from, I think we all know where it comes from and the reason behind it, but I think a better term might even be learnable.

[Ahmed]

Yes.

[Jaz]

You know, it’s teachable is more in the teacher perspective. I think learnables in the learners perspective.

[Ahmed]

Yeah. So again, if you look at the learning pyramid, you’ll see that 5 percent of knowledge is retained by reading or going to a lecture, but 90 percent of your knowledge is retained when you can teach that thing to somebody else.

That’s the golden nugget right there. Not the lecture, not the audios, not the rewriting of the lecture. But being able to relay that information to somebody else, that’s when you know you’ve got 90 percent of the information in your head.

[Jaz]

I am a big fan of encouraging young dentists to go on courses and then the next week, obviously getting to implement it, but just arrange a meeting with the other associates in practice. So whenever you book a big course, right, that you’ve been looking forward to, just tell your work colleagues, hey guys, I’m going on this course the week after on the Thursday when we usually have a dentist meeting. Can we just make it about everything I learned on this course? How wonderful would it be for that individual who went on that course to share everything to really harness the power of the learning, right?

And really cement in place and then to also spread some joy and knowledge and efficiency. So I think that’s going to be the Protrusive Dental Pearl for this episode. There we are to start sharing because that’s the highest form of learning. And just like you said, I think this is where the magic really happens.

So when you actually came away from Italy with that technique and you’ve been using in place and just tell us about the beauty of the term. So at that point, it was it fast modeling technique as we know it, or is it was it already called Espresso? Just tell us about the evolution of that before we then describe one example scenario.

[Ahmed]

Sure. It was actually in 2014. When professor Louis Hardan, a professor of St. Joseph’s university in Lebanon and Dr. Murad Akhundov from Azerbaijan, they actually came up with the technique, the fast modeling technique. And what they did is they published a paper in polymers. I don’t remember the impact factor, but it was quite a high impact factor for the study they did.

And they showed a one year follow up using a bulk fill material and the technique, which was fast modeling technique. And I think you can just type in a fast muddling technique, polymers.

[Jaz]

And we’ll put it in the show notes and the downloads.

[Ahmed]

Yeah.

[Jaz]

Protruserati just interfering here with an update about Nafisa. You know, Nafisa is a girl who’s the daughter of one of our own, one of our own Protruserati. Her name is Sakina and her daughter, Nafisa needs our help. She’s got SMA type one. Now I made a really important video talking all about this condition. And if you want to see that, it’s on our Instagram @protrusivedental.

But essentially we’re against the clock here. We don’t have much time. We need your donations to help save her life. Even if it’s just something like 100, that would honestly go so far to getting to that 1million dollar mark, that actually they can start the therapy and save her life. And then they have a whole 800, 000 still to pay from installments, which I’m hoping we can catch up to as well.

But they’re basically at 860, 000 at the time of recording this, which is spectacular, but we’re not there yet. We really want to save Nafisa’s life. So don’t hear it from me. I’m going to play this one minute video of Sakina’s plea.

Hello, Protruserati. My name is Dr. Sakina Isaji. I’m from Dar es Salaam, Tanzania. I’m so grateful for Dr. Jaz for giving me this platform. I never thought I could ever get here, at least not for this. Today I’m here to fight for my daughter’s life. My beautiful daughter who has a rare genetic disease called Spinal Muscular Atrophy type 1. We have been fundraising for her. We have raised 840, 000 so far, and we still need about 1 million to get her treated on time. I urge you all, if all dentists can come together to join this cause, we could save her on time. I believe every life is worth saving. Please help me save my daughter.

Protruserati, you’ve been following my newsletters, I’ve been emailing you as well, and every newsletter, I talk about Nafisa and how you can donate, so please go ahead to one of my old emails and then click the link to donate, or just head over to protrusive.co.uk/nafisa, N A F I S A, that’s her name.

Now when you get there, it’s like a Canadian fundraising page for Nafisa, which actually feeds into the main fundraising. So the amount you see might be over 200, 000 Canadian dollars, but don’t worry. This is still legit. This is still the same cause for Nafisa. I’m hoping that we can all club together and help one of our own. Thank you.

[Ahmed]

Anyways, it goes through that and it showed that actually it was not only more predictable to do, but the results versus the traditional layer by layer or increment by increment this, this was on that level, if not better. And why that’s important is, as we already mentioned, if you’re able to implement a material.

Or use a material in a bulk filled manner doing all the other things first, which we’ll talk about in a minute, but and be able to place a single shot of material in one go and then carve it out. Not only do you eliminate the risk of voids, air bubbles, all that stuff, but when you actually do. the cutting because you can essentially erase everything and start again.

You can actually get much better cusp formations and anatomy overall without making the mistake of building a cusp, maybe over building it or under building it and then having to go around that by building all the other cusps or go back and cut. It’s a really nice way. If you’ve got one single mass.

You can build everything up, check it before you cure, if you’ve got a mistake or something. Essentially, erase it or erase that part and redo it without the risk of having a problem later on. So now, more recently, just to unify the term-

[Jaz]

I was actually recording with the BioClear guys yesterday. And so very similar concept, so essentially over contouring and being reductive. Right? Is it a fair way to describe it?

[Ahmed]

I would say that not really overbuilding. No, it would be more following reading the tooth. So you would build a mass, let’s say four mils. It depends on how deep your cavity is. But even if you’re using a bulk fill, we do say use bulk fills cure up to six millimeters.

And they cure from the base to the top. That’s how the particles are made to work. We would never do 6 mil. We would do maximum 4. So depending on the depth of your cavity, if it’s, let’s say, 5, you do a 2 mil first, and your final 3 or a 3, and then your final 2. Nothing less than 1. 5, essentially. But let’s say you got a 4 mil cavity.

Once you’ve treated the cavity, and there are things that you have to do beforehand. But imagine when you put a single shot of composite in one go, you are eliminating the risks of voids, bubbles, things like that, because you’ve got less tampering with the composite. That’s the advantage of the technique. Then when you’re cutting the composite, you are reducing the shrinkage stress anyway, because you’re cutting each cusp. at a time.

[Jaz]

Oh, okay. This is where I got confused. This is the beauty of me. I’m glad I didn’t read up on it before I spoke to you because this is me now in the same mindset of someone listening to this for the first time, right? So when you said cutting, I thought you meant like once it’s cured, you get a bur and you cut back. That’s what I thought.

[Ahmed]

No, no, no.

[Jaz]

Actually. Yes. What you mean is using that Fissura instrument or similar and actually doing the magic bit, which I can now visualize, but you’re going to explain shortly. Okay, wonderful. I’m now in a happy place.

[Ahmed]

Okay, good.

[Jaz]

So let’s go with that. So that’s why I thought it was reductive. You see, okay, now it makes sense. I think the best way to approach now is let’s just talk through a scenario. The scenario is a lower right first molar. It’s a leaking distal occlusal amalgam restoration classic.

It is for the sake of covering all bases. It is going to be a five and a half millimeter depth cavity. Okay. And it is just very slightly subgingiva, a little bit tricky, but it isolates and everything. In fact, let’s not even talk about isolation. Let’s talk about, it’s there, you anesthetize and then go from there. Just, I want to know your exact step by step sequence, every geeky goodness, and I’ll probe you various stages.

[Ahmed]

So actually it starts with the radiograph first and foremost. So reading the radiograph before you start, that gives you all the clues or most of the clues as to how to approach the treatment. I like to use the power of three super gingival, sub gingival, crestal.

If it’s super gingival easy, you don’t need to consider gingivectomy crown lengthening or whatever. A wedge and a rubber dam does the trick. If it’s sub gingival, you might have to do gingivectomy. You might have to use a bigger wedge or you might have to do some form of non surgical crown lengthening.

And if it’s crestal, obviously you might have to pick up a blade or do crowning thing before do anything else. So we start with that first and then we move on. Now the scenario that you’ve mentioned is subgingival. Again, if it’s subgingival but not crestal, then usually I’ll just place the rubber dam. So once I’ve anesthetized, the rubber dam goes on.

I like to do a quadrant isolation, so whether I’m doing one tooth or three teeth, I’ll isolate from the distal most tooth to the central incisor. If they’ve got a retainer, then it’ll be distal most tooth to the four or five, and then the opposite five, again, just to retract the rubber down in a way that you can visualize the whole area.

[Jaz]

So it’s split down, so between the retainer part it’s split down?

[Ahmed]

Oh, no, you just do, let’s say, 7,4 – 7,6,5,4. And then 4. It pulls the gum down and just pulls them off.

[Jaz]

Hide over the incisors basically.

[Ahmed]

Exactly, exactly. And reduce the risk of saliva creeping in and stuff like that. And then the next question is to pre wedge or not to pre wedge? That is the question. So depending on where the cavity is, you would either pre wedge or not pre wedge. Now, when you wouldn’t pre wedge is if you’ve already got a broken contact and you’ve got, I don’t know, sharp area or cutting area, obviously you probably want to remove that before you even try the rubber dam even because you will tear the rubber dam as no matter how many rubber dams you go through.

So all of these things you have to think about before. The other trick I would say is take a piece of floss and if it goes through and it keeps breaking, Then you know that your rubber dam is going to probably tear and break. So you might be better off cutting the cavity before you put a rubber dam on and then putting on the rubber dam to do the next steps.

But let’s say that’s fine. Then pre wedge and choose the right wedge. Again, there’s a fantastic article on the style Italian website called mind the wedge. by Dr. Giuseppe Chiodera, and he basically goes through everything about wedging, like from wooden, plastic, silicone, cutting, wedges, customizing, the whole shebang. Free, so not to bore them about wedges.

[Jaz]

We will add that on because we all like a bit of info. I mean, nowadays I’m doing a lot of wedge lists because I’m using certain matrices that negate the need for that, which is great. But I mean, I’m still wedging the time, especially when I’m using my sectionals and the circus and the trial error and the trials and tribulations, but when you learn a bit more and get a lot of experience, which wedge to use in which scenario, how to modify the wedge and when to use a diamond wedge, all these little nuances that we love in restorative dentistry.

[Ahmed]

Exactly. And then I would cut my cavity. Now, this is a very important thing when it comes to restorative. One thing that we’re taught at university and I appreciate, and I think we should respect, but not to be too bogged down by is minimally invasive dentistry. Now the term minimally invasive dentistry doesn’t mean to be highly stupid dentistry.

So what I mean by that is that when we cut a cavity, we have to think about why are we actually cutting the cavity in the first place because. Primarily, the patient isn’t cleaning it. If the patient can’t clean it, what makes us think that if we remove just that part of the cavity and restore it again, that the patient’s going to be able to clean it?

So we’ve got to ensure that the cavity is cleansable by the patient first and foremost. And secondly, if it’s hard for the patient to clean, it’s going to be hard for us to restore. The smaller it is, the more difficult it is to place a matrix to place a wedge and more importantly to place material. So one thing that Walter Devoto told me again on the course was to be conservative is not to be stupid, probably print those phrases out and put them on every single dental school entrance, because that has changed my life really.

Why not use the word optimally invasive? Rather than minimally invasive. So to be optimally invasive means two things or three things. One, the patient can clean it, whether they brush twice a day, 10 times a day or no times a day. It’s more cleansable. Two, it means it’s easier for us to restore.

And if it’s easier for us to restore in a class two setting where the most important part of the whole restoration is that class two wall. If you’ve got a leak there, if you’ve got a problem that it doesn’t matter what you do. After that, it’s a failing restoration. So we are able to be more predictable to treat that part.

And therefore the success of our restorative treatment is higher. And that’s how you win your patients. That’s how you gain your colleagues trust. And that’s how you build your rapport and confidence as well, because the last thing you want to do is think in your head, oh, I’m a really invasive dentist, but the patients come back with a second round of carries in the same spot.

There’s a problem there. Then you’re going to cut even more of the tooth away. So you’ve got to be smart with your cavity design. So flare it, make sure. that it’s accessible by the patient with a toothbrush. More importantly, then you move on to the next bit, which is matrix.

[Jaz]

Before we cover matrix one, give a few reflections on total sense you’re talking when we’re being minimally invasive. Lincoln Harris taught me that minimally invasive is not a goal. It’s a modifying factor. The goal is like you said, to get a cleansable restoration and someone who may be more carries prone. And therefore you can’t be but the goal can’t be minimally invasive because if we do that, then it won’t become cleansable.

So we have to remember that that’s a modifying factor. It’s not a goal. Sometimes we have to remember that the matrices that we’re working with, and you’re going to cover this, obviously we have to design our cavities to accommodate our matrix because If you don’t design a cavity well, and then you get a kink in the matrix, then you’re not using the matrix how it was designed to be used.

We sometimes need to be a little bit slightly more invasive to allow the passivity or the correct functioning of the matrix the way it was designed. And so that’s really important. And then the last thing there is the struggles of a claustrophobic class two, right? We hate doing these claustrophobic class dues.

And so having more space is just going to reduce your stress massively and actually makes you eat a better outcome. So totally echo everything you said there. So please tell us about matrixing, but I’m really excited to get to the actual bit where the espresso technique actually comes in place. But by the way, what you’re saying, please continue. Cause I think we’re getting so much value from, cause you’re not only just giving us a protocol. You’re giving us the why and the reason. So I’m really enjoying this so far. Please keep going.

[Ahmed]

Thank you. So now it comes to the matrix thing part, which again, a lot of people have quite a lot of stress about or confusion. Unfortunately, to this day, there isn’t one matrix system fits all. So you might have to have two different matrix systems in your practice to kind of cover everything. There are some, maybe a ring coming out, which might cater for everything, but for now, I’m not allowed to talk about it, but if you had to choose two, I would say the Polydentia system and the Palodent system.

Works very well or Polidentia and Garrison Composi-Tight, or I’ve never used the BioClear system myself personally, but I’m sure use the system that you’re familiar with and that you’re comfortable with is what I would say. And if you’re not sure, if you don’t know, then obviously go on a course and try it out or see your colleague and see how they do things and go from there-

[Jaz]

But let’s just say having six different matrix systems, as a business, so it may be that if you want to do bioclear, go on the bioclear course and embrace their philosophy and then 10, 20 percent time, you just have to have the other backup matrix for the other scenarios where it may not cater for it.

Or if you’re going to go all into polydentia and then have the other, I agree, not one matrix, but two, three systems max that you have in the practice and that is going to be enough. But I totally agree. There’s no one matrix that’s going to be optimal.

[Ahmed]

Yeah, exactly. Now, the question about pre wedging or not pre wedging, the advantages, let’s say, of pre wedging are the most obvious, which is separation of the teeth. Again, when you’re using rubber dam, you will get some separation of the teeth from the rubber dam itself. But obviously the more separation you do or the earlier the separation you do, the higher the chance you have of actually moving those two teeth away from each other and reducing the risk of iatrogenic damage.

The second important thing with pre wedging is again in a deep cavity, the longer the wedge is in that sulcus for the higher the chance or the more that the gingiva is depressed by the wedge, which means that if you’ve depressed the gingiva over that time, you’re going to access that cavity much more predictably than you would if you then saw, oops, I’ve got a slightly deeper cavity now, now let me put the wedge in.

The risk of then putting the wedge in, not pre wedging, is that you might tear your dam. You might have some bleeding if you’ve been cutting the bow and you’ve accidentally slipped and you’ve shredded the rubber dam itself. There’s so many little things that can happen along the way. So again, if you’re not sure, my advice would be pre cut your class two before you put the dam on and then wedge and dam and wedge and go ahead.

If you’re definitely sure based on your x ray. That you’re clear of the gingival margins, then pre wedge is what I would do. And then I would check my cavity, make sure that I have no undermined enamel. This is another thing, a bit controversial. Again, if we think about it logically, a lot of the time when we are doing the class two cavity preparation, we end up with a very thin amount of enamel.

And what I used to do even before I was taught this way is I would take an ultrasonic and whiz it all away. Or I would take a thing, a chisel and chisel it all away. And if you think about it, you’ve just removed the best bonding material that you’ve got in that space. So unless it’s like completely thin and you can see it’s all cracked and broken apart. Try to preserve that extremely precious bit of enamel there and what you can do before you remove your wedge or if you’ve not wedged, it’s more even it’s better if you haven’t wedge is reinforcing just that part with a drop of flowable and making it strong enough to put a wedge in and then do your matrixing and your class two.

So there’s a little bit of. talking about that. I don’t want to confuse the audience, but this is maybe for a course, but let’s just ignore it. And let’s say we’ve got perfect enamel and everything’s is lovely. You put your wedge in or you take your wedge out. Sorry. Check your cavities clean before you put your matrix.

You want to clean the cavity or a final clean with the AquaCare if you’ve got it, or even a sandblaster. If you’re using a sandblaster, just be careful. You’re not too zealous with the button because then the patient turns into snowman. And a trick is just, if you get a piece of gauze and you wet the gauze and you place it over, then it will kind of soak up.

A lot of that sound if you don’t have an accurate care, but if you have an accurate care, just run it around your cavity. I also like to use a greenie just on the periphery of the cavity preparation. Again, almost like beveling the enamel because that will give you a much better integration of composite.

And also it will strengthen the composite in that area. Often when you see the shrinkage stress or you see composites after eight, seven years, whatever, you’ll see that white. Sort of a dark ring around and that’s because there’s not enough of a bevel, let’s say in that area, so it’s a little bevel around and then you’re ready for bonding.

Now, depending on the cavity spaced into proximal space, I’ll either put my sectional matrix in the right direction, or if I want to bond and I haven’t got a lot of space, I’ll turn it the other way around so that I don’t have bond on my matrix, because again, what happens is you end up with a pool of bond and once you cure it, you’ve got now half a mil of bond.

Or if you’re using optimal on the fell, you’ve got a millimeter or bond, and then you’ve got your composite. And if you take a post op x ray or you take an x ray in a couple of years or whatever. You think it’s a void or someone else thinks it’s a void, so yeah, it’s better.

[Jaz]

It’s like an open margin, almost.

[Ahmed]

Exactly. So you’ve got to be just be careful. Those little things again, depending on the bond system that you use. Now, if you ask me-

[Jaz]

How I get that, I didn’t quite get that bit, though. So what’s the tip in terms of reversing the matrix? So?

[Ahmed]

Yeah.

[Jaz]

So basically, you instead of using it as you normally do, you just for a moment, turn it around. And how does that actually prevent the pooling of the bond in that area? Yes.

[Ahmed]

So it doesn’t prevent pooling of the bond, but it prevents the bond sticking onto the bit of the matrix that you’re then going to use to pack your composite against.

[Jaz]

Got it.

[Ahmed]

So for that part, and then again regarding the pooling, what you want to do is you want to leave the bond for a minute or so just to naturally be absorbed by the tooth. And then if you’ve got a good 3 in 1, go around it gently. Check it on your neck or your arm first to make sure there’s no water or use the suction tip on sort of a halfway suction just to remove any solvent. Now, we missed a bit about etching, which I’ll just quickly go for, go through. I do selective enamel etch only.

And that’s because I’m using a universal bonding system. So going back to the easing and the predictability, let me just tell you one thing, guys, these companies, it’s in their best interest to give us the best material, because if it doesn’t work, we won’t buy it. And if we don’t buy it, they don’t make any money and they don’t make any more product.

I’ve been to the labs. I’ve been to the companies where they make these things. And if you think we’re OCD about doing fissures and dentistry, trust me when I tell you, the biomaterial scientists are the worst OCD people you can come across. They care a lot about what they produce. So, just to give you an example, Universal Bond, they attached a car and they lifted a car with Universal Bond.

So, If you use the bond according to the manufacturer’s instructions, which is very important, then the bond will give you exactly what the manufacturer promised, which is a good bonding, a strong bond, and you have no problems. You have you can sleep at night. This was another factor actually that changed my life because prior to that I was etching dentine.

Now unless you’ve got a stop clock and you’ve got the most incredible reflexes and your nurse is on the ball every time, you cannot tell me that you’re etching dentine for 20 seconds or 15 seconds or 10 seconds. There is no way. Never, no matter how good you are.

[Jaz]

So what happens is you’ve taken a photo of your etching the dentine, you over etched.

[Ahmed]

Exactly, exactly. So like one of the main things that we have is people say, oh, post op sensitivity, mainly because that dentine is being over etched. And when you over etch dentine, it means that you have a higher chance of over drying it. And then there’s an argument of people saying, Oh, but you can then re wet it.

Okay. I tried to re wet it, but at the same time, I’ve now wet my enamel. Okay, I’ll re dry it and then I’m over dried my dentine now, so you’re going backwards and forwards and okay, let me use the primer let me use this bottle and then the nurse gives you the wrong bottle because you’ve got three bottles out already and you’ve got a gloomer here.

You’ve got a primer there. You’ve got an a and b1 one’s blue one’s white. But there’s another blue one from a different thing. It’s so confusing. So having a simplified workflow makes it much easier to do your work. Now I’m not saying if you’re using a two step system or whatever, use it. And if you’re happy with it.

I have no issues at all. They all work brilliantly if you use them to their instructions, but just talk about me. So I selectively etch the enamel and another little tip when you etch enamel, what often happens is people etch the bit that isn’t really necessary. So they etch the top of the enamel and they forget about the inner part of the enamel, which is where you want your enamel to be etched, really, because that’s where you want your bond.

[Jaz]

So let’s say, that’s where the issue could happen more by the fissures they’re etching, but that enamel there might be one and a half, two millimeters thick. And then the bit where by the ADJ, they’ve missed that enamel there, right?

[Ahmed]

Exactly. And that’s a crucial enamel because that’s where you want your bonding to be very good. So one of the other things that we find with etching is that you press and it goes all over the place. So another tip, just like you do with your air, just extrude your etchant first on a bracket table or on a piece of tissue or something, make sure you’ve got a nice, smooth, consistent flow, or what I tend to do now is I extrude it onto a little pad and I’ll use the fissura and to run it across my enamel because I don’t want to risk an accident and whatever.

So I have a lot more control. So enamel. etch only for 30 seconds, wash it for 30 to 60 seconds. Now, this is also very important. When you’re not timing 30 seconds, it seems like two seconds. So if you think about 30 seconds, You might just do five if you time 30 seconds. It’s a long time. It’s a very long time so time 30 seconds at least and why I say that is because one of the byproducts of etching is Salts and now if you don’t wash those salts properly, you’ve got salts that are then Playing around with your bonding.

So what we’re talking about is important if you wanna get optimal bonding, and that’s what we all wanna do. So again, based on manufacturers, we need to make sure we follow their instructions in order to get the best out of the products that we’re using. But sometimes on a course, I say to people, what bond are you using? And they’ll be like, the black bottle. Which one is it? What do you use? I don’t know.

[Jaz]

When we ask them what medicines they’re having, they’re saying, Oh yeah, that purple pill, or the blue pill, or whatever. You know, like, how does that help you?

[Ahmed]

This is really important, Jaz, because, like, guys, if you’re using something, especially on a patient, and you don’t know what it is you’re using. So how do you know how you’re using it or how you’re supposed to use it? And then how do you know what you’re doing is actually going to be proper and right. So it’s our duty to understand or at least know what we are giving the patients, like you said, it would be like prescribing amoxicillin to someone who’s allergic to penicillin.

It doesn’t make sense. So you’ve got to know what you’re using before you actually do it on a patient, not just, oh, it’s the black bottle that was in the drawer or that the nurse gave to me, that’s where all the voids and mistakes and problems arise from us not knowing. What we’re using and how we should use it. So this is really important.

I wonder, I mean, if you’ve ever done this experiment on one of your courses, whereby you will ask your cohort how many of you etched dentine? And then you see the number of hands go up, right? And if you haven’t done this before, do it and do it next one, right? And then you ask them all which bond they’re using.

[Jaz]

And for those that know, and then you know, actually part of the protocol at a bond is that you shouldn’t be etching the dentine. It’s like someone messaged me once saying, Oh, my paracore kept falling away. Well, I did you and you know what? Tell me a protocol. And then I looked that bit where they said, Yes, I accidentally knows that.

Well, did you know that for the paracord protocol you don’t etch dentine? And so people that when they migrate from the earlier bonds to the more universal ones because they’ve always etch dentine from dental school. They continue to etch dentine and therefore that’s completely diminishing the bond strength of dentine by etching it.

So if anyone’s multitasking, they missed, they missed that. This is probably extremely important game changing, simple thing that you probably are sure you might be embarrassed, but there will be some dentists out there thinking, holy moly, I can’t believe I’ve been etching dentine when I shouldn’t have been etching dentine. And so it’s really important just to emphasize that.

[Ahmed]

As you say, on the courses, we do say that it’s amazing, but yeah, like jokes aside, this is really important. Now we come to the bonding. So as we said, I use a universal bond, important to try and avoid over pooling, especially in the class two area.

A couple of things

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‘Tell all my patients I’m running 20 minutes late..’ - sound familiar? If so, this episode is for you!

Punctuality goes beyond habit; it reflects our respect for others' time and professionalism. In this episode, we delve into mastering punctuality in dental practice, exploring the balance between patient care and schedule.

Join Nikhil Kanani as he unveils his five actionable strategies for refining workflows, improving communication, and boosting efficiency in your practice.

Protrusive Dental Pearl: Explore the Greater Curve Matrix Band for your restorations - it's now my preferred choice for around 70% of my cases. Wherever you are in the world, find a Greater Curve dealer and discover their range of products.

Highlights of this episode:

05:28 Protrusive Dental Pearl

11:08 Nikhil Kanani Introduction

16:13 Preparation

20:33 Stick to your Time Allocation

25:39 Have a Protocol List

28:39 Work Simultaneously and In Flow with your Nurse

31:33 Use Templates/Pre-written Procedure Protocols

35:58 Learn more from Nikhil Kanani

Join the Nicest and Geekiest Community of Dentists in the World: Protrusive Guidance

If you loved this episode be sure to check out 10 Habits of Highly Successful (and Most Valued) Dentists – PDP042

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Welcome back to another episode of Interference Cast! Today's episode is a bit unique—it's all about me. But here's the twist: I wasn't the one asking the questions. Instead, I had the pleasure of being interviewed by the incredibly talented dental student, Nav Bhatti.

During the interview, we explore my story, origins, and what fuels my passions. It's a deep dive into who I am and what drives me. Plus, I'll share insights into one of my top strengths, according to Tom Rath's Strengths Finder 2.0: being a learner. Join me as I discuss the importance of focusing on our strengths and the joy of continuous learning and sharing.

Highlights of this episode:

6:51 Get to know about Jaz Gulati

8:35 Jaz’s Journey in Dentistry

11:49 Ensuring Quality in Dentistry vs Income

15:33 Highlights and Challenges in Studying Journey

18:42 Advice for Dental Students: Balancing Academic and Social Well-being

21:18 Journey to the World of TMD

26:36 Difference between TMD and TMJ

28:13 Q&A: Dentistry and Kids - is it possible?

29:12 Why is Dentistry better than Medicine?

I recently took a bold business risk, urging subscribers to switch to Protrusive Guidance for a sleeker, more user-friendly experience. Despite initial hiccups, the response has been overwhelmingly positive.

We also offer payment plans for educational content and CPD options. Students, stay tuned for exciting updates! Join us on Protrusive Guidance to elevate your learning journey.

If you loved this episode, be sure to check out Expat Dentist in Singapore

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Dr Lane Ochi is such a legend that I wanted to throw ALL of Dentistry’s tough questions at him - and as you guys requested, it’s MOSTLY about CRACKS!

Dr Ochi practiced in Beverley Hills for 43 years and embodies the Protrusive values of a lifelong learner, avid sharer and with so much humility.

Dr Lane Ochi and another of my mentors Dr Michael Melkers will be visiting London on 27th and 28th July in London for a 2 Day course. Click here to book on!

The Protrusive Dental Pearl – Intraoral Photographs: encourage your patient to capture intraoral photos on their phone, giving them a copy for reference. This empowers the patient to stay informed, facilitating their understanding and ownership of the situation

Highlights of this Episode:

01:24 The Protrusive Dental Pearl

03:40 Dr. Lane Ochi

09:11 Amalgam Restorations

16:16 2 Types of Wearers

19:27 Virgin Teeth

20:00 Mechanical Failures in Dentistry

27:33 Force Management to Prevent Cracks

34:35 Micro Leakage - When to and When Not to Intervene?

39:32 Should you chase cracks?

45:17 Second Molar Problems

48:41 Posterior Severe Wear without Anterior Tooth Surface Loss

53:42 Management of Symptomatic Cracks

57:42 Direct Composite Overlay Protocol

Join the Nicest and Geekiest Community of Dentists in the World: Protrusive Guidance

If you liked this episode, you will also like I Hate Cracked Teeth with Kreena Patel – PDP028

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In the previous episode, Jaz and Zahid explored the foundational concepts of IDS and its transformative potential in preserving dentine integrity.

In this second installment of our Immediate Dentine Sealing (IDS) series, Jaz and Zahid turn their focus onto the critical stages of the fit appointment and reactivation process, pivotal milestones in realizing the full benefits of IDS.

Protrusive Dental Podcast: Summarized Infographics of Immediate Dentine Sealing (IDS) Clinical Step-by-Step

Highlights of this episode: to be checked on the final eps

00:00 Local Anaesthetic after IDS?
03:19 Trying in the Onlay
11:53 Ceramic Bonding Protocol
16:28 Immediate Dentine Sealing (IDS) Re-Activation
18:31 Disadvantages of Immediate Dentine Sealing (IDS)
21:56 Zirconia For Indirect Adhesive Dentistry?
23:22 Evolution of Immediate Dentine Sealing (IDS)

If you didn't see the first episode, don't forget to check Part 1

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How and Why to do Immediate Dentine Sealing: In this first episode, Zahid and Jaz not only explored the fundamental principles of IDS but also offered a practical guide for its smooth implementation in clinical settings. Every single step of IDS is broken down and made tangible. Protrusive Dental Pearl: When dental work fails after a long time service, remind the patient that 'it does not owe us anything' and 'What could they buy today that would last X years?' Highlights of this Episode: 00:00 Introduction 07:13 Zahid Shaikh Introduction 11:39 Immediate Dentin Sealing (IDS) 14:54 History of Immediate Dentin Sealing 18:47 Onlay vs Overlay? 21:33 Occlusal Reduction for Ceramic Onlays 23:28 Caries Removal and Isolation 24:58 Air Abrasion in Adhesive Dentistry 27:36 Clinical Steps in Immediate Dentine Sealing 35:48 Thickness of IDS Layer 40:12 Enamel Refinement 42:02 Preventing Temps from Sticking to Your IDS 51:11 Liquid Dam to Temporise Onlays 52:47 Removing Temporary Onlays In part 2 of this episode we will explain how to reactivate your IDS layer. Check out Dr Zahid Sheikh on Instagram! https://www.instagram.com/yourdentistzahid?igsh=MXJvaWNycWtyejhpNw== We're thrilled to announce the upcoming arrival of our Protrusive Guidance App, not only just a great source of CPD but a community of the nicest and geekiest Dentists in the world.

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Because You're Worth It - this episode is your L'Oréal moment

How to take pride in what you charge.

Stop Diagnosing wallets and giving discounts, these negative practices hurt our business and highlight a mindset issue.

In this Ask Jaz episode I discussed all the reasons why you need to STOP underselling yourself, starting from a lesson me and my wife learned in Singapore.

I explored common reasons behind this trend, such as fear of rejection and a lack of confidence, particularly among new practitioners. I shared my perspective, emphasizing the importance of building confidence through continual learning and practical experience.

I also discussed the concept of 'neuro-fiscal drag' – the phenomenon where a figure in your mind gets substantially reduced by the time it comes out of your mouth. This mindset often leads to dentists undercharging for their services. It's crucial for dental professionals to take pride in their work and understand the value they bring to their patients. After all, we're not just providing a dental service; we're restoring confidence and quality of life.

Remember, valuing your work appropriately is not just about financial gain; it's about respecting the skill, effort, and care you put into each procedure.

Highlights of the Episode:

0:00 Opening Snippet

0:52 Experience in Singapore

4:24 The Late Night Emergency

5.37 Don't apologize for your fee

6:32 Introduction

10:24 Neuro-fiscal Drag

11.38 Why NOT to give Discounts

13.37 Don't diagnose wallets

15.03 Gaining Confidence

23:35 When a patient laughed at the fee!

32:42 Protrusive Guidance

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Ever heard of fremitus? Wondering what it really means for your patient's occlusion? In this episode we're joined again by Dr. Mahmoud Ibrahim, by popular demand, for an insightful discussion on dental fremitus. We understand that this topic can be a bit perplexing, so we're here to break it down step by step.

We share how we seamlessly integrate a fremitus check into an occlusal assessment, discussing the crucial aspects of when and how to intervene effectively, all while preserving your patient’s chewing space.

Check out our upcoming course “Unchippable” to learn about how to prevent chips and breaks on your lovely anterior composite restorations – protrusive.co.uk/unchippable

Follow Dr. Ibrahim on Instagram @drmoidental

Want to learn more about Occlusion? Head over to occlusion.online.

Highlights of the episode:

00:00 Intro

00:39 The Protrusive Dental Pearl

04:17 Dr. Mahmoud Ibrahim

05:17 Mobility vs fremitus

08:26 What is fremitus?

09:52 The PDL

12:54 The weakest link theory

16:21 Checking for fremitus

17:19 Class 1 fremitus

21:57 Class 2 and 3 fremitus

23:03 Treatment

27:24 Envelope of function

29:21 Orthodontic treatment

36:34 Final remarks

39:44 Outro

If you liked this episode, you will also like PDP150 - Occlusion on Class IV Composite Restorations

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If the thought of dealing with little patients sends a shiver down your spine, then this one might be for you. This week we teamed up with Dr. Emma Ray-Chaudhuri, a paediatric specialist, to tackle the topic of children in dental pain. We discuss pain assessment for all ages, radiographs, and treatment options in hopes to make this topic a tad less daunting and a bit more fun!

Check out Dr. Ray-Chaudhuri’s website for further details on upcoming lectures spanning various dental topics: graystonereferral.com

SDCEP guidelines: https://www.sdcep.org.uk/media/2zbkrdkg/sdcep-prevention-and-management-of-dental-caries-in-children-2nd-edition.pdf

Highlights of the episode:

00:00 Intro

01:32 The Protrusive Dental Pearl

03:11 Dr. Emma Ray-Chaudhuri

09:23 Children in pain

11:13 Babies and toddlers

12:18 Preschool/school children

13:20 Teenagers

15:15 Building rapport

17:00 Radiographs

26:06 Fissure sealants and brushing

29:58 Abscesses

31:10 Irreversible vs. reversible pulpitis

32:49 Temporary restorations and the hall crown technique

39:08 Pulp therapy

42:24 The FiCTION trial

44:45 Cleansable cavities

45:59 MIH

50:03 Sensitivity

54:24 International variations

55:56 Dr. Ray-Chaudhuri’s socials

56:58 Outro

If you liked this episode, you will also like Paediatric Dentistry Communication and Prevention Part 1 and Part 2

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

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‘Easy Dentistry on Difficult Patients is still Difficult’ - Dr Lincoln Harris

Patients with small mouth opening can be a huge pain in the back for Dentists - but did you know there are ways we can significantly improve their mouth opening through physiotherapy?

In this episode I’m joined by Dr. Tzvika Greenbaum, a specialist TMJ physiotherapist who's here to spill the beans on his journey from headaches to jawaches. We bring to light the jaw-dropping collaboration between dentists and physiotherapists, making dental treatment easier for both you and your patients.

Highlights of the episode:

00:00 Intro

01:02 Dr. Tzvika Greenbaum

03:39 Dentistry meets physiotherapy

09:33 Range of movement

10:23 Asymmetry

11:20 Prevention

12:20 Advice to dentists

14:34 Stretching

16:17 The dental gym

16:57 Sleep bruxists vs. awake bruxists

19:28 Reducing sleep bruxism

20:52 Obstructive sleep apnoea

22:03 Statistics and diagnostic criteria

25:16 At-home exercises

27:20 Pain and discomfort

28:39 Rehabilitation

30:14 When to involve a physiotherapist

31:12 Expected results

32:21 Screening

34:15 Dr. Greenbaum’s event

39:04 Outro

Dr. Greenbaum’s upcoming course: protrusive.co.uk/greenbaum

If you liked this episode, you will also like 3 Simple TMD Exercises

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

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Do you know the difference between indemnity and insurance? Today we have Dr. Neel Jaiswal, founder of Professional Dental Indemnity (PDI), to shed light on these options. While indemnity rests on discretion, insurance offers secure contractual coverage, exemplified by real cases.

Dr. Jaiswal's transparent advice aids in choosing between claims-occurrence and claims-made policies.

Get a quote from PDI: www.protrusive.co.uk/insurance

If you liked this episode, you will also like 10 Commandments for Staying Out of Trouble

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Ovate pontics are what you choose when you want the best aesthetics for fixed dental bridges - but how do you go about prescribing this to your lab?

How do you carry out 'pontic site development' and how can you assess the soft tissues for suitability?

Get your onions ready, Protruserati, it's another cracker with that man Dr Jason Smithson who will make ovate pontics tangible.

We've also made a kick-ass infographic for you to download alongside 2 PDFs recommended by Dr Jason Smithson, summarising all that Dr Smithson taught on this episode. [Also available in the Protrusive Vault for premium subscribers]

Protrusive Dental Pearl: Jaz's Rule for Resin Bonded Bridges

For Metal winged adhesive bridges, do not accept more than 1 compromise
For Zirconia RBBs, do not accept any compromises!
Examples of compromises: small abutment teeth (and thus smaller surface area for bonding), poor quality enamel, awkward path of insertion, dodgy occlusions etc

Join us on Saturday 30th September for Occlusion and Communication Day at London Heathrow - amazing speakers on 2 huge topics!

As promised, check out the PDF on Ovate Pontics by Professor Bill Robbins and more about the E-Pontic here.

Learn more from Dr Jason Smithson and his Restorative Programme.

Also, check out his courses with Spear Education.

If you enjoyed this episode, you will also like PDP132Success with Resin Bonded Bridges

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Welcome back to part two of this ‘Restoring the Single Implant Crown’ podcast series that’s about to kick start your implant career. We’ve teamed up with the uber-knowledgeable Dr. Devang Patel, a dental wizard with over 13 years of spellbinding experience under his belt.

Leading on from the previous episode that focussed on case assessment to impression taking/digital scanning, we now cover the step by step protocol for fitting the implant crown, maintenance, and troubleshooting.

https://youtu.be/FDB72GtYAAs Watch PDP157 on Youtube Dr. Patel’s got your back (or should we say teeth?) every step of the way! Check out his social media platforms for further information about his upcoming implant restoration course:

@dr_devangpatel
info@drdevangpatel.com
www.drdevangpatel.com

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:00:00 Intro01:12 Restoring Implant Crowns Infographic02:03 Recap Part 103:45 Inspecting the labwork05:52 Assessing the occlusion06:22 Keeping the implant clean during the fit appointment07:21 Anaesthetic Prior to Implant Crown Try-In?08:20 Screwing in the crown11:13 Occlusion and guidance17:18 Temporarily restoring the access hole18:33 Review19:49 Definitive torque and sealing the access hole25:46 Yearly review of Implant Crown27:18 Radiographs29:21 Excessive blanching when fitting crown31:21 High occlusion management32:06 Open contact points for implant crowns34:43 Other implantologists’ work38:29 Angulated screw channels43:24 Loose implant crowns45:52 Implant passports46:57 Adjusting the occlusion48:24 Dr. Devang Patel51:13 Outro

You can now download the infographic that sums up Part 1 and Part 2 of An Idiot’s Guide to Restoring Single Implant Crowns. Just head to protrusive.co.uk/idiot

If you liked this episode, you will also like Full Mouth Rehabs Part 3

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

Click below for full episode transcript: Jaz's Introduction: Hello, Protruserati. I'm Jaz Gulati and welcome back to Part Two of an Idiot's Guide to Restoring the Single Implant Crown. Now, if you haven't yet listened to the first part of this episode, that's PDP156. Jaz’s Introduction:You should probably start there first because Dr. Devang Patel, our esteemed guest, he talks us through from the very beginning, like how do you assess the site that might be suitable for an implant and what to actually do if someone else’s placed implant is coming to you for the restoration.

And let me tell you, I learned so much. The episode is called an Idiot’s Guide. I’m the idiot, right? So I was learning so much as getting along. He taught us about internal hex, external hex, conical, or butt joints, all these things I was learning about implants. Then we talk about impressions and scanning.

And now we’re going to be talking about what happens when the lab work comes back from the lab and you’re going to assess it. You want to take a radiograph. You’re going to actually screw the screw retain crown in. But what are you checking for? Do you have to give local anesthetic, for example? How much talk do you need to give at that point?

How do you then restore the screw access hole? And what should be the follow up protocol going forward, as well as the all important troubleshooting? It’s really important when you learn a new skill, that you learn about the troubleshooting. So any of the common complications that you can get ahead of it.

Protrusive Dental PearlSo just before we go and join Devang for that Part two, I’m going to give you the Protrusive Dental Pearl. It’s basically a summary of both these two episodes, so PDP156 and this episode, because I imagine as a learner, it can become quite overwhelming, especially if you’re commuting, chopping onions, and then to try and remember and think, you need like an aid memoir.

I know the premium notes are there. But this is like a step-by-step appointment by appointment summary, which I will make available. So if you’re a premium subscriber, you will find it in the app already, but if you’re not, and you’d like to get your hands on this appointment by appointment checklist, if you’d like based on everything that Devang is teaching, then all you have to do is go to protrusive.co.uk/idiot. That’s right. It’s protrusive.co.uk/idiot. And I’ll take you to the landing page so I can email you the PDF. Thank you to Devang for helping us make this so we can make this confusing topic tangible for you. Let’s now join Devang for the main episode and I’ll catch you in the outro.

Main Episode:Welcome back again Devang. We covered last time about restoring implants and there was so much to it that we split it into a two-part episode. Just briefly remind us the three steps that we covered so far and what step four is today and the journey you’re going to take us on today.

[Devang]Okay. So thank you very much Jaz for having me again. So it’s always delighted to come to your podcast. In step one, we discussed about how to do clinical assessment for the implant restorations. We discussed how to record impression, how to take a impression for implants. And we mainly discussed how to communicate with the laboratory, what to write in the lab docket, because if you are really taking digital impression for implant, it’s quite easy, very straightforward.

You just need to put the scan body in, scan it like you normally do. But it’s the communication with the lab and you need to be a little bit in control as to how labs are making the restoration. Are they using Ti bases, which is off-the-shelf abutment and then cementing crown on top, because that’s the cheapest way to do it.

So if your lab cost is really low, that’s how your lab is doing the crowns. And nothing wrong with it, but many time Ti bases are very very small and there is a risk of their crown decementing even though you have a screw retained crown. Because lab would make the crown in the lab, create a hole through the crown and cement it onto the abutment.

You can gain access to the screw really. So you need to be aware of that. And now in today’s episode, we’re going to discuss about step number four, which is Fitting of the Crown, step number five, which is Maintenance. And we’ll discuss some of the complications because when you start doing everything, everything’s going fine. That’s great. But really, you understand your depth of knowledge when something doesn’t go right, and you need to correct it.

[Jaz]Great. Well, if you pick up from the point where you sent your scan body or impression to lab, you put the healing abutment back on. A few weeks later, you’ve done your lab communication, the patient comes back, and you’re now going to remove the healing abutment? Or what are the procedures, checking lab work? You take it whichever direction you want, sir.

[Devang]Okay, so, first of all, when the lab work comes in, I would check, make sure that on the model, the crown looks fine, okay? So, make sure that you check it on the model, what you need to do is when the model comes back, most of the time it will come up with a gum attached to the, you have a fake gum on the model, it would be there.

I take the gum off and then put the crown in on the model. Check, make sure the crown seat’s okay. The other thing you need to do that is that you need to have, or you need to ask your lab to get you a new screw. You don’t want to use the same screw which lab used in this lab to tighten patient’s mouth because the screw have gone in and out multiple times and it’s not ideal.

So you want to use, maybe you can use the same screw to try in the crown and make sure everything’s fine before you use, but finally, right at the end, you want to use a fresh new screw to screw the crown in. So you’re going to check everything on the model, make sure the contacts are not tied.

[Jaz]Devang, is this standard protocol or is this you being like extra careful? Is this like what is standardly taught and practiced?

[Devang]This is how I was taught when I was taught, implant restoration at Eastman. That’s how I was taught. I know it’s not a standard protocol in the sense that I know most of the technician will not send you a new screw. You do need to request for it.

I have actually, I’ve just bought the screw from the company itself because it’s cheaper for me to buy it that way. So, I buy it on bulk, like 50 screws. They’re not very expensive. If you buy 25 BioHorizons screws, they are like 80 pounds, 85 pounds. So it’s not tremendously expensive. So I just buy it. I have it with me and the technician will send me the crown and I’ll change it myself. It’s a recommended protocol-

[Jaz]Good point.

[Devang]And that’s how I was taught, but I don’t think that’s a commonly used protocol, if that makes sense. But it won’t add too much to your lab costs.

[Jaz]A nice little tip and a pearl for those implant dentists.

[Devang]Now, once you assessed on the model that everything fits fine, now you’re going back to patient’s mouth. So patient come in, you are doing the same protocol like you do for normal cementation of the crown, right? So you’re going to check. Before you even put the crown in the mouth, you’re going to check shim stock holes. You’re going to check the occlusion before you put the implant crown in the mouth. So you’re going to really assess patient’s current occlusion, which we don’t want to change after we place the implant.

Once we assess that, we take the healing abutment out. Any time I put, or I take things out from the implant screw on screw, I would irrigate using chlorhexidine because you don’t want to really push any bacteria into the implant, into that channel, screw channel when you’re pushing the crown back in. So even like during the appointment, if I take the crown in and out, patients close their mouth, I would always irrigate with the chlorhexidine.

So my protocol is anything, every time I take the crown to patient’s mouth, I would irrigate before with chlorhexidine. Again, it’s a little bit OCD, but I know Khoury, I learned it from Khoury where he would put antibacterial sort of a gel or antibacterial sort of a paste in the screw channel just because he was worried that there could be infection leading or bacteria leading from the screw access channel to the implant causing bone loss.

So, again, what was the study behind it? Not much, there is not much evidence behind it. But we want to make sure that we don’t really push any bacteria in there. So then I’ll take the healing abutment out.

[Jaz]That makes sense. Now, just a bit more, a step back, actually. How often would you be anesthetizing these patients? Would you have to ever give LA?

[Devang]Oh, well, good question, actually. So when patients come in, I tell patient that around 60% of the patients, 70% of the patient can get away without any injection. Would you want me to give you injection or you want to see how things go? While I’m doing the treatment, fitting the crown in, if it’s painful, you can stop me and I can give you injection then.

Or I can give you injection from beforehand. Some of the patients, if they are really anxious, they’re like, no, just give me injection. So I’ll give them injection, which is fine. Some of the patients, they don’t like the numbness and they will be saying like, okay, we don’t want to. So I don’t. Generally, when I do the crown, I don’t really compress the gum too much.

So my instruction generally to the technician would be, I want a narrow emergence profile. So compression to the gum is not excessive, so I would generally, it’s okay for my patients, but yes, I do give patient an option that whether they want LA or not.

[Jaz]Okay.

[Devang]So once that’s done, so I would take the crown to patient’s mouth. And generally, when you put the crown in, it should slot in unless you’re using very old type implants or it’s a different implant, like the name of the implant, it’ll come to me, but where there is no connection, you literally, it’s a friction fit connection where there is no hex or anything like that.

But generally, most of the implant would have some sort of a hex where you would, you will feel the crown slotting in. When that happens, yeah, conical connection or it could be a butt joint connection, but either or any internal connection will have an internal hex in there. So the crown will feel going in unless your crown is really compressing the gum a lot, that time you might not feel the connection.

But generally, you will feel the connection, you will slot it in. And then start screwing the screw in. As soon as you feel the first resistance, you need to stop. And you need to check the contact point. Because what will happen is, if you’re taking a general, normal impressions, open tray or closed tray impression, you are, there is a small chance always that, during the process, the impression post moved a little bit, and the crown might not be in the really exact position.

So, if the contact point is a bit tight, Then you could just keep screwing it in and you will use a cross thread the screws and you ruin the screw threads. So you want to make sure you first resist and you check the contact points. If the contact points are fine then you carry on because it may be just compressing the gum and the gum is sort of giving that resistance if that makes sense. So you would keep doing it.

[Jaz]It’s just normal checking with floss, right? Nothing more to it?

[Devang]Yeah. No, just floss and you checking that floss goes in nicely. With implants I’m slightly more sensitive So if the floss goes in but with the bit more pressure, I don’t like that. So I want it with the gentle pressure floss should go in click click. So you should feel still here or feel the clicking but I want that to be lighter because with the screw-it-in crown you never know, the crown might be compressing a bit, little bit too much and it may not seat completely and you won’t know because floss will still go in because the crown’s nice and smooth.

Generally, technician make the crown with the small point contact rather than surface contact interproximately. So it’s easy to just go through that even though they are quite tight. So I would, I would do that and keep checking going back and forth, back and forth, back and forth until I know the crown’s completely seated, the screwdriver’s not turning more and contact points are fine.

Only then I would really check occlusion. Okay. So I’ll need to make sure the crown and this is the same thing with the normal crown fitting, right? So you want to make sure the interproximal is fine before you start checking the margin or occlusion, really. So I’ll come to that occlusion in a minute.

So I’ll check occlusion. Everything’s fine. Then I’ll take a radiograph to make sure that the crown’s seated properly on the implant. I’ll come back to the occlusion that with regards to occlusion, if you think that the occlusion is quite high, which you weren’t expecting, then you take a radiograph first, because it could be there is something not allowing the implant to seat properly, implant crown to seat properly in the implant, you take half an hour adjusting occlusion, and then you think, oh, the crown is not seated properly, and then you have to send it back anyway to the lab.

So make sure that if you think that it’s way off, then check the radiograph first, before you check the occlusion. Now, with regards to occlusion, we want our implant to be 30 micron off occlusion in the sense that you don’t when patient closing. You want 30 micron space between implant and opposing tooth, okay?

[Jaz]Clearance.

[Devang]Yeah, that’s because obviously we know that our PDL, the teeth have PDL ligament, and then, you know, when patient closes and grinds, they intrude the natural teeth, but the implants don’t intrude. So because of that, we want to give some sort of a cushion effect, some sort of a leeway when patient bite really hard, then all the teeth will intrude and then implant will be very small in contact, very tiny bit.

And one of the easiest way to measure that is to, I use articulating paper which is around 12 to 14 micron thick. So, I just double the articulating paper and then ask patient to close and check the occlusion that way. So, make sure that you have 30 micron clearance. Now, guidance is another thing you may need to really consider when it comes to occlusion, whether you’re going to use your implant for the guidance or not.

For a single tooth, I will never put guidance on my implant because you can get away with most of the things. So let’s say if your implant is upper right one, you have rest of the anterior teeth, do you use a protrusive guidance? If your implant is upper right three and you prefer, you can’t use canine guidance because it’s your implant.

Then you can use a group function. I’m not really too faffed about using group function. Obviously I like canine guidance because it’s easy, but if I have to use a group function, I would use group function. So I would avoid for single implants anyway, my guidance. Now, if you’re doing small bridges and if you cannot avoid guidance, then you need to spread it, spread it out.

As much as possible, because I’m doing a full arch implant now, I can’t really avoid guidance on full arch implant. So you need to spread your guidance as much as possible everywhere. So it’s very simple for single tooth.

[Jaz]Now just a question on that, just making it really practical, just basic occlusion checking is, if you put in your article paper and you fold it, so let’s say you’ve got roughly 30 microns and the patient bites together and you want to see it pull through because it’s clearance, but do you then check again with the patient clenching really hard and then you don’t mind if it just contacts a bit? Is that right?

[Devang]Yes, clenching hard, I want, I mean, if you really want to assess with the clenching hard, then you want to put shim stock in there. When they’re clenching hard, your shimstock may be just about to, just about whole, but you should be able to still pull through, but you may feel a little bit of resistance when they clench hard.

[Jaz]Like a drag, like a shim drag basically.

[Devang]Yeah, exactly. That’s what, but if it just pulls through and there’s a little bit, a small gap, I’m not terribly worried about that to be honest. I don’t want too much load on my implant.

[Jaz]Here’s an interesting question for you then Devang. If you, let’s say you’re doing a lower first molar implant crown. Okay, and you want it out of the occlusion. Now, let’s say this patient is half a unit class two. Therefore, the opposing tooth would be like an upper molar as well. So, now you’re out of the bite, but over time, wouldn’t that upper molar just keep erupting, keep compensating, keep coming into the bite? Because it doesn’t have like half a cusp on the tooth behind or tooth in front. So how do you guys deal with that?

[Devang]Yeah, that’s a really good question. And I don’t have the answer to it, to be honest. What happens is, which I’ll cover in maintenance is that when patient comes in every yearly, you would assess the occlusion. And what I’ve found in many time is that’s exactly what’s happened there.

Especially sevens. Sevens are buggers because you create a clearance, and you lose it like this. Like when patient come back, I can guarantee you that you lost that clearance, which you made in a year’s time. There are a few options you have, you’re either adjust the opposing tooth because you definitely, you don’t want your implant to be loaded.

Unfortunately, you will, there are lots of problems, lots of issues. I actually saw a patient this Thursday came in with a loose crown, screw retained crown, and that was because I fitted the crown and then I checked the occlusion. It was proud. And that crown’s been there in six years in his mouth.

So I know I’ve checked it last year and he wasn’t proud. So it just becomes, it was the first, almost first point of contact and it was last tooth in the arch. So recurrently, this is how I manage. I either adjust the implant crown. or adjust the opposing tooth. Generally, I adjust the implant crown. And that’s it. I leave it like that.

Now I’m starting to change my philosophy in the sense that I don’t think the material we are using for implant, I don’t think it’s the right material. I think we should be using more sort of a shock absorbing material, such as like a composite for implants, where we can get away with a little bit of occlusal load, where it absorbs the shock of that little bit of occlusal load.

Otherwise the same thing happens. Keep teeth keep moving. We know that teeth move all the time. That’s what I do, for now, but I don’t have any robust answer as to what to do. Then someone would say, okay, give them a mouth guard, give them Essix retainer, so teeth don’t move. Studies have shown that it’s not reliable. Teeth still move, like small movement, it still happens with the Essix Retainer on. But if you want to be a bit more-

[Jaz]Yeah, because we’re dealing very minimal amount of microns.

[Devang]Yeah, exactly. But you can give Essix Retainer just to make you feel a bit better. I’ve tried both ways and I’ve still seen teeth move. Because exactly, we’re looking at microns, we’re not looking at millimetres.

[Jaz]Fine, so you’ve checked the occlusion thoroughly, static and dynamic, what next? Are you finally going to switch, get your screw, the one that you have, the one that you bought, independently?

[Devang]Yes, so, what I tend to then do is, once everything’s fine, I’m happy. This crowns fitted. I’ve shown it to patient patients happy. At this time, I show them the screw access hole as well, that there is a hole in the crown. They usually don’t feel surprised because I would’ve shown them during my consultation that this would happen. Initially, I didn’t. And then patient’s like, what you going to gimme hole in my crown?

Like this is a new crown and you really get a crown with the hole in it. So I need to, I generally explain it to them on the consultation appointment that this is how I approach it. So I show them everything, explain that our hygiene patient’s happy. Then I would take the old screw out, swap it with the new screw.

And I would hand tighten it. And I would put a PTFE in there and then I would put a, some sort of a material like a clip or sort of temporary composite material in there, in the excess hole. Generally, so I put a PTFE until, let’s say, 3mm spaces left. So you don’t need, like, small PTFE and a big TFM sort of a material.

You want big PTFE and then small material. It just makes your life easy next time when patient comes in. So I would do that and then I will let patient go for a test ride. So that I’ll see patient for anything between 6 to 8 weeks after I’ve fitted the crown for a second, for a review. To make sure patient’s happy, I look at the gums, make sure everything’s happy, take the photos, because on the day, gum will be blanched, so, you don’t want to take photos on that day because it won’t look nice, so you want to wait till six weeks anyway, six to eight weeks, but mainly patient would give you an opinion. With a screw-retained crown, it’s really good, if patient comes back and like, I don’t like this, I don’t like that, you unscrew it. Put a healing about them back, send it back to lab for whatever amendments you want to make.

So it’s fine. However, I tell patient that as we know with porcelain, if you’re using UCLA type crowns, where the lead porcelain, they’ve used a PFM type porcelain. The longer it stays in patient’s mouth, refiring, when you want to change, it becomes a bit trickier because of the water content.

So the water goes into the crown, it gets moisture in there, and then when you put it in a furnace, there is a chance that everything just breaks apart. So I tell patients that if you don’t like anything, don’t wait till six weeks, just come sooner, okay? But generally, 99% patients like fine.

Everything’s happy. They’re happy. So when they come back in six to eight weeks time, then I would torque the implant. And torque range, it ranges from 20-35 N-cm. You need to check which implant company you’re using, and you need to use a torque setting to the recommended implant company. So Neodent, I know, I think they recommend 20, Straumann’s 35. BioHorizons 30. So it depends really what kind of torque range implant system you’re using. I’ll torque it.

[Jaz]And does each implant system have its own torque wrench? Or does one torque wrench be applicable to all the systems?

[Devang]No, but just to make your life difficult, each company will have their own torque wrench. However, each company will have a machine fit driver, which means it’s a latch grip driver. Now, if you have a torque your own torque wrench, you can put that let’s grip into your torque wrench and you can use one torque range for everything. But generally your restorative kit would have some sort of a torque wrench which company has provided.

So it’s not a big, big issue. When you are like me and you’re treating like multiple implants and everything, then it may be worth having a universal torque wrench kit where it comes with a handle. I don’t know if you remember, when we removed gutta percha for doing post and core preparation.

We used to have this handle and then you snap the drill into the handle rather than using the slow hand piece to remove the gutta percha you can use a handle and use the hand to remove the gutta percha. So you’re not really removing it too much. But at least at Eastman we used to taught it like that teach it. So you can use a majority gutta percha with the hand piece and the last bit you can use with the hand. But it’s basically a latch grip.

You can just put it in the handle and you can use it. You can torque it and then a new PTFE. If you, let’s say patient comes back and your crown’s loose, the screw is a little bit loose. Then you need to go back and check whether your contact points a bit tight or why this screw became loose. Generally, they don’t become loose that easily.

So you need to make sure that it doesn’t, if it has become loose, then I’ll retighten it. And review the patient again, in six to eight weeks time. I don’t want to become loose within eight weeks time, even if I’m hand tightening it. That means there is some other issue going on. So once it’s fine, I’ll torque it.

I’ll irrigate the channel, make sure there is nothing in there. Dry it. PTFE, new PTFE. Now, there are lots of material people have used. So not just PTFE, they’ve used antibacterial seal to seal the whole access hole. But I’ve seen studies and they recommend PTFE with composite on top. Works fine. Cotton wool actually doesn’t work very well.

So PTFE is much better than a cotton wool. So PTFE again. And then if you have, if your technician has done their job properly, what you would have is you will be able to see the screw, the metal channel extending right just above the occlusal surface. So just one millimeter shy, because you want metal to cover, support the whole porcelain, right?

But the problem is with the screw retainer, especially the mandibular, let’s say molar, it doesn’t look nice when you put the cement, the metal shines through. Okay. So patient will be like, it doesn’t look nice. So, what I tend to do is PTFE, 3mm gap, and I have a Opaquer. I use a similar Opaquer where technician would use for composite to hide the metal. So I would use Opaquer to bond to metal.

[Jaz]Is this like a liquid form? Like a Tippex kind of thing?

[Devang]Yeah, it’s a dental version. Do you know a pink opaquer from Cosmedent? That works fine.

[Jaz]Yeah, I use the Ivoclar one, the direct opaque.

[Devang]Yeah, same thing. Any opaquer. So I would use silane metal primer first to prime the metal. Dry it. I tend to use bond. There is no evidence behind it, but you can use a little bit bond. Cure it and then metal opaquer. Cure that and then composite and that will mask the hole. You don’t want to mask it very, very nicely because obviously you want to go back again. You might have to go back again at some point. So you want to see where the marginal hole is. So I would explain to patient always and patients generally are fine. They don’t, they’re not that fussy.

[Jaz]Yeah. I’ll just ask a timely question then Devang, because you mentioned the fact that you want the retrievability. So you want to be able to go in again. How often, like for restoring the single implant crown let’s say a premolar molar and you see them at the six to eight week control and then this time you’re going to use a torque wrench whereas before when you fitted it you used the hand tightening but this is the first time you use a torque wrench you do your PTFE you do your Clip or Telio or whatever. How often through the lifespan of the next 20 years on average would it be required for someone to go back in and remove the clip, remove the PTFE and unscrew it? Obviously, there’s going to be various reasons this can happen, but is there an average in your experience so that you have to go back in?

[Devang]Well, I would say less than five percent. So you don’t have to do too many times, like less than five percent of the patients would need me some inter- and generally there is a reason behind it. Either they chipped something, there is an inflammation or they have some sort of-

[Jaz]Screw loosening.

[Devang]Have done or something. Yeah, screw loosening. Screw loosening is more prevalent with the implant with the butt joint than the conical connection. So if you have a conical connection, screw loosening is much less unless the occlusion comes in a way.

So if occlusion changes, then there is a screw loosening. So these are the reasons. Generally, I would say posterior teeth, you get more through loosening the anterior teeth again because of the occlusion, but yeah, so not very often if patient comes in for a review, so that’s really, as you said, timely question.

So the next thing is really a Maintenance. When patient come in for maintenance appointment, right? So now you’ve seen patient, torqued it, filled it. Now I would tell patient that, okay, I’ll see you in a year’s time. So I’ll see patient in a one year time for a review. So when the patient come back for a review, in a year’s time, I would make sure that I’ve done the full assessment, I gain occlusion.

First thing I check because that’s the thing support probably would have changed. I would assess the pocketing. Now, there is a controversial thing where there are some people recommend to pocket probe around the implant. Some people don’t recommend probing around the implant. And there are two different camps.

I gently probe around the implant because without that you’re kind of blind. But I’m not going to worry too much if my probe goes down as far as there is no bleeding because you need to imagine that the implant is quite subcrestal. Crown and abutment almost will be four millimeter before it emerges out from the gum.

So three to four millimeter. So pocketing of three millimeter is not really a pocketing. You’re going towards the implant level really. So, plus it’s very difficult to probe because of the convexity of the crown. So you don’t know. So what all I’m checking is when I do probing, is there bleeding or not.

I’m checking that I’m taking a radiograph to assess the bone level to make sure everything’s fine. Checking occlusion, checking mobility of the crown. So make sure you check. literally grab the crown and just try and move it to make sure that it doesn’t move. So these are the main checks I do with regards to implant restoration. Now, if there is a bleeding and everything, we can then discuss next, but it’s very simple, few checks when patient comes back for a review. So it’s nothing really complicated.

[Jaz]And at this point, how many years would you continue to see this patient for? For doing that protocol and for how long do you take PAs for? Is it every year for five years or any guidelines on that?

[Devang]Yeah, so generally the protocol which I’ve read in old ADI website, I think it’s still valid, is that you need to do it for two consecutive years. And if you don’t see any changes in the bone, everything’s fine. Then you can do it every other year, every three years or something like that.

So you don’t need to take it every yearly radiograph. I give after two years. So I would do it for two years. After second year, everything seems fine. Then I give patient an option. I tell them that, okay, you have an option. You can either see me every two years or you can either see me still every yearly.

I personally prefer to see patient yearly. Like, nice guidelines about patient. Some of the patient. You can-do two-yearly checkup, right? If there is a very low risk of caries, just generally, generally. Yeah, I just don’t agree with that personally, because there’s so many things can change in two years.

People, lifestyles can change. Their habits can change. So, you don’t know what you see. In two years time, things can be completely different. So I prefer to see patient on a yearly basis. And I tell them that, look, you’re paying me whatever review, assessment appointment for like five minutes for me to have a look in your mouth.

But I would rather you do that. Then I have to work hard in your mouth because you cause some problem. But it’s entirely up to you. If you want me to see you, I would prefer to see you. But if you say, look Dev, I want to save money and let my general dentist assess my implant, then that’s fine.

So I give them an option after two years. First two years is kind of non negotiable. So I tell them and they’re generally happy with that. And then after two years, some patients would be like, look Dev, there’s nothing wrong with it. I don’t even know which tooth is implant. And also if the patient is our own patient, then I feel a bit more comfortable because all our associates understand how to assess implant. So I’m comfortable referring them back to their dentist. And I know that if there is any issue, the dentist will refer a patient back to me.

[Jaz]Amazing. So that’s the maintenance capped up there. And then troubleshooting. I mean, one thing that I wanted to ask you by saved it for troubleshooting is a scenario whereby you’re placing the crown back from the lab and you’re getting maybe excessive blanching, or the soft tissue is just, it’s impeding the seating of your crown too much. At which point do you get out the laser or do you get out some sort of a gingival removal? Is that something that you want to cover?

[Devang]Yeah. Okay. So it generally doesn’t happen. The reason being that if I feel that I want a bigger emergence profile, I would have put a bigger, wider healing abutment to already while when I do the second stage surgery for me to get the the structure of the gum ready for my final crown.

I sometimes do custom abutment if I feel that I want a better emergence profile. So I would have done all that before I fit the crown in. So it would have been done before. It used to happen when I started restoring implant where I would use your wrong healing abutment, like a very small one, because like if you use a big healing abutment during the second stage.

You need to know how to close the wound if because it’s difficult to close it before the big healing abutment. So I used to use a small healing abutment so I can close the area nicely. And then when it comes to doing fitting of the crown, crown would always be like really really stretching the gum. So no laser, nothing.

I would give patient obviously LA by this time patient would have been pain anyway. So you need to give patient LA, use a blade to just put into proximal incisions to sort of a crestal incisions, loosen the flap a little bit and put the crown in. So what will happen is the ground gum has become loosened.

You literally move the gum, crown goes in. If you feel that it’s opened up the flap, then just a couple of interdental stitches and then that’s it. If it’s not, then you don’t even many time need to use the stitch. It will have a small gap interproximately which will heal by secondary intention. Okay? Does that make sense?

[Jaz]Okay, very good. What other complications do you want the general dentist to know about?

[Devang]Okay, so there are 6 plus 1 because you discussed last time about the open contact points. So we’ll cover that. So let’s start with that. So, apart from high occlusion point, which you must check because you will see much more commonly than normal.

And this is when you would understand that occlusion is very dynamic. It keeps changing. So, this is when you realize because implant doesn’t move. And then if you know, you’ve made sure you got 30 micron clearance and patient comes back in a year’s time with a high occlusion on that tooth, you know that something’s changed.

That’s the main thing that’s the most commonly happens. So I would expect that on my review appointment. The other thing can happen is open contact points. Now there have been studies done and we know that the teeth have the tendency to move mesially. So there is a higher probability with the molars.

There is lower probability with the premolars and the higher with the molars because of the bite and everything that there will be mesial open contact point at some point in next 10 years. Okay. The studies done for five years and the probability was probably, I think it was 38% to 42% that there will be some sort of an open or light contact will develop.

However, the good thing is they could not find any correlation between open contact and peri implantitis. So, they didn’t find any correlation between open contact and any issue with the implant itself. So that’s a good thing, but obviously, nonetheless, that can happen. The other scenario can happen where there is a space distal to the implant.

So if I placed restored 6, there is open contact between 6 and 7. There is no clear cut answer to that. There is no study suggesting, oh, if this happens, you do this. What’s clear is that the occlusal splints doesn’t work. So if you give patient Essix Retainer, it does not work. But you by all means give them just for your security.

So what are the other options? Someone has suggested that if there is a space between 6 and 7, you could do occlusal adjustment so that 7 is not as high, not too much load on the 7, because the theory was that because of the occlusion, because of the closure backwards, causing the space in the front.

So you can, if you need to see if there’s a first point of contact on that seven and that’s causing the space. What I have done in past is I’ve done two things. One is if it’s a light contact, then I don’t do anything. Just leave it and monitor it. If it’s open contact, then I have done in past, taken the crown off and send it back to lab to add some material on there, which is a lot of faff. What I’ve done in past is this is a normal tooth on either side. Then I would add composite to the interproximal surface of the tooth. So to close the contact, basically you take the can off, add some composite to close really.

[Jaz]That’s what I’ve done before actually. Like if there’s a DO composite and then you just make the DO wider.

[Devang]But none of the study mentions that, you know. So then you’re thinking, am I doing the right thing? But that’s the logical thing to do, really. There is no clear-cut answer, if that makes sense. So does that answer your question?

[Jaz]Fair enough. What are the other three?

[Devang]So the number one scenario, which is not really a complication, but it’s a scenario where patients come to you, and patients, because they love you so much, they want you to restore their implant. So someone else has placed the implant or someone has already restored the tooth, but the tooth is fractured, porcelain is chipped or whatever.

And now patient wants you to restore that implant. What kind of information would you need? So first of all, when patient like that comes in, I might always, even though I can restore implants, might always go to suggestion for patient is to go back to the dentist who’s placed the implant. Not because I don’t want to take responsibility.

Especially whether it’s in UK because it will be cheaper for patient to get it replaced by the dentist who is referred. So now if I have done the crown if patient comes back to me within like less than 10 years time and needs a new crown because I’ve done it. I have all the instruments. I have all the healing abutment.

I have impression post. I won’t have to source it If that makes sense. So my life is easy. So I generally don’t charge patient much more than a normal crown fees. But if patients coming to me and with the implant, which I don’t restore generally, I would add probably four or 500 pounds more.

Because I need to source all the material. I need to call the rep. I need to get the impression post. I need to get the drivers.

[Jaz]Devang, I think that’s totally fair. Like, it’s kind of like an inconvenience fee, right? Because you’re seeing someone. It’s like the patient may know you and love you, but it’s the tooth. The implant is still a stranger to you. So I think that’s completely justified. I think you had two more complications you wanted to cover. And I’m going to then go back to complication number one. I just want some more information about that. But let’s just finish off the two complications.

[Devang]Okay. So, so this one actually, so I just took, close this conversation, this first one, the patient’s coming, you need to know few details before you can restore the implant, right? So you need to make sure that you know when the implant was done. What, when was it done? So if it’s like 15 years ago, you may have an old implant. You need to know, you need to do clinical assessment to see is it viable for patients to spend another 1500 pounds to restore the tooth with implant crown.

You need to take periapical radiograph. And I take a small CBCT to really check the implant, because I don’t want to charge patient 1500, load that implant and then realize the implant fails because there is no bone.

[Jaz]Do you not get like lots of scatter from the implant? Is it possible to get this data?

[Devang]Yes, you can remove scatter from implant sort of smart CBCT assessment softwares can remove, scatter enough for you to know roughly. Now, if there is a one millimeter bone buccally, you will not be able to see it, but generally you will get an idea, vertical height of the bone. You’ll get some idea of the bone.And then you need to make sure you know what type of implant it is. If unless you know what type of implant is it? You can’t restore it. And then, as I said, you need to consider the fees.

[Jaz]Do you use that website Devang? What’s that implant dot com or whatever?

[Devang]Yeah, I know it was helpful to me. Like there’s so many, so many implants in there. You get locked down.

[Jaz]They all look the bloody same.

[Devang]Same. Yeah, they all look the same. So what I do is I go by when was the implant done. If it’s pre-2005, then it is more likely possibly Nobel or Straumann, some sort of a older companies. And I ask around most of the time, someone from the group somewhere would know what implant it is.

[Jaz]I think there must be some AI now that there must be some AI where you upload your radiograph and the AI will tell you which implant that is, rather than, I know that’s the whole point, the website, but then he still gives you some options, but now it just does all the work for you. It actually tells you, is this implant?

[Devang]Yeah, that would be amazing. So the second most common complication you would come across when you are doing screw retain restoration is the screw hole comes out from the buccal aspect. Okay, so if the implant is not in the right position placed not in the right position and you want to make the screw retain crown, but the screw access hole is coming out buccally then if you’re restoring central incisor, you can’t really restore the incisor with the aesthetics. So then you need to do an angle correction.

So in angle correction is all it is, is basically a screw head and a special screwdriver where that screw driver can engage that screw head at a certain angle. So you can tighten, you know, usually to tighten the screw, you need to go 90 like straight to the angle of the screw head and then you tighten the screw.

Now, if you want to tighten the screw with the 25 degree angle. You need a special screw head and special screwdriver so you can avoid the angle. You can still tighten the screw because the fact that the screw needs to go into the implant doesn’t change. Implant doesn’t change where it is. So now you need to, you’re thinking about the excess of the screw hole and if you have a special screwdriver, then you can, and that’s all is angle correction basically.

So you’re not angle correcting implant, you’re angle correcting, not even a screw, you angle correcting your screwdriver so that your screwdriver can fit into the screw at 25 degree angle. Does that make sense?

[Jaz]It makes sense to me but this is all so that we can still do it in screw retain and avoid the cement retained.

[Devang]Cement retained, exactly. Now the other option is you can go straight to cement retain, avoid all that issue and cement retain crown. But now 25 degree screw channel angulation correction is very common nowadays and very predictably done, so I wouldn’t hesitate doing the angle correction. Now-

[Jaz]And this is all, like, all the hard work here is pretty much done by the lab, right? You’re just writing on your prescription and they just send you it, so really-

[Devang]You’re not even writing it.

[Jaz]Your steps aren’t, yeah, okay, the lab will know, yeah.

[Devang]Yeah, you’re just telling them, I want screw-retained crown, so the lab should call you saying that, look, the crown needs angle correction. Most of them, the problem is that the lab doesn’t call you. They will just use angle correction screw and send it back. And now you’re thinking, oh, my screwdriver doesn’t fit into the crown because you’re using normal screwdriver. Lab hasn’t told you that they’ve used an angled screw and you need an angled screwdriver. I had a dentist who fitted the crown.

What happens is the screwdriver, normal screwdriver, went into the screw and half turned the screw in. Now the dentist couldn’t turn it back off and couldn’t tighten it either. So the patient came with a dangling crown to see me. Just because I had this, so, lab communication is really important.

So lab must tell you what screw they’ve used so you can use appropriate screwdriver. But you’ll be surprised how many times labs don’t tell you, give you the information.

[Jaz]And this is like all part of the kit, like, whichever implant system you use, you got like different degrees of angles of screwdrivers. Is that right? Is that how it works?

[Devang]No. So again, no, it’s a separate kit. So you need to buy a separately that screwdriver depending on what screw channel. So the lab would have tell you that they’re all same, angle corrective screwdrivers, you can use one angle corrected screwdriver for everything. It’s not true in my book I’ve got several screwdrivers lined up and you can tell that they are different heads. So you need to know-

[Jaz]Is there a 15 degree one different to a 20 degree one different to a 25 degree one?

[Devang]Yes. But in similarly like if you have a 25 degree one, you can use it for 15 degree correction. Does that make sense? It’s not like that. So but Straumann has their own angle correction screwdriver, the Createch lab, which mills the thing in Spain, they have their own angle corrected driver, Bio Horizon they have their own, Nobel has their own.

So it’s a plethora of angle corrected screwdrivers. Now if you can’t angle correct because it’s more than 25 and you still want to do screw retain crown, then what I have done in past once is when patient came to see me where her bridge was de cementing. Someone else placed the implant, cemented implant bridge, de cementing.

So we wanted to make a screw retained bridge and the screw hole were coming out buccally. So we made a composite bridge. So metal framework with the composite on top with the buccal screw holes. I tightened the screws and did a buccal filling, buccal veneer on the thing. So masking the screw hole. Okay, so it’s a composite bridge. And that’s the compromise again. Where you cannot really even angle correct.

[Jaz]Okay. And it is a composite bridge because you were able to then use your direct composite to fix it.

[Devang]Yes. To fill the hole. So that’s the really, the main complication if you want to make a screwin crown would come across. Now the long term would be really generally two things. Screw loosening we already discussed. But when you, when patient comes with a screw loosening, you need to make sure you take the crown off. Don’t just tighten the screw because food and back, everything would have gone under the crown.

So take the crown off, clean it with the brush, disinfect it with the chlorhexidine, clean the area of the gum, everything in the implant, and then fix the crown back in again. Don’t just, like, screw the crown in. Okay, because you are then pushing all the bacteria back into the screw channel. So you need to disinfect, dismantle everything, clean it and put it back in.

[Jaz]And then thoroughly check the occlusion again.

[Devang]Yes, 100 percent. Yeah, 100 percent. And there will be some issue with occlusion unless there was issue with the contact points. And then obviously there is a bleeding. So if you feel that there is a bleeding around the crown. Give it a good clean using either titanium instrument or the plastic instrument, which I find plastic instrument a bit of rubbish. They don’t do anything. So you can’t use ultrasonic around implant because it just scratches the implant surface and the crown.

So you need to use titanium instrument or they are like a jet wash sort of a perio jet instruments around. So you can use that to clean around it to break the biofill, but it still doesn’t work. Give patient oral hygiene instruction If it still doesn’t work Then you take the crown out, scrooge and crown, put the healing abutment back in again and let that heal because sometime I would notice that patient hasn’t been good and they start, there is inflammation. And the cycle starts because there is an implant crown, patient can’t clean properly, patient can’t clean properly, there is inflammation.

So you need to break that cycle by just taking the crown off and giving the healing abutment. That leads to another important thing, that when you finish treatment, give patient everything back. Which means you give patient, most of the components, the implant companies are clever, they are 2-cross. So in the sense you can’t reuse it anyway.

So you can’t reuse healing abutment, you can’t reuse impression post. So I give everything back to patient. I can’t store everything everywhere anyway. So I give everything back to patient, including their provisionals, which I give if they needed one, which I give them back and get them signed that paperwork that they’ve got it.

So if I need to remove the crown back, I use the same provisional which I fitted before. So if I’ve given them denture, I fit the denture back in because they need some, if it’s an anterior tooth, they need some sort of a provisional, right? So they don’t have to pay again to make the new provisional.

[Jaz]And at what point is this implant passport that I’ve heard about? Giving patients so they have this information carry around? Is this something that you do? Is it something that’s company specific? How does this work?

[Devang]I don’t do implant passport. So I do like every company does it. But what I tend to do is I do this where at the end of in a discharge patient, when let’s say, the eight weeks appointment review appointment, I’ve talked everything at that discharge appointment, I give them a clinical log sheet.

So I have a log sheet with the stickers of the implant and components and everything. So it’s a A4 size paper with the table on it. And I scan that and give them that. And I give them the consent form saying that I’ve hand over all the lab work material and what I have given it to them.

Everything’s in there, patient sign it and take it. So that’s all with the patient. So patient knows, but most of the patient, they end up losing the information and calling the practice if it’s needed. But at least you’ve given them the information. So I think these are the really the main complications which you need to be aware of.

[Jaz]Well, the only one I had a question about then is, again, about frequency of things, right? As someone who doesn’t routinely restore implants, I’d like to get an idea of how frequent it really helps when you give me a 5% of the time, 10% of the time. So this thing about constantly, dynamically checking the occlusion to make sure that things are no longer proud where they weren’t before because things are always changing.

How often do you think there will be some adjustments being made? For example, you see a patient annually for the next 20 years. Is it that every patient for every 20 years you’ll need to do a little tickle or certain percent of patients for certain years? Any guidelines on your experiences?

[Devang]So my experience is that some patients are more prone to the others. So I have one patient every time I see. Occlusion is a little bit high every time I see, but majority of the time, let’s say you will have 70% of the patient, nothing would have changed. Let’s say in five years, maybe one time adjustment, maybe.

[Jaz]Okay.

[Devang]

I haven’t been placing implant for 20 years, so I can’t really, I’ve been placing for 13 years. So I can tell you 13 years experience. So it’s probably five years, I would say yes, but there will be 20% to 30%, which is still a high number of cases where you will have to adjust it. Maybe every other year, if you, or every three years.

[Jaz]That does help. It just highlights the importance of it and highlights the frequency of it. And I think in terms of a common complication, which if it goes undetected, can lead to more porcelain chipping, screw loosening, and maybe even overload and failure. Dev, you’ve covered a lot in these two episodes, as I always like to ask my guests, where can we learn more?I know you, you mentioned the book a few times, your occlusion, your FMR book was a huge success. Tell us about the implant book and where else we can learn from you.

[Devang]So the implant, yes, I’ve just finished writing an implant book and this time the implant book is part of my full core course. So the way I’ve structured this is I have an online course implant book and a hands on course.

It’s a full circle where if someone comes into that, they will end up restoring implant by the time they leave and finish the course. So if they need more information, then I’m available on social media or they can contact me at info at drdevangpatel.com.

[Jaz]Any website yet?

[Devang]So I, yeah, I have a drdevangpatel.com website. So it’s www.drdevangpatel.com. That’s the website.

[Jaz]I’ll put it in the show notes. So you can just click on it and the implant restorative course is on there?

[Devang]Yes. So it’s coming soon of course. So it will be launched by end of August.

[Jaz]If you guys don’t know Devang, like he’s such a brilliant educator. He gives all his delegates so much of himself and his energy. Like he, as you know, already, he gives all of his patients his mobile number, right? You said that, right? And I’m pretty sure you give all the dentists your mobile number as well. So you must be like the busiest guy ever which I know you are.

But you will always go out of your way to help a dentist. So if you’re always looking for people to learn from, Devang is very, very good person to, as a mentor in any realm, where there’s FMR implants. So, I appreciate everything you’ve done in terms of giving to the Protruserati, all this knowledge and for some of them who need handholding.

I was strongly encouraged to look at Devang and it’s a big topic. Where do I learn restoring implants from? So, I’m hoping they’ll be able to learn those things from you because you’re so good at supporting them. You see?

[Devang]Yeah, I hope this two episode would help them as well, because as I said, my aim is to give everything and then some people would just say the episodes enough and that’s fine. I don’t generally hide anything. So, it’s not like you come to my course, I’ll give you more. It’s everyone should be, you get information in all sorts of formats.

[Jaz]It’s like case specific, right?

[Devang]Exactly.

[Jaz]Case specific. And there’s so many nuances to every single individual case that can’t be covered in an episode. And that’s where if you’re taking this seriously, but you need a course or a mentor, that’s where you come into equation. So I’ll put all the links below. Dev, thanks so much once again for really wowing us. You did the whole FMR series many episodes ago, and now they’re storing implants. I don’t know how you find the time to write these books and do these things.It’s quite spectacular. So, kudos, my friend, but keep going, my friend, keep going, because what you’re doing, the energy you’re putting out to the world, it really helps all dentists.

[Devang]Thanks for having me, Jaz. And thank you. I’ve learned a lot from the community itself as well. So thank you again for giving me the opportunity.

Jaz’s Outro:Thank you. Well, there we have it, guys. Thank you so much for making it all the way to the end. Remember, you can download a guide or a summary and aid memoir of the previous two episodes by going to protrusive.co.uk/idiot. Now, if you’re someone who hasn’t reviewed the podcast before, would you consider reviewing it today?

I’d really appreciate that. So whether it’s on Spotify or Apple or wherever you get your podcast, consider leaving a review if you learn something with me and Dr. Devangkumar Patel. And again, thank you to Devang for being a brilliant guest, not only in this series, but also the Full Mouth Rehab in 11 appointments.

If you haven’t heard that series before in the podcast, do check that one out as well. If you’re part of Protrusive Premium, you can answer a few questions and get the CPD, like you’ve already listened to it. Just verify your learning, do the reflections, and you’ll get your CPD or CE certificate. And that of course you can access on the web on protrusive. app, that’s protrusive.app, or on your app, whatever you prefer. I’ll catch you guys in the next episode of Protrusive.

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Welcome back to part two of this ‘Restoring the Single Implant Crown’ podcast series that's about to kick start your implant career. We've teamed up with the uber-knowledgeable Dr. Devang Patel, a dental wizard with over 13 years of spellbinding experience under his belt.

Dr. Patel's got your back (or should we say teeth?) every step of the way! Check out his social media platforms for further information about his upcoming implant restoration course:

@dr_devangpatel
info@drdevangpatel.com
www.drdevangpatel.com

Highlights of the episode:

00:00 Intro

01:12 Restoring Implant Crowns Infographic

02:03 Recap Part 1

03:45 Inspecting the labwork

05:52 Assessing the occlusion

06:22 Keeping the implant clean during the fit appointment

07:21 Anaesthetic Prior to Implant Crown Try-In?

08:20 Screwing in the crown

11:13 Occlusion and guidance

17:18 Temporarily restoring the access hole

18:33 Review

19:49 Definitive torque and sealing the access hole

25:46 Yearly review of Implant Crown

27:18 Radiographs

29:21 Excessive blanching when fitting crown

31:21 High occlusion management

32:06 Open contact points for implant crowns

34:43 Other implantologists’ work

38:29 Angulated screw channels

43:24 Loose implant crowns

45:52 Implant passports

46:57 Adjusting the occlusion

48:24 Dr. Devang Patel

51:13 Outro

If you liked this episode, you will also like Full Mouth Rehabs Part 3

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

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One of the reasons I did not proceed further in Implant training is the sheer frustration and confusion surrounding all the components and nuances of restoring Implants.

This is why I have Dr. Devang Patel sharing his 13 years of experience in the field to break every stage of restoring a single implant crown. All the terms, components and stages for implant restoration are explained during this 2 part series.

https://youtu.be/TAzbZW_Yk_Y Watch PDP156 on Youtube The Protrusive Dental Pearl: How I use the software Motion to better manage my time and productivity. Check out the 7-Day Free Trial Here

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:00:00 Intro01:56 How I use the Motion App04:26 Where to start?07:03 Dr. Devang Patel13:30 Assessment and treatment planning22:19 Space requirements27:49 Temporaries28:48 Occlusion and diagnostic wax-ups30:10 Impression technique39:31 After the impression42:29 Connections48:19 Screw-retained crowns vs. cement-retained crowns58:18 The lab67:39 Digital impressions72:15 The next episode74:48 Outro

If you liked this episode, check out Adhesive Full Mouth Rehabs in 11 Appointments (Part 1) – PDP103

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

Click below for full episode transcript: Jaz's Introduction: If you're like me and you don't restore implants and you want to learn more about this area or if you're new in the game and you've got your first couple of cases on the go, this episode will be absolutely invaluable. If you remember Devang, he did a few episodes with us about full mouth reconstruction in 11 appointments and he went through appointment by appointment, and that episode is like a Protrusive Hall of Fame. Jaz’s Introduction:In that same style Devang covers over the crosses two next episodes, the Five Different Stages of Restoring the Single Implant Crown. We’re going right to the basics, starting from assessment all the way to screwing or cementing your implant crown, and we leave no stone unturned.

Hello, Protruserati. I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. For me, implants are super confusing. When I was in the first few years after qualifying, I did go on some courses to learn about restoring implants, even learning about placing implants. But I just decided it wasn’t my bag. It’s not what excites me.

Orthorestorative excites me, occlusion excites me, and implants are at the moment in my career is not something that I’m spending more energy and time on. I’m doing a lot more TMD now I’m doing restorative but who knows what’s in store for my future. But as we know dentistry is a long game and that could change in the future, but I definitely needed to serve my patients better by learning more about implants in general. I think we can all do with foundational knowledge and where better to start than learning about restoring implants which is exactly what Dr Devangkumar Patel will do today.

Now, please, no one be offended by the episode title, An Idiot’s Guide. If you listen to the end of the episode where we discussed naming of this episode, it’s a bit funny actually, but I mean this with the best intentions because actually when you listen to the interview, you’ll see that I’m stopping Devang and I’m like, hang on a minute.

When you say this, do you mean this? And I’m learning as we’re going along. And when we’re talking about internal hex and external hex, for me, that just got really confusing. So I made this analogy of like a belly button, like sticky-innie, sticky-outie. So, you’ll see lots of Jazz-isms in there about me just trying to break things down, trying to make it tangible. So please, no one be offended by the title.

Protrusive Dental PearlThe Protrusive Dental Pearl today is from the recent webinar I did. I did All My Productivity Secrets Revealed. Because you guys ask me all the time, like, Jaz, how do you manage to be a father, work in clinic, have a podcast, do all these courses, social media, et cetera, et cetera?

So, I gave away every one of my 17 secrets from getting someone else to do your emails and getting a PA to getting a team for social media, to little things that which apps to use. So, I’ve covered that all on this webinar and it’s now available as a webinar replay. So, if you head to protrusive.app as the website, that’s protrusive.app and you make your login, you can access that right away. There’s even a two-week free trial you can use.

One of the secrets I shared is how I move from a to do list to a calendar. Because the problem with to do lists is that you make this very ambitious list, right? We often overestimate what we can do in a day, and we underestimate what we can do in a year. So, our daily lists are just way too long. And then at the end of the day, you feel really down that you didn’t even cross off half the things on your list. Instead, I now put it in the diary.

So, I know that this task will be done at 2PM to 3PM on this day, for example. By slotting it into a diary space, you know it gets done if you respect your diary. The problem is life happens and you don’t always get to do the things in your diary, right? So again, I used to hate having to move things and edit and move it to like a week afterwards and try and think where I can slot this task in.

Now I use something called Motion. So, Motion is like a calendar app, and it’s like a, it’s a replacement for Calendly as well. It’s a replacement for Acuity Scheduling, which I used to use. So, you can actually book meetings, ClinCheck reviews with patients. You can book meetings with others who sort of book into your diary.

So it’s a really good calendar tool in general. But what I love about Motion and the reason it’s called Motion is because let’s say you set some tasks in your diary; you diarize it. If you don’t complete it that day, it then figures out where in your diary it should place it in the future based on some parameters that you set, like how high of a priority that specific task is, which days you’re willing to work on these kinds of tasks.

So Motion actually decides using AI technology to where it should move your task into the future. So I love this. It’s been great for me. It’s pretty cheap. It’s about 170 pounds, $228 a year. So if you’d like to check out a free trial of motion, head to protrusive.co.uk/motion. That’s protrusive.co.uk/motion and just make sure it’s right for you like using it.

I did a seven day free trial first and it worked well for me. So I ended up taking it and by taking a membership, I was able to cancel my Acuity membership basically cause I was already paying for that for booking meetings and booking links and stuff.

This does all that. It is like Calendly and Acuity, but much more with the whole AI integration and your diary. I have to say I wasn’t that overwhelmed by the mobile app. So I use it on the desktop and I like how it syncs to my Apple calendar or whatnot. I try it for free. And then if you like it, then obviously go with it.

If not, then at least you tried something. It’s got to work with you and your workflow, but I’ve warned you. The mobile app is perhaps needs to a bit of work on it. But the desktop app is what I use. And that works really well. This is an affiliate link by the way. So protrusive.co.uk/motion does take you to an affiliate link.

So if you do sign up, we do get a small commission, which goes towards supporting this channel. If you want to catch all the other 16 secrets, then do check out my webinar on the Premium Clinical video section of the app. Now let’s join Devang to make implant restorations tangible.

Main Episode:Dr Devang Patel Kumar, welcome back to the Protrusive Dental Podcast. You are a very welcome guest. Like I said before, if you haven’t heard of Devang’s series on Full Mouth Rehabilitation in 11 appointments, there’s a three part episode. People message me Devang saying that they learned more from that three part episode compared to big occlusion camps that they’ve been to. Can you believe that?

[Devang]Wow, I’m humbled.

[Jaz]It’s always great to have you.

[Devang]You are very good at taking information out, Jaz. So, I think the credit to you as a host.

[Jaz]Dude, I’m going to suck so much information out of you today about implants. But, let’s really make it basic. Talk to me like I’m five years old and I’m going to be placing my restoring, restoring. Talking about placing, we’re talking about restoring our first implant. Let’s say, and I’ve heard this before, Devang, is a really good place to start for a GDP is like a lower premolar or an upper premolar. There’s no mental nerve. And so an upper premolar is a great place to start. Would you agree with that?

[Devang]Yeah. I mean, for restoration, it doesn’t really matter. Any posterior teeth is fine because we’re not worried about the nerves or any anatomical area because when you receive a case for restoration, you would have hopefully healing abutment in place, which you will go through anyway.

So any posterior teeth is generally ideal case when you start doing first. And if you are restoring, maybe you want to look at the CGDent guidelines on implant placement, actually, but it gives you some ideas to how or what type of things you need. Implant is, I always tell people, because I mentor, I used to, well, it’s hard work mentoring for implant surgeries, yeah?

So, but I mentor for some of my friends and I always tell them that, it’s all well and good for you to learn, but you need to be able to show here, at least in UK, because of the regulatory body. If something happens, you need to be able to show that you are capable of doing that. So it’s a very good document to go through where you need to really ideally have log, you need to have mentored cases. Because implant is completely different branch kind of as you’re learning dentistry all over again.

[Jaz]I mean, this is the same also if you’re doing Botox, it’s the same if you’re doing sedation, if anything that you do that is pretty much a postgraduate discipline, it’s a really good thing to have a log, a reflective log and evidence to show our governing bodies that, hey, you know what? I’m doing the right steps to make sure I am well trained.

Now, before we go through the Five Step Process plus the bonus of troubleshooting. So, five steps from going to, Hey, there’s an edentulous region here to actually fitting your implant crown and checking the occlusion and then any troubleshooting.

So that’s the way we’re going to go across this two part episode. But before we go in, Devang, for some people who’ve been sleeping under a rock for the last year or so, and they haven’t seen the amazing things that you’re doing, just give us the, a quick one on you and your mission statement, my friend.

[Devang]Okay. So I’m Dr. Devang Patel and I am the FMR guy. So I teach full month reconstruction to the dentist and I’ve created formula. I’ve written a bestseller book on full month reconstruction. It’s available on Amazon. I have a Facebook group called Full Mouth Reconstruction for GDPs and I run all sorts of courses.

I have a podcast as well, inspired from Jaz, called The Ultimate Dentist Podcast, listen to that. And I talk about full mouth reconstruction on that podcast. And my mission statement is really, I want every dentist, every general dentist practitioner to do simple full mouth reconstruction, and then take up from there because I see now cases on referral basis and I don’t see cases until general practitioners has identified.

And many times when you don’t do stuff you don’t even identify because you don’t you’re not even thinking and that’s why many people who do Invisalign they do more Invisalign because they are looking actively for ortho cases whereas if someone who doesn’t do Invisalign, they don’t do ortho treatment because they’re not looking for it.

It’s just passing through under their noses and ultimately the patient will benefit. And I always tell them, you don’t need to do MSC diploma certificate courses in order to learn full mouth reconstruction. You need a structured course and you need a structured training path in order to learn. So that’s my admission statement full mouth reconstruction.

And you may be wondering, why am I talking about implant today? Right? I’ve been placing implant for 13 years. I’ve placed over a thousand and restored over a thousand implants and I have a passion about it. Most of the cases I receive nowadays are implant related and then I convert them into full mouth reconstruction because many of them need a full mouth reconstruction.

But I’ve written a book now on implant and I’ve created an online course and I’m teaching implant because when I teach full mouth reconstruction. Many cases involve edentulous spaces and those that patient who wants full mouth reconstruction, they have a money power to go for implant most of the time.

And that’s why many of my course delegates asking me, oh, can you teach us implant? Because they like the way I teach. So they want me to teach them. And that’s why I created this cohort. That’s why I’m asking you to see if I can help anyone else really.

[Jaz]Amazing. Now, you made some good points earlier that if you are trained in GDP orthodontics, then your antennas will be more receptive of crowding, base simple crowding that you can help your patients.

Now, let me draw a real world comparison, very relevant to our conversation today, Devang, which is if you are implant trained, then you see the dentures area and you think, hmm, can I get an implant in there? If you are not implant trained, you’re thinking denture and bridge as your default. You just are.

It’s just it’s the real. It’s the truth. I know the truth hurts and some people like, oh, give a patient all the options. But it’s true. Some implant dentists are probably doing implants where really a resin bonded bridge could have been done specifically, especially for lower anterior, single lower anteriors.

Why are we placing implants? That’s my feeling, Devang. You place implants. I don’t, but that’s my strong feeling. Whereas those dentists who are really doing elaborate bridges on like post crowned abutments. You need to be doing an implant, right? Or need to be referring for an implant.

So I think there’s a middle ground somewhere. Nowadays, implants have become a postgraduate discipline. Okay, it is what it is. You do some training. Where do you think it starts? Do you think that we should start by restoring implants first, placing implants first, or should we be looking at doing both simultaneously?

[Devang]I’ll tell you my journey. At least I started restoring implant at when I did my MSc in Cons. So we were not allowed to place implant until we restored some implants, because the philosophy was that you when you’re restoring it’s failsafe. So, you know, it’s not as difficult as placing and also you will see what mistakes you’ve done the same philosophy where you make your own crowns and you see oh i’ve done under reduction. Does that make sense?

Like if you start doing your own laboratory work, you start noticing your mistakes and then when you start doing crown prep you understand, okay, I need to do this. So that was the same philosophy that I was trained. So I certainly started restoring implants and what says for something I would recommend everyone and then see whether that’s your cup of tea, because I’ve known a lot of dentists who invested thousands of pounds learning implant placement, and they’re not placing them because they don’t like it.

So I think it’s a safe start to start restoring implant. And then for sure, placing simple implant for a good restorative dentist is it’s really, really straightforward. So I would always recommend to start placing implant at some point, but start with restoring.

[Jaz]Restorative consultant, Ken Hemmings, he told me once that taking an impression for an implant crown, obviously we’re talking about scans today as well, but taking an impression for an implant crown is easier than taking an impression for an actual crown preparation. Would you agree with that?

[Devang]Ken was one of the person who taught me. So yes, I would 100% agree with that. So it is, if you know the principle, if you know what you want, if you have planned everything right, then I can now place an implant and restore it in totality of on the appointment within 40 minutes.

It takes me 15 minutes to place implant. A patient can be in and out within half an hour and then scanning will take another 5-10 minutes and then fitting will take another 5-10 minutes if everything works fine. And I can’t imagine me doing endo. Or even a crown prep. It takes me more than an hour to do a crown prep on a single molar.

So yes, it is simpler, but if you make mistake, the effects can be much more catastrophic as well. So it goes either way. And that’s why you really need to know what you’re doing.

[Jaz]In my first five years, when I started to kiss a lot of frogs before you find your prince charming. And I was kissing lots of frogs, seeing which is the area of dentistry that I like the most.

I went on some implant courses. I went on some restoring courses and stuff. And whilst I, this message was received by me that, okay maybe I can restore implants. Maybe impressions are easier on implants, which obviously going to break down today. Just a sheer number of like connections. You have to talk about screw retain, cement retain, just a different combination.

And then to complicate it, different brands of implants, different screwdrivers. I know there’s a proper term for it. It just gets very, very confusing, and overwhelming, but anything worth doing. It has a steep learning curve. There’s not a low entry point. You have to do your hard work. You have to do your due diligence.

But a lot of people tell me that once you get there, once you’ve restored a few and become second nature, it can be very efficient, very profitable, and what a great service to your patients. Right? So let’s start my friend. Step number one is identifying. Oh, you tell me what step number one, because you’ve got it all laid out.

[Devang]Okay. Yeah. So, the way I look at for any process, I look at it in steps. So again, if you follow me or follow through with my reconstruction, I look at things in steps. So the steps are broken down into five steps. So first step is your Assessment, really, and Treatment Planning step. The second step is Impressions. Third step is Communicating with the Lab because that’s really, really important. Fourth step is Fitting of the Crown. Fifth step is Maintenance. And then, obviously, you have Troubleshooting and complications and how to manage those complications. So, these are the six main steps.

And with regards to, let’s start with the step one where we do the Assessment. Before we do this, we need to understand that there is a difference between implant and a tooth. Okay, so the main difference is the implants fused into the bone and tooth has periodontal ligament and that gives you much more proper reception and because tooth has a periodontal ligament and implant is fused in the bone, the mobility of the tooth is different than implant.

So we know that if you if you push the tooth down it can intrude up to 25 to 100 microns whereas if you are applying jiggling forces again it can move up to maybe let’s say 56 to 108 micron whereas the implant is fused almost, it has a little bit movement because of the osseous, so the bone moves as well but in less than 10 micron and that’s one of the main reason we will come back to when we are going to discuss about occlusion in implant because you need to understand that the implants don’t move but the teeth do move, even healthy teeth and that’s how you need to manage it.

So having said that, let’s look at the time where patient sitting in your chair and now you’re thinking, shall I take this patient for restoration or not? Remember as a General Dental Practitioner, you are the person who’s going to see that patient first before your implant surgeon sees it, okay? So many of the decision need to be made by you and that’s why you need to understand the process of Implant Planning, Placement as well, even though you’re not placing it. And yes Implant surgeon might come back and do a consultation with you and decide, okay, whatever you plan is rubbish, but that’s fine.

You learn from planning. Okay. And that’s how I plan. I mean, what you don’t know, you don’t know until you start doing something, right? For any case, my first thing I’m going to check is patient expectation. Whether, am I going to be able to match or my implant surgeon is going to be able to match the patient expectation?

It could be realistic, but you’re not trained for it. It could be unrealistic or simply put you don’t like that patient or that you can’t get on with the patient. And that’s the biggest factor for me. If I don’t get on with the patient, I don’t treat them for their sakes really.

[Jaz]And with implants, it’s like something that hopefully it’ll be a long term thing. And it’s kind of like orthodontics is that it becomes like a marriage, right? I know plenty of patients who like to go back to their orthodontist or the dentist who did the orthodontics to go back for their retainers and reviews and plenty of patients who, although we can maintain their implant for them now, they still prefer to go back to their implant dentist once a year, once every two years to do that. So do you really want to see his patient in the longterm? And if you’re not going to see eye to eye, then you’re totally right. Agreed.

[Devang]Yeah. And with regards to long term as well, I tell all my patient from the day that implant won’t last for a lifetime. And that just breaks the ice and you then don’t have to tell them that there’s 80% chance, 85% success rate over or survival rate over 10 years.

And no patient has said no to me because of that, but you need to put it out for upfront and you need to tell them that they don’t last lifetime. Because many times-, I had a doc-, and I learned because I had a doctor, a GP. Once I finished my implant, this was early days. He’s like, oh, now this is, I’m set for rest of my life.

And I’m thinking you’re a GP, like, I mean, how many times we’ve done things and you know that it doesn’t last lifetime, not even teeth. Like you buy a hundred grand car. They don’t give you lifetime got a guarantee. So, but that’s something, a mentality really, we need to shift.

So once that’s done, then as you really importantly said, we need to really discuss different treatment options. So I am very aware that I’m biased towards implant. So I tell patients that, look, I am biased towards implants, but let’s figure out what’s best for you, not what’s best for me. And I have this open discussion with patients, and this is something I learned from Otto Zuhr and Markus Hurzeler.

They are good periodontists, and they are very aware that when we do one thing all the time, we get biased towards it. So we need to really have that separate mind which is not biased and think both ways.

[Jaz]It’s like the saying where when all you have is a hammer everything looks like a nail and that’s been used a lot with a certain implant dentist who perhaps overzealously trigger happy with their implants where they could have been doing other modalities. So we need to give all the options that are appropriate.

[Devang]I have had a situation where associates send a case to me and I say this tooth can be saved and they’re like, no, you can’t. And now I’ve went on and saved it because I do restorative treatment as well. But that’s something you need to really discuss.

So I discuss with patient all the options, denture, bridge, and sometime I’ve done bridges like 90 year old, 91 year old needs a big bone grafting. Okay, just do conventional bridge. There’s nothing wrong with that, so that’s something we need to discuss. Then, we need to discuss, we need to see smile line, if obviously, if you see your first few cases, I wouldn’t recommend touching the anterior teeth.Although if the implantologist has done a good job, they are no different, because the impression process is same, if your lab technician does a great job. Then you can just literally go straight to finish.

[Jaz]But if you are going to do anterior teeth early on, you got to pick someone with a low smile line. So when they smile, they don’t even show their papilla ideally, right? In the first few cases.

[Devang]That was one of the criteria, but you need to make sure you give patient a mirror and see how they look at it. Because even though patient’s smile is low, they might pull their lip up and look, trying to look. And if that happens, that’s a high lip line case for me, if that makes sense.

So you need to really also assess patient how they’re looking at their smile. Then obviously we need to look at the oral hygiene, whether patient’s oral hygiene is great, periodontal condition. This is something really important and many time implantologist misses that because they don’t have a restorative background.

You need to look at the adjacent teeth. Okay, we need to look at the contact points. Sometimes the teeth are tipped. Can we correct that? There are restorations which are sticking out which will create a point contact and I want sort of a surface contact if that makes sense. Can I adjust that? So we need to look at all this adjacent teeth.

[Jaz]You’re talking about like amalgams, right? Amalgams with ledges, amalgams with the old amalgams, which are still perhaps don’t need to be replaced, but just actually polishing them, getting a red diamond and getting the right contact surface.

[Devang]Yes. So that’s something which I even miss sometime, time to time. And I wish that we had technicians who would. Because sometimes, when I do my own wax up, I really, I’m sitting in calm. There’s no patient. I’m thinking, I wish the technician would take a lead on them and then when they receive a walk, it’s like, Dev, you could do with a little bit bonding on the mesial aspect of central to get the mesiodistal dimension perfect of both the teeth.

They’ll just restore the gap. But if we get some sort of a guidance, then that would be really helpful from technician. And then this is also come under secondary treatment. So you need to always look at whether patient need any whitening, whether they need any ortho because you can’t. It’s very difficult to do ortho after you’ve done implant.

It’s not impossible. It’s tricky. All patients need any full mouth reconstruction. And this discussion needs to happen before patient has implant, even if you think patient is not going to go ahead with it. So even if patient says, no, I don’t want full mouth reconstruction, at least you need to have a discussion because guess what I’ve replaced someone’s-, a few dent-, a few implantologists’ implants, implants were fine, crowns were fine, just patient needs full mouth reconstruction, patient wasn’t aware of that.

[Jaz]I’ll ask you a tough question Devang. Obviously, you teach full mouth rehab and you’re also teaching restoring implants for GDPs. I think, and see if you agree, I think if you’re going to go on a learning journey with you, that you should learn full mouth reconstruction first, then implant, right?

Because if someone’s lost vertical dimension, they’ve got tooth wear issues, generalized, and the teeth are really, really short. And then you put an implant in there and try and conform in that bite. Really, they would have benefited from opening the vertical dimension. It’s much better to plan the implant from that new occlusal position, right? And same with orthorhontics.

Or have a eyesight on assessing which patient need full mouth reconstruction. If you don’t do it, refer to your colleague who does do full mouth reconstruction, if that makes sense. So, because I understand learning full mouth reconstruction and implant can be quite daunting like together and expensive because learning any of those two skills is not cheap.

[Devang]But yeah, you need to have an ability at least to plan those cases when you are doing implant restoration. Then you need to look at the the space whether you have enough space because for restoration and that really matters. If you’re looking at interage because sometimes posterior teeth I actually saw a case two days ago one of my mentee showed me and this was on a full mouth construction we do a two weekly sort of case discussion and someone literally placed an implant on lower right seven recently two months ago implantologist and patient got collapsed bite patient, upper right seven is touching, healing abutment of lower right seven, which is equigingival.

So they are now considering explanting that implant and giving a patient refund and then doing another implant. So I mean, I had few thoughts about that in the sense that you could use the implant to literally intrude the tooth. If implant fails, fails. But at least you’re doing something with that implant rather than explanting it.But what I’m trying to say, the implantologist did not see, they just saw the bone, saw the edentulous area, placed the implant really nicely. But did not check the occlusion.

[Jaz]Which is why it should all be restoratively driven. And that’s the basic thing. When the patient bites together.

[Devang]Yeah, and that’s why I feel genuinely that as a general dental practitioner, it’s our responsibility. Because implant surgeons, they’re trained for surgery, not trained for occlusion or anything like that. So I don’t blame them. It’s our responsibility when we refer a patient to tell them that, look, this is the case, there is no inter-arch space. A patient will need something else doing or don’t refer a patient until you sort that out, if that makes sense.

So we need around five millimeter from gum to the cusp tip, at least space for the posterior teeth. You could do clever tricks and you can do alveoloplasty and you can do all sort of stuff to do that. But and I actually recorded a “supra erupted teeth” podcast episode. So that covers it a little bit more in there.

[Jaz]What about mesial distally?

[Devang]Mesial distally depends on the tooth. Okay. So, and obviously how tall is, and you gave a really good example of the lower central. I completely in agreement with that.

So if you have one lower central incisor missing. then you need to decide, okay, you can’t really place an implant without damaging. Having said that I don’t see that many cases where just one incisor is missing is usually perio or some issues where at least two of them needs to go. If that’s the case, even then I do tooth to tooth resin bonded bridge sometime, because placing implant right in the middle where most of the time other incisors are not good bone support either.

I just do that and then when the two laterals fail, then you can do two implants on laterals and replace four teeth and that’s more predictable with implant. So that’s kind of you need to assess, but generally you need to assess for the rest of the teeth. Mesial distal space, if you have enough. Now, if you’re placing, let’s say, whatever sizing plan you’re placing, you need to add three millimeter to it. So if you place three-

[Jaz]Let’s make it very tangible, Dev. Like we could talk about every single tooth of the arch and then we won’t have time to record the other steps. So let’s say we’re doing an upper first premolar. Let’s just go with run with this one example and go deep into this one example.

[Devang]What is the width of the premolar, that particular premolar?

[Jaz]Well, actually, I’d like to know for you, what is the minimum that you want? And at what point does it become one and a half units? And then you’re struggling and there’s going to have to accept aesthetic compromises, you see?

[Devang]Yeah. So basically for premolar, I would want ideally to place around 3.8 millimeter width of implant. It depends on the system. Yeah. So if you’re placing Ankylos, you have 3.5, which is fine for premolar. If you, I’m placing Bio Horizon. So you, at the moment, so I placed, I’ve used all, but right now I’m using Bio Horizon where it’s 3.8 is the size. So that’s the minimum I would want to use.

And then you need to add 3 millimeter on either side, because you want 1.5 millimeter safety distance between two teeth. Now I have encroached that safety distance in past and everything’s fine. So, you don’t need to panic too much. Even if you think the space is a little bit tight, maybe half a millimeter, you can still gain consent from the implantologist, let the implant surgeon decide, but generally 3.8 plus 3, 6.8 millimeter width you want between roots. Okay. And if you have around three millimeter on either side, then it almost becomes a molar. Now. If, let’s say, two premolars, which are next to each other missing, that’s a little bit tricky scenario because sometimes you can’t put two implants together.

Remember, between two implants, we need three millimeter distance. So now we place it, we need six millimeter, just a space, plus whatever size implant you use, two of them. So many times you may decide to have a cantilever bridge, which is not my favorite option. I prefer if there are two teeth missing, two implants and two teeth. But I would rather do a cantilever than put two implants next to each other very close together and then make a problem with that. So that’s how I make a decision.

[Jaz]Implants are like trees. They want space. I don’t know, some famous implant surgeon said that once and I heard it. And so I like to, that’ll be my one contribution to this episode. Implants are like trees.

[Devang]Yeah, so you need to really make sure that they have space, basically. Okay. They like breathing space.

[Jaz]Yes. Whatever size your implant is, add three millimeters. That’s how much distance you need between the roots. And obviously you’re looking at between the adjacent teeth as well. Make sure for aesthetics that you plan for it. Often a wax up may help you in such scenarios. What more do you want to add in terms of the assessment before we move to stage two?

[Devang]So assessment stage, quickly, you need to also make sure that you have planned for temporary or provisional. When you are doing these kind of planning these cases, because if it’s an anterior case, even premolar, some patients don’t want to go without, so my go to method is, used to be Maryland Bridge or resin bonded bridge.

The problem with that is they can come off, and if I’m working in 11 different practices. It’s a nightmare. So also what I’ve seen is I’ve used to use for canine. So if lateral incisor a lot, and if the resin bonded bridge, if you use it for a long time, some of my cases, like if I’m doing autogenous block grafting and soft tissue grafting can last for 15 months.

Maryland or Resin Bonded Bridge put on high for 15 months will create a space when you remove it. So the canine guidance gone. So I now use most of the time Essix retainer with the tooth. The problem with that is patient can’t eat on it. So I give them a denture but not to use it straight after surgery.

So that’s something you need to assess. Then you need to assess occlusion. We discussed that, the guidance. You need to really have a vision as to, after you finish the treatment, what type of occlusion patient’s going to have? So if you need to add canine rises to miss the implant, you need to do that before the treatment so that you get, you have the occlusion which is optimized. And then, of course, as I said, diagnostic backups. You need to make sure. that you have done diagnostic wax up in order for you to plan the treatment properly.

[Jaz]Is this mandatory? Do you think this is a mandatory step with the dentist who’s starting to do a restorative implant?

[Devang]If they’re starting, yes. I think it’s, I’m not there to make regulations. I can tell you that I don’t wax up all my cases. When you place over a thousand implants, you can really assess if the tooth is bound, that’s the simplest case to place implant because you’ve got the reference from either side. I do get waxed up when there are more than one implant I’m placing. So if I’m placing two implants next to each other, then you need to know exact distance you want these implants to be placed in order to get the good restorative.

But if you’re starting, I think you would be better covered if you have done diagnostic wax up or if you’re doing surgery then had a surgical stent made up. But if you’re restoring that, at least have a diagnostic wax up done and gain consent from patient.

[Jaz]Okay, great. Well, that was a whistle stop stall of assessment. Let’s now get to the real deal, the meat and potatoes of restoring implants. Absolutely.

[Devang]So now we’re coming to step two, where we are ready to take Impression. So what will happen is that once you refer to your case, in which I would recommend you plan with implant surgeon, not just refer the case, ideally stay within that consultation appointment, plan it together, and you learn more planning process and how your implantologist think, because everyone thinks differently, that he or she will place an implant and send back.

And do a exposure of the implant, send back the case to you, where you will see a healing abutment, which is in the implant. Now, healing abutment could be customized, so they may have customized the healing abutment to give you nice form of the gum, or it could be a stock healing abutment, which may look like a silver sort of a metallic color and would be round.

[Jaz]For an upper premolar. What would typically come back with it? Would a custom one come back or would a standard one come back?

[Devang]Usually it will be cost. It’ll be standard.

[Jaz]Okay.

[Devang]So you will have a standard healing abutment. Now, again, you would have known which implant system your implantologist uses. As I said, I would recommend that you observe at least five cases restoring that in person, restoring it before you start just jumping and start restoring the implant cases so you can log that you observed. And ideally for at least my mentees, I tell them that I would observe their five cases. So at least 10 kind of observed cases before they go on themselves.

It’s a bit of an overkill, but I think that’s the safest way to learn. So now once you get the back, you will have a healing abutment. Gum should have healed nicely. Sometime if the sutures are still there because they want you to take the sutures out and take the impression at the same time, which I tend to do if it’s a simple exposure.

Then you just need to take the stitches out. Make sure the gum’s heel looks pink. Sometime if the implant surgeon has done soft tissue grafting, it will take a while before it heals. But most of the time, as an implant surgeon, I only refer a patient back to a dentist once I know it’s complete, it’s ready to take impression, basically.

So that’s where you are. Now, when it comes to taking impression, you have three different ways to take impression. Okay, so you can take impression using closed tray method. You can take impression using open tray method and of course you can use digital impression as well. Okay, closed tray method is the least favorite method of mine because the way it will work is you put something, you take the healing abutment out, you put this impression post in the implant and you take like a normal conventional impression like you do for crown and bridge. And what would happen is whatever you put the impression post in the implant will come out. in your impression.

[Jaz]I’m asking very noob questions here, right? So this is like, a very basic level, but the impression post, when it attaches into the implant, it’s not like fixed. It’s allowed to come out, come away in the closed tray.

[Devang]So it’s not screwed in. So for closed tray, if you’re not screwing in the impression post sometime, and this is where the confusion comes, right? So some implant system has screwed in post and you will have a toggle on top, like a small insert on top. So you only get the insert picked up in the impression, not the whole post, but you will have to see, I’m just giving you a general idea because it’s difficult to cover every implant and how they work.

But generally the concept is you take a normal impression and this concept was developed because to make general dental practitioners life simple, plus to do an open tray impression, you need to be able to put the post, the screwdriver, everything in patient’s mouth. And if you’re doing upper right seven, you might not have access to do all that.

That’s the reason closed tray was one of the benefit of closed tray impression. Putty wash. Yeah. Just normal crown and bridge material. You could use ideally Impregum which is more rigid, but I do putty and wash most of the time to be on, because not all my surgeons, they don’t have impregnum.

So coming back to the issue of you’re not being able to access upper right seven is that if the implantologist has managed to place an implant, which is basically you have a driver, implant is on top, place all that in upper right seven, then there’s always patient has immediate effective mouth opening for you to take open tray impression.

So in last 13 years, I probably have done one open tray impression, sorry, closed tray impression. So now, I almost 99.9% take open tray impression, which is more accurate.

[Jaz]Why are you so against closed tray? I’m still trying to suss out what is it that you don’t like about closed tray?

[Devang]Because what will happen with the closed trays is, you know the thing you picked up in your impression? Then someone needs to manually put the impression post, click into that impression. Now when you’re doing all that faffing, you can move stuff. It’s easy to move. And make the impression inaccurate. And one thing we want to know, we want to do is when we take implant impression, we don’t want our impression post to move. We want it to be rigid. Because implant is fixed in the bone. Few microns here and there, the crown won’t fit very well.

[Jaz]So just describe open tray, because what you haven’t mentioned yet, but I’ve done it before is, it’s like, do you always need a special tray? Or can you use a stock tray for these?

[Devang]No, you can use, I use stock tray most of the time. Unless I can’t find a stock tray which fits in patient’s mouth properly. Okay. So when I put the, you select the stock tray, I select the biggest tray I can fit in patient’s mouth because I want material thickness, right? So you want thicker material in order to pick up the implant. So it’s much secure.

Okay. So let me go through step-by-step process of taking impression. Okay. So once you have your healing abutment, patients in the chair, you need to, before you do, you see a patient, you need to make sure you have all the components. You have appropriate impression post. You have all the drivers you need for the impression.

Having a short driver is helpful because sometimes it can get a little bit tricky. If you’re using a driver first few times or ideally all the time, you need to floss it just so that you don’t drop it down the patient’s throat. So you kind of have secured it. So make sure that you check because every implant system may have different impression force posts for different implants.

So check what implant it is. Check whether you have right post and make sure you have right components. Once the patient is in the chair, you will take the healing abutment out. I always irrigate with chlorhexidine to make sure that before I put the impression post, I’m not really putting anything in there.

My impression post will be in the chlorhexidine as well. I pick it up, put the impression post, try a tray in patient’s mouth and see where the impression post sticking out on the impression tray. Use a straight handpiece or a fast handpiece to create a hole. So then it sticks out of the impression tray so I can unscrew it once the impression material set right.

My nurse would then mix the putty and I would squirt some light body around the implant and occlusal surfaces of all the teeth. I will then place the impression tray and quickly find the post. It’s really important that you find the post. Otherwise, if your impression is covered, the post is covered by your impression material, you can’t unscrew it and the impression won’t come out.

[Jaz]So just to make that tangible, like once you’ve got the, you’ve drilled the hole, like you said, you try the tray and you see where the impression post is prematurely hitting the tray, right? And then that’s where you drill the hole and now the tray can seat fully but once you’ve got the putty wash in. That’s all going to get covered in impression material and it’s about just searching for it with your finger. Is that what you mean? Right?

[Devang]Exactly. Yes. So make sure you create a bigger hole than you think you’re going to need because the tray is not going to always go straight in that position. So make sure you have a little bit leeway and then you’re with your finger.

Really you press in the putty where you created a hole to palpate the tip of the impression post. Once you’ve got the tape, I would keep my finger pressed there so that the material, impression material doesn’t cover over while setting and then let the impression set. Then I’ll use a straight probe to flick the impression which is there on the screw access hole because you know there will be some impression material in the access hole.

Straight through, flick it out and then unscrew the impression post. Now, you need to make sure it’s completely unscrewed before you yank the impression out of patient’s mouth. The way to know that is when you’re unscrewing something, anything really, and if it’s completely unscrewed, it will click. So because the threads are jumping, right? So if you’re reversing, if it’s clicking, that means it’s completely undone, basically. Take the impression out.

[Jaz]I’ll ask a question, another silly question, if you don’t mind. Is this impression post completely cylindrical.

[Devang]It has notches and it has small grooves. So you can have the impression sort of get. Is that what, is that the question?

[Jaz]Well, my thing is, I’m imagining now, this is years ago since I last did this, but if I am twisting and unscrewing it, then isn’t the impression material getting distorted?

[Devang]No, so there’s a screw within the screw, right? Impression post has a hollow channel.

[Jaz]The screw within the screw.

[Devang]Yeah. There is a hollow channel. So impression post doesn’t move, but the screw under inside moves, same way you fit the screw, retain crowns, right? So the crown don’t move the screw inside the crown would sort of engage.

[Jaz]Got it. Now I’m with you.

[Devang]Cool. So, now you’re taking the impression out. I would irrigate the area with the chlorhexidine place, the healing abutment in which was there in the chlorhexidine back into the socket, right? Screw it, screw it back in. You don’t need to torque, and do not torque the healing abutment, just hand tighten and don’t use a torque wrench. Now, some people like to take x ray when put after placing the impression post just to make sure it’s seated properly.

I don’t because nowadays impression post comes with the definite seating. So, if it’s not in a definite position, it will not seat and you will see it click most of the time and that’s how you would know that it’s seated properly. However, if you want to really take an x ray, then by all means do an x ray to understand whether it’s completely seated. Now, one thing we haven’t discussed is there are two different types, two different main types of connection inside the implant.

[Jaz]Before we get to that, if you don’t mind, because this is a really important conversation coming now. So let’s just finish off on the impression for the newbie dentists, really new in the world of implants here, which is what we’re targeting at the moment and helping the Protruserati out who’ve never done this before.

You don’t need any retraction cord. And is there usually a bleeding that you need to deal with? So this is what makes usually this kind of stuff easier than a normal crown, right?

[Devang]Yeah, generally there is no bleeding. There is no bleeding when you take the healing abutment out. You may see a little bit of bleeding maybe, if the gum is still a little bit raw from the surgery, but no, generally there is no bleeding.

And if there is a bleeding, you don’t need to worry about bleeding. Even, let’s say you take an impression, and you know the impression pose where it connects into the implant, and you tip your impression, and you see usually crown, when you do the crown impression, you want to see the margin nicely.

You don’t need to worry about all that because if the margin is slightly uneven, some of the material is not a little bit flowed, it’s okay because technician can figure that out. It doesn’t, as far as you can, you’ve got the connection, right? The impression post seated completely in the implant. That’s all we want to capture.

So it doesn’t have to be like a crown prep and that’s where it is. So you don’t need to use a retraction cord. I don’t know about you, but if I’m taking, let’s say two, three crown prep together. It never comes up in one impression. I have to at least attempt twice to get all of them in one go.

[Jaz]So, air bubbles are forgivable as long as the impression post in general fits very precisely into the impression, right?

[Devang]Yes, and it’s not moving. Okay, in the impression.

[Jaz]So now let’s talk about this really mammoth topic of different connection types. Because like I said, as someone who once ventured into learning this stuff, it got overwhelming. The different connection types, different brands. So let’s try and make it tangible now for me and for the Protruserati.

[Devang]Okay, sorry, just to complete the impression steps, you need to then take the opposing arch. If any occlusion, you need to record, you need to take the bite registration. But for single tooth, generally, you don’t need bite registration because you can hand articulate, right?

And then once that’s done, you need to package it in a bubble wrap, put it in a box, and then, like a wood or cardboard box, and then send it. Don’t just put it in a bag and send the impression because you haven’t seen people collecting those bags. It gets, lots of things goes on top of it, right? So things can distort the impression post.

So you need to make sure that is secure before you send it to technician. Now, before you do that, actually, you need to write a prescription, right? So you need to make sure that you’ve written a prescription to the laboratory technician, and that’s where all the connections and everything will come in play, right?

So now you’re telling your technician few information, okay? So you are going to communicate with technician what you’ve just done basically and what you want them to do. Now before you do that, you need to know a few things, okay, about implants. So first is connection, obviously. There are lots of connections and it’s difficult to cover all of them, but there are two main connections.

You have external connection and internal connection, which means implant is solid and then the crown goes on top of it and externally hooks into the crown. Whereas internal connection implant crown will literally go inside the implant. So there are two different connections. Internal connection is the one which is most widely used. So there is a very high likelihood for a single crown, you will receive an implant with the internal connection.

[Jaz]I’m a simple guy, Devang. Listen, I’m a very simple guy. Am I, is it an oversimplification if we call an external hex connection, an outie, like belly button, an outie and an innie, would this analogy work?

[Devang]Yes. So you have the internal connection, like a belly button. So, you go inside and that’s the internal connection. And the reason is that it’s a bit more secure for the screw. Okay. So there’s less screw loosening with those connections, especially for single crowns. Generally for single crowns, you will not see external connection implant nowadays.

[Jaz]Okay.

[Devang]Now we decided, okay, we’re going to mainly dealing with internal connection implants. There are two types of internal connection, main ones. One is a butt joint, like surface on surface connection. And the other connection is a conical connection, like cone within the cone.

[Jaz]Okay.

[Devang]Okay? Now, if you imagine, surface to surface connection, it’s easy for you to know if it’s not seated properly. Like, if it’s not completely seated and there’s a millimeter gap, if you take an x ray, you will see a black margin. Does that make sense? Because there is an air in between.

[Jaz]This is the butt to butt.

[Devang]Butt to butt. So it’s a butt joint connection. You would know easily if your crown’s not seated properly. Whereas if you have a conical connection, difficult to know exactly whether the cone is completely seated or a few microns off. Okay. So that’s the difficulty with conical. However, conical connection gives you more secure connection than butt to butt. Because with butt to butt, butt joint connection, if the screw becomes a little bit loose, It just starts wobbling all of a sudden.

Whereas with the conical connection, if the screw becomes a little bit loose, the conical connection itself will protect the crown. So you get less screw loosening with that. Plus, this is for implantologists as well, that it gives you nice emergence profile and it prevents your bone. So bone stays better. So I prefer personally, conical connection. So when I use Bio Horizon, I prefer CONELOG implants in there because it has a conical connection. Does that make sense?

[Jaz]So we like, yeah, it does. So we like sticky-innie implants, with a cone connection. But like all of this stuff, like for example, you said you use Bio Horizons. Do they have a Bio Horizon sticky-innie? Do they have a Bio Horizon sticky-outie? Or is a brand generally one type of way? So you can get every, it’s like a candy shop. You can get every single combination.

[Devang]Yeah. And unfortunately, you’re not going to be the one who will select that because your implantologist would have selected it. You kind of mercy of them, whatever they select, you need to restore it. Right? So I have made a lot of my associates life difficult when I, by selecting some of the implant system, but that’s how it is. They all have ins and outs. They all have problems, but no system’s perfect. So it’s not that if you get a butt joint connection, it’s not good. You just need to know what it is and how to assess it really. So that’s one thing.

[Jaz]But this is a feature of the implant that’s already in the patient’s mouth. You are just, A) finding the information of that implant, identifying it correctly. So this is something that your implantologist, when they send it back to you, hey, I used a Bio Horizon 3.8 sticky-innie internal hex, with a cone. Make sure you know this information. Is that kind of how it works?

[Devang]Yes, exactly. So I always send my associate, someone who’s referred cases to me, a log sheet with the sticker because I might make a mistake in writing what connection it is. But generally when we place implants, we use a sticker from that implant to put it on a paper. I scan it and just send it to them. So there is no ambiguity as to, no miscommunication. And that’s something I give the patient at the end as well.

[Jaz]Now Devang, before we continue again, I’m going to suggest, because I’m really enjoying this, I’m going to suggest we nail this part one. Right? Like really just slow down a bit. Let’s nail this part one. I think let’s re record for part two one day. But I’m just letting you know that I’m really, I’m learning a lot here as well. And I think this is really going to be like, for a lot of people new to implants, it’d be like, wow, the sticky-innie, sticky-outie. This would be really good for us, I think, if we just slow it down and keep finishing off part one, like we are. Is that okay with you, buddy?

[Devang]Yeah, yeah, that’s fine. That’s fine. Yeah, no worries.

[Jaz]Okay, cool. Okay. So now you know which type of implant it is. And then I guess the impression post will also depend on that information as well, like the impression post that you select?

[Devang]Exactly. So you would have known this information kind of beforehand anyway. This is not the time you would know what, this is too late kind of. You would have known when you receive the patient, all the information, because you need to have all the components ready.

This is for you to tell your technician, right? But when you tell technician what implant it is, what platform size it is and what sort of connection it is, implant, the laboratory technician will know, but I’ll come to that in a minute. So first thing you need to know what connections implant has.

Okay. The second thing you need to know is screw retain crown and cement retain crown. That’s a big, two big different camps, really. Some implant, they are like truly believe that cement retain is the way to go and some people believe screw retain is the way to go. I’m in a screw retain camp.

As I said, I’m biased. The reason I prefer screw retain because it’s easier to manage if there is, let’s say a patient doesn’t like it. You fitted the crown and we all have this patient sometime to time to time where you fitted patient like yeah, everything’s good, perfect, and then you get a text message because all my patient has my mobile number. You get a text message or when patient come for a review appointment like mmm. I don’t like it. I want to change this.

Now, if you have used a cement retained crown, which I will go through the process in the next episode, that it’s difficult to take the crown out and change it. If it’s a screw retained crown, you can unscrew it, send it to the technician, and change it. Future complications, like if something’s chipped or broken, if patient’s broken the porcelain of it.

It’s easy to manage if there is inflammation around the implant. You want to take the crown out to assess properly. It’s easy to do that. So for me, and also the main reason I stopped doing it years ago, 11 years ago, doing cement retained is because there is a risk of pericementitis, which means that the cement can go into around the implant tissue and cause irritation and that can cause implant to fail. And this is a very well known, studied fact that many of the cement retaining plant fail because of this reason.

[Jaz]Did you just say pericementitis?

[Devang]Yeah, it’s just-

[Jaz]Wow. Wow, I love this.

[Devang]

So it’s a made up word, but yeah, I think it’s been used quite frequently, not made by me. But I read it, but it’s not a proper, I think it won’t be there.

[Jaz]Like I knew peri implantitis. Like was a first, like when I was a fourth year student and then someone said peri implantitis, me and my friend Clifton looked at each other like, wow, that this is a thing. There’s a word. And every time it’s like a running joke between me and him. But peri cementitis is like my new favorite implant term.

[Devang]Yeah, exactly. So that’s the reason I don’t use a cement retained crowns and I do anything and everything and which will go in troubleshooting anything and everything to make my restoration screw retained crown.

Okay, so let’s say there are two cement retained crown. If you are doing it, it will come in sort of two pieces. You’ll have abutment, which you screw into the implant, and then you have a crown which goes onto the abutment. Whereas the screw retained crown will come in one piece, where you literally screw the whole crown into the implant.

Why the channel not so the crown doesn’t move you have a screw access hole. So you see the crown into the implant is snuggly seats in and then you screw the screw it from the channel to make it secure.

[Jaz]Is anything that we talked about previously because you menti

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Are you a dentist looking to venture into the world of implant restorations? Have you ever wondered where to start or how to ensure predictable outcomes for your patients? Look no further!

In this insightful two-part podcast series, we dive deep into the art and science of implant restorations, guided by the expertise of Dr. Devang Patel, a seasoned practitioner with over 13 years of experience in the field.

Dr. Patel expertly breaks down this mammoth topic step by step. He discusses assessment and treatment planning, emphasising the importance of patient expectations and optimal occlusion. Exploring space requirements, he delves into mesiodistal space and considerations for both posterior and anterior teeth. Uncover the topic of temporary restorations during the healing phase, followed by detailed insights into impression techniques, lab communication, and implant connections. Finally, they unravel the differences between screw-retained and cement-retained crowns, offering invaluable tips for dental professionals seeking to excel in implant restorations.

Don't miss this opportunity to gain a comprehensive understanding of implant restorations from a true expert in the field! You'll be sure to gain a solid foundation for your implant restoration journey.

The Protrusive Dental Pearl: www.usemotion.com

Highlights of the episode:

00:00 Intro

01:56 The Protrusive Dental Pearl

04:26 Where to start?

07:03 Dr. Devang Patel

13:30 Assessment and treatment planning

22:19 Space requirements

27:49 Temporaries

28:48 Occlusion and diagnostic wax-ups

30:10 Impression technique

39:31 After the impression

42:29 Connections

48:19 Screw-retained crowns vs. cement-retained crowns

58:18 The lab

67:39 Digital impressions

72:15 The next episode

74:48 Outro

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We speak with Dr. Pav Khaira, a total implant nerd, who shares 4 of his top tips for maximising osseointegration:

Biological ageing: discover the time-sensitive nature of implant bioreactivity and its impact on integration (and how to improve the bio-reactivity of your implants)
Mastering the osteotomy: fine-tune your skills in shaping the osteotomy based on bone quality and type
Disinfection: explore disinfection techniques of the osteotomy
Systemic factors: optimise early-stage healing and understand long-term immunological balance

Don’t miss an upcoming exclusive live event on “Superosseointegration” on 15th and 16th September 2023 in London hosted by @Dr.Pav.Khaira – www.academyofimplantexcellence.com

https://youtu.be/fBfnxubdgpc Check out PDP155 on YouTube Maximise the osseointegration of your implants and uncover the intricate relationship between the skeletal system and the immune system (known as osteoimmunology) and its impact on implant success.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:00:00 Intro01:19 The Protrusive Dental Pearl03:11 Dr. Pavandeep Khaira04:29 What is osseointegration?05:04 Osteoimmunology07:39 Early-stage failure09:52 Success and survival rates12:33 Biological ageing15:45 Decarbonisation for Implants21:18 Bone density24:10 Overheating the bone27:16 Disinfecting the osteotomy29:21 Systemic factors33:03 Superosseointegration36:58 Outro

If you enjoyed this episode, you will love Why Should You Avoid Flapless Implants? – GF015

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

Click below for full episode transcript: Jaz's Introduction: We know that implants are a great way to restore an edentulous area. It is not a replacement for a tooth, because teeth are still the best, but the next best thing for a missing space at least, are IMPLANTS. Now, implants can get very complicated, different stages, surgical, restorative, but the very initial stages is all to do with ossteointegration, which is essentially, in a crude way to describe it, would be the fusing of the implant to a patient's bone. Jaz’s Introduction:Or as I like to call it, how long it takes for the implant to cook, so it’s ready to accept load. Today on the show, I’ve got Dr. Pav Khaira on again, he’s our resident implant expert and a titanium nerd, and he’s going to cover four techniques he uses, and most of these are very quick to act on, very simple, and something that you can apply straight away.

One of them does involve you to buy some extra kit, but the reasoning is really solid, and it’s something I hadn’t heard of before, so it’s four ways to BOSST your OSSEOINTEGRATION. That’s the success rate overall, and the quality of your osseointegration itself. Like Pav taught me in this episode that most implants, when they’re placed, about 56% of the implant is covered by bone, or rather 56% of the implant is actually directly contacting bone.

And with his techniques, he’s getting that much higher, which he believes results in a longer lasting, more successful implant. So he calls this all super osseointegration.

Protrusive Dental PearlNow before we join Pav to reveal those four ways, I’ve got your Protrusive Dental Pearl. Now please bear with me because I do have an ulcer on the inner side of my upper lip. It’s a little bit painful, but the show must go on. And my son is home today because of school holidays. So I’m hoping he doesn’t barge in and have to record this all over again, but let’s go, let’s do our Protrusive Dental Pearl, which is not an implants one. I don’t do implants myself, but I can tell you is about COMPOSITE BONDING.

Here’s a tip I picked up when it comes to anterior composite bonding. You need to evaluate what percentage of your appointment are you going to actually devote to the placement of your composite and what percentage of your appointment is going to be the finishing and polishing. And if you think about your last few cases, what percentage of your appointment was the placement.

Well, if you’re like most dentists and certainly me many years ago, I would do like 90% of the appointment actually placing the composite and 9% of it checking the occlusion because that’s very important to me. And then you’re looking at the time and you’re running late and then you quickly, you know, finish and polish and you try and make it as shiny as possible in that valuable one minute you have left before your nurse starts giving you the eyes.

And really, if you look at what the masters do and how they get wonderful results in their composite bonding, we need to really change this. So I was always advised 50% of your appointment length should be the actual placement of the composite. And the rest of the appointment should be, yes, checking the collusion thoroughly at the end, but a huge bulk of that will be finishing and polishing because that’s how you get a stunning, long lasting, unstainable result.

And of course, if you nail those line angles and that secondary anatomy, even tertiary anatomy, you make it look more lifelike. So the way you can action on this tip is either you need to book longer for your appointment. So you got more time to do finishing polishing, which is such a crucial step, or you just need to be a little bit quicker in your placement and actually devote more time to getting it all perfect in the finishing and polishing.

So less time placing, more time finishing and polishing. That’s the tip for today. Let’s join Dr. Pav Khaira for the main episode and I’ll catch you in the outro.

Main Episode:Dr. Pav Khaira, the titanium nerd. Okay. You are Mr. Implants for me, you know that. And we bring you back again to talk about, I don’t want to ruin the surprise, but ossteointegration and then how you do ossteointegration and all the levels of details that you go into.

You’ve done so many episodes of us four. So if anyone hasn’t heard of Pav, check out the dental implant podcast or listen to some of the previous ones we’ve done covering all sorts of things such as can you probe this implant to how to clean under your implants to finding your niche and dentistry. So lots of different implant topics that we’ve covered already. So if anyone hasn’t, for those few people that haven’t heard our episodes before, just tell us about yourself, Pav.

[Pav]Jaz, thank you very much for having me back. I am a titanium nerd to the core and I’ve mentioned this several times, but you’re the one who inspired me to start the dental implant podcast. And I just, all I do is place implants, restore implants.

I absolutely love it. And I just love studying. I love teaching. I love helping patients. I love helping other dentists increase their skills. So anything titanium related, my wedding ring is made out of titanium. My daughter got me a a chain for father’s day. That’s made out of titanium. Everything’s just titanium for me. So that’s why I call myself Titanium Nerd to the core.

[Jaz]I love it. And today what we’re covering is Osseointegration, which you can explain what it is for the dental students. We know is how you get the screw to fuse to the bone. I’m sorry. If it’s said very crudely by a non implant dentist, but you say it more elegantly, but how to get your implant to, it’s fuse the right word?

[Pav]I don’t want to get too technical about it because technically fused isn’t the right word, and effectively what integration is nowadays, we classify it as a controlled rejection of the implant but for simplistic terms, yes, let’s call it fusing to the bone, yeah.

[Jaz]And this is something that if it fails to happen, it’s a heart sinking moment for a dentist and a patient. And we can find out, we can get an idea from you, what are the signs to look out for? At what point does this happen? So let’s say you place an implant and it fails to osseointegrate. When would that typically happen? And what is the number one cause of that? Before we then delve in to your multiple levels and layers of tips to make sure that we increase our percentage chance of osseointegration. So what commonly causes the downfall of implants?

[Pav]So there is a concept now called osteoimmunology, which is an interplay between bone and the immune system. So this is why I called it a controlled rejection. Because what happens is, if you think about it in terms of fusion, the perception is that the bone fuses to the surface and then kind of like, that’s it, it’s like a cement post in the ground, you put the cement in, the fence post goes in, and the cement sets, that’s kind of like it for a very, very long time.

So we know that that doesn’t happen is the body recognizes the implant as a foreign body. And it almost, it wants to reject it, but it kind of like encapsulates the implant within bone. And then there is then healthy bone around the implant. It’s aiming to contain the implant and not have it kind of like leach out into the body.

So it’s a paradigm shift in its definition. But what that then tells us is there’s this balance backwards and forwards, Jaz, of the body being successful, and it is a balance, the body being successful versus the body’s starting to reject the implant, and this is why implant rejection can happen many, many years down the line.

So if the patient gets sick, if they get put on certain medications, all of a sudden this implant that you’ve had success with for 15, 20 years, it may start to give you problems and fall out within the space of six months. So gone are the days where we think about an implant as being fused to the bone and kind of like, that’s it. There is a constant backwards and forwards, the bone remodeling around the area constantly.

[Jaz]Dynamic situation, right?

[Pav]Completely dynamic situation. So what we can do is we can split up this lack of integration. And to clarify integration of an implant is not just this. Again, let’s keep it simple. It’s not just this fusion to the bone Jaz.

It’s the absence of any types of inflammation, disease, and it’s the ability for the implant to bear load as well. Because if the implant can’t bear load, what use is it? So the definition is multifactorial. Now, there’s a number of points at which we can have failure. And one of the failures is early stage, which is from when the implant goes in to when you take compressions.

And sometimes we get patients coming back and they come back because they’ve called after two weeks and they’re like, ‘Pav, I’ve got a lot of pain. It feels really weird.’ And all this, but there’s a strange taste coming from it. And you look at the implant and you’re looking at it and you can just tell something’s not quite right.

And at that point you need to make a decision. You’re going to take it out or you’re going to wait. And normally the best thing to do is take it out. So that’s kind of like the early stage failures before we’ve even managed to put a crown on the tooth.

[Jaz]What I’m already thinking about, Pav, in terms of my restorative background is, resin bonded bridges, for example, we know that they could fail within the first four years, but if they make it to four years without any issues, they’re going to make it 10 plus years without an issue.

So most failures, when they’re going to happen, are going to happen within four years. Do you have such stats for implants or your experience that you’ve learned that when you get implant failure? Because the way you suggested it is that even 20 years later, it could have a failure, which is a really obviously we know that they don’t last forever, but the type of failure may change. Any stats on if you get past this point, then you’re looking good?

[Pav]Yeah, 12 months, 12 months after loading. And the reason for that is quite simple. If the bone metabolism is compromised, if the patient’s not quite as healthy, there’s the number of factors which come into play. It may be that at the time of impression that the implant’s absolutely fine and then you put a crown on it and you start to function on it and that may tip the balance that there’s too much force going through the implant into the bone and then the body decides, no, I can’t deal with this and just splits the implant out.

I generally tend to find once we’re past that 12 month mark, at that point, we’re kind of into average territory. And there’s a number of factors we, I do a risk assessment, which tells me based upon these parameters, I’d expect a lifespan of the implant of 10, 15, 12, 15, 20 years, whatever it is, but that danger zone is really within the first within the first 12 months, because if you’ve made a technical error or your labs made a technical error is going to come to light really quite quickly. And so I generally say 12 months is kind of like the point after which I’m just like, ah, okay.

[Jaz]Good. And then with my endo hat on, how an endo, they’ve got studies like survival versus success. And survival was like, well, the tooth is still there. Yes. There’s an apical infection, but the patients don’t choose on it. So it’s survival, but it’s not success. Is there such stuff about implants? Like you could have an implant with peri-implantitis it’s oozing, it’s pussing. A patient still chews on it, and it’s just slowly dying its death. Do you have such data like endo, like survival and success?

[Pav]Yes, absolutely. So most of the statistics where people talk about success rate with implants, they actually referring to survival rates. And this is a clarification that a lot of dentists need. And then we need to define what success is, there’s a number of different parameters to it. There’s a mechanical success, there’s a biological success, and then there’s an aesthetic success.

So all of these factors kind of like come into play, but most of the stats that you hear when people talk about success, they’re actually survival. So when people say, oh, implants have a success rate of 98% over a 10 year period, the caveat to that is actually that that’s normally a survival rate. The success rate is normally significantly lower around the 68% to 70% mark.

Now, a lot of these problems are iatrogenic and they can be avoided, but in order to avoid them, we end up needing to do more complex treatments such as more complex bone grafting and soft tissue grafting. So this goes back to the osteoimmunology principle that I spoke about before Jaz, and the best way to think about it is the plaque, the bacteria, the biofilm, they cause an inflammatory wavefront.

Okay. And it’s about two millimeters away from where the biofilm is. Now, what all of the evidence tells us is we need two millimeters of bone around an implant and two millimeters of soft tissue as well. And it’s not just any soft tissue, you need keratinized tissue. And what that does is when you have that, the survival and the success rate significantly goes up for the implants.

So when people do that, that’s when you have true success rates of 98% over a 10 year period. Because what you’re doing is you’re keeping that inflammatory way front away from all of the sensitive area. And when you do that, all of the remodeling, all of the dangerous stuff happens at a remote distance.

And this is why all of the studies suggest you need two millimeters of bone, you need two millimeters of keratinized tissue, because what it’s doing is, that then falls in line with the osteoimmunology principles, which we’re starting to employ nowadays.

[Jaz]Okay. Well, if you’re a young dentist and you’re starting new or if you’re an established dentist and maybe you’re getting into implants or you don’t do implants, but this is something that’s quite fundamental to know, right?

It’s like even though you don’t treat lots of perio, you should know about perio. Implants is obviously everywhere now. So we should appreciate how our colleagues can get better osseointegration. Some of it is actually factors that the GDP can help with while they’re on the way to see an implant dentist or, and their journey into implants. So what are some things that you employ in your protocols to boost that percentage? That at 12 months, everything and beyond, everything’s going to be hunky dory.

[Pav]Oh, how much time have we got Jaz? This could be a very long podcast.

[Jaz]Six minutes, no I’m joking. It’s got a bit longer, as long as it takes, but let’s cover some quick tips to help people out to maybe some of, oh, I didn’t appreciate that or, okay, that’s a really good point.

[Pav]So my master’s thesis, cause my MClinDent is in implantology. My thesis was on ‘What’s called Biological Aging of Implant Surfaces’. And what happens is once implants are manufactured and they are sterilized and they are packaged, their bioreactivity, which is their ability to interact positively with the body, reduces very, very quickly. You can get a measurable drop within 24 hours.

[Jaz]Wow.

[Pav]And after four weeks, Jaz, the bioreactivity has reduced by 50%. Okay, so this bio reactivity is reduced by 50% and the bone to implant contact ratio that we’re getting of integrated implants and bone to implant contact, very simply it’s an indicator of how much bone is touching the implant and it’s an indicator of success.

And a successful implant generally has a bone to implant contact ratio of 56%. So there’s only 56% bone around an implant and these implants are still lasting a long time. Now, what I found out is if you decarbonize an implant chair side, just before it goes into the patient’s mouth, that bone to implant contact ratio jumps to 98%.

It’s a huge increase. So the discussions that I’ve had with colleague is yes, but is it clinically impactful? Because we’re still getting a very high success rate with this 56% bone to implant contact ratio. Well, the answer to that is really simple Jaz is what’s the other 44%. It is soft tissue, it’s biofilm, it’s all sorts of stuff.

So we want to exclude that as much as what we possibly can. And in addition to that, when you decarbonize an implant before it goes in, it reduces the biofilms adhesion to the implant surface as well. There are also what are called finite element analysis studies, which show how much stress and strain go into certain systems. That they’ve shown that when you decarbonize an implant and you put it into place, the forces around the neck of the implant are significantly reduced because you’ve got this tighter bone seal around.

[Jaz]Now I’ve seen some videos Pav on Facebook. Is this the purple beaming light on the implant that you’re doing? Is that the decarbonizing because it literally looks like you’re in Wakanda and is vibranium implants is why I commented ones on your Facebook post. So that’s what you’re talking about I mean, is this a machine you got to buy or how does this work?

[Pav]So there is a number of ways to do it. One of the first ways that came out was a UV-C chamber. The issue that we have with that, A) That chamber is incredibly expensive. B) It’s not available in Europe anymore. And C) The cycle is about 12 minutes long. So basically, if I want to decarbonize an implant, I take it, I put it in that chamber, and it takes 12 minutes for the implant to be spat out before I put it into place.

And another way of doing it is to use an alkali solution. Now, alkali solutions are used by a company called Thommen, and their implants come pre packaged in this alkali solution. You press a little button, it surrounds the implant, give it a little bit of shake, count to 60 and place it. So some people, I know they purchase the alkali solution, they just use it like that way, but other people are, I don’t want to add anything to the surface of the implant, particularly something which is kind of like they’re just like, I’m not comfortable doing that.

And this new plasma unit, which is the Actilink. It’s nice because it’s only a 60 second cycle. And that’s that really cool video that you saw. You put the implant into the chamber, you press it and it goes, activation starting, and then it does this whole, Emperor Palpatine zaps it with this electricity.

And at the end it goes, activation finished. And the patient goes, what on earth was that? And so it’s nice because it works incredibly effectively and it’s only a 60 second cycle. Now, what I would say Jaz, on top of that, there are certain implant systems, which come prepackaged in a sodium chloride solution, because they’re trying to prevent this contamination as to happening on the surface.

So there’s two things that I would say to that. Firstly, when I take these implants and I condition them just before they go into place, I still get a better result with them. And secondly, there is a link between implant surface corrosion and peri-implantitis long term. And all of the people that I’ve asked, I’ve asked some very high-profile people, ‘Does storing the implants in this salt solution increase corrosion of the implant surface?’

Nobody’s been able to tell me yes or no. So in my mind, it’s actually an untested system. It’s an untested surface, but not only that, is even if it were a tested surface, you still get a better result by chair side treatment just before the implant goes into place. And this is one of the most impactful things that I have done for my implants.

I’m not worried about marginal bone loss. I generally don’t see that anymore. I’m getting vertical bone growing around it. And it’s not just the amount of bone that you get adhering to the surface, Jaz. The quality of the bone is significantly increased and the speed of integration is significantly increased as well. So it’s upregulated on every level.

[Jaz]I mean, it makes sense. It’s one of those things where it just makes sense to do because like you said, what’s the other 44%? Are there any long-term clinical trials yet to support this? Or is this something that we’re waiting to see if it actually results in clinical differences?

[Pav]So there are some clinical trials as with everything it started with animal trials and things like that. But we’ve known of this concept since about 2008. So it’s not a new concept.

[Jaz]Okay.

[Pav]As with everything it kind of takes a little bit of time to get the ball rolling with this. There are some good studies coming out now, which is what they’re showing and these are human studies taking what are called ISQ readings and ISQ reading, you use a little peg and it gives you a numerical number as to how much your implant has integrated.

So it gives you a numerical value as opposed to us just guessing. So these new studies, what they’re showing is we can take these implants and put them into patients who are very medically compromised or whose bone is so poor that these implants are just spinning. There’s a term for it in implantology, we call them spinners.

We’re always worried whether they’re going to integrate or not. And some of these, what we call ISQ readings, they’re so low to start with. That the ISQ is, it can’t even be measured because it’s so low. And then what we know is if we can achieve an ISQ of 70, again, it’s just a numerical value.

We know at that point, the implant has integrated. And what we’ve shown is we’ve shown that these patients who have this extremely low ISQ get an ISQ of way above 70 within 12 weeks. And normally we wait six months for these patients. So we’re getting integration within 12 weeks. And then from the point of restoration, these patients would be followed up for two years, showing that you don’t get an increase and then a decrease again, you get this increase in bone quality and then it’s maintained as well. So there are some studies starting to come out now, and I’m confident that as time goes on, we’re just going to see more and more of this.

[Jaz]Excellent. So the first tip there is decarbonizing. I’m just, all I can think about the whole time is this company that produces this, the unit they use, they need to make a Marvel Black Panther version. I would just love it. That if it just had the music going and then suddenly, like they said in Black Panther’s voice, like a vibranium completed, like, I would just love that. That’s mostly what I’m thinking about right now.

[Pav]Maybe I should get like a bespoke one made just like that. For me, like all marvels.

[Jaz]I’d buy one. I’d buy one. I didn’t do it, but I just buy one and I zapped my crowns with it. And I just wait for that. And I’m patient. Be like, wow, what’d you just do to my crown? Like decarbonising. There’s all sorts. We can do that. The world’s our oyster. Okay. So tip number one, that is a decarbonize. This is brand new to me. So decarbonize your implants. Thanks for sharing the science behind that. Another thing.

[Pav]So another thing is drilling in the correct sequence and in the correct manner with the right tools based upon the patient’s local and systemic factors. Okay, let me explain that a little bit more detail. So there are four different qualities of bone that you get bone, which is really, really soft. And then you get bone, which is really, really hard.

[Jaz]It’s like wood.

[Pav]Yeah. Either one of those two extremes is not good. So when bone is very, very, very hard, it generally has a very poor blood supply. And when it’s very, very, very soft, it is generally not very metabolically active.

[Jaz]That’s the spinners. Yeah? The soft ones are more likely to be spinners.

[Pav]Those are the spinners. Yeah. These are the patients where you open a flap, you drill and it’s just yellow fat-

[Jaz]Vanishes in there.

[Pav]Yeah. It just vanishes. You put suction on it and all of a sudden it is, there’s no bone left. And you’re like, what am I supposed to do here? So we want something kind of like in the middle. And that’s the best bone to actually put it in. Now, one of the things that I always get into, let’s call them discussions about is there is something called initial torque value.

Okay. Initial torque value is kind of like how tight that implant goes in on the day of surgery. Okay. Now, a lot of people incorrectly state that if you put your implant in at too high torque that it causes pressure necrosis of the bone. Now, there are some really good studies to show that this doesn’t happen, but I think it’s a little bit more nuance than that Jaz.

Okay, so there’s two different types of bone. We have trabecular bone, which is the bleeding bone. It’s the soft bone in the middle, and then we have the hard cortical shell on the outside. So on that scale of very soft to very hard bone, we need to know what our bone type is so that we modify the shape of the recipient site called the osteotomy based upon that bone type.

So what I’m saying to you is if I’ve got softer bone, I can under prepare and squeeze in that implant and achieve the same torque value as very, very dense bone where I over prepare. And I get the implant to drop in almost to the apex and then it’s the last two turns where I achieve all of my what’s called initial torque value.

So the initial torque value on both of those may be the same. It may be 50 newton centimeters. But where and how we attain that 50 newton centimeters is very, very different. It could be 70 or 100 newton centimeters. So it’s not just simply a sequence of going through your implant drill kit because your drill kit’s really nice quite often it’s color coded and you get told use this one then this one then this one then this one. Unfortunately, it’s not as straightforward as that so you need to shape the osteotomy based upon the implant and the type of bone as well.

[Jaz]Okay.

[Pav]The other aspect to that as well is You don’t want to overheat the bone. If you overheat the bone, that’s when you do thermal damage, and that’s when you’re definitely going to have issues as well. I’m actually surprised at the number of people who don’t track how often they’re actually using their burs, because they should actually be replaced very, very frequently. And the denser the bone, the more work that bur is having to do, so the more frequently you need to replace it.

[Jaz]And any guidelines? Some people might be doing this thinking, ‘Oh, I’ve never replaced my kit.’ What’s the life cycle of a drill kit?

[Pav]Every 10 uses at the very most your burs should be changed, at the very most. And sometimes if I’ve got really, really, really dense bone, I will use the bur once and that’s it. I’ll get rid of it. I don’t want to take that risk. Just for the sake of saving a few pounds, a few dollars that all of a sudden that I’m going to increase my risk of problems, and lack of integration. Now, the other aspects of that as well, it’s really a nice biological drilling is we reduce the speed at which we’re actually drilling.

So what we know is if we put the burs in at 150 RPM or less, without irrigation that we don’t get that much thermal damage. Now there are certain bur designs which are even more efficient than that. So I have a bird design which I use very frequently, use it pretty much all my things and I could run that at, so the cardinal rule is, you don’t want to drill more than a thousand RPM, 1200 RPM if you’re really feeling like an absolute madman.

So with these burs, they’re so hyper efficient at how they work, I can run them at 2000 RPM without irrigation in the most dense bone and they still won’t generate heat. The downside to it is you don’t get much tactile feedback. So they’re only really for more experienced implant places, or if you’re using a guided system, then you can use it.

But by reducing the amount of thermal damage again, we’re just accelerating the body’s ability to heal. And in addition to that, if you do get thermal damage, firstly, you’re going to have more pain. You have this zone of death around the implant, which the body has to clear first, and then it reattaches the implant to the surface. So having the correct osteotomy shape for your implant design in the correct bone and using the correct burs in the correct fashion and reducing thermal damage, it plays absolute wonders.

[Jaz]So I love the zone of death that made me chuckle. And so the summary there is the right tools for the right job and respecting the bone in terms of making sure that it’s irrigated and preventing thermal damage.

[Pav]Correct.

[Jaz]Amazing. Shoot us with love. And you got to tell me roughly when you think, okay, we’ve covered the main things because this, as this episode is your baby in terms of your top tips for osteointegration. So we’ve covered two already. What else have you got? Because I think something more systemic and medical is coming soon as well, I think.

[Pav]Yes, correct. So Just before we move on to the systemic stuff, I think we don’t disinfect the osteotomies as well as what we should. We just drill and then we just place. So there are good studies to show that if you have a big periapical lesion around a tooth and you take that tooth out, you degranulate it and you wait for it to heal, you come back in six months time, those bacteria that were present are still present.

They’re not cleared in the bone, even though the bone appears to be healed. So then if you are preparing your osteotomy and putting your implants into this position, the bacteria are still there and they are linked to failure long term. So what we need to get in the habit of doing is disinfecting the osteotomy.

So it’s a little bit too nuanced for this, but I would recommend that everybody should be disinfecting the osteotomy just before the implant goes in place. So the way that I do it is I know what implant I’m placing, I prepare the osteotomy, I start my disinfection process and I then put the implant into the decarbonization chamber and then it all starts to kind of like tie in together.

[Jaz]Are you squirting some chlorhexidine or some ozone or like, what’s your chemical or mechanical?

[Pav]No chlorhex, should not be using chlorhexidine when it comes to implants or surgery. So there is risk of anaphylaxis when it comes to chlorhexidine. It also reduces fibroblast development as well. So I don’t like, even when I was doing general dentistry Jaz, I didn’t like it. There was always something that I preferred.

So my go to at the moment is Clinisept+ mouthwash, which is hypochlorous acid. It’s very, very mild. And then what I do is when I am disinfecting the socket, I will use either iodine or I will use a bluem gel or I’ll use a hypochlorous acid. It depends on what I’m trying to achieve, but there’s a number of ways of effectively doing that as well. Okay.

[Jaz]Okay, great. So decarbonize, respect the bone in terms of thermal damage and correct sequence and disinfect the osteotomy, osteotomy being the hole that you make in the bone.

[Pav]Yep, correct. So systemic factors. Now this is where it starts to get interesting. There are a whole host of factors which can interfere with your early stage healing but are also involved in this osteoimmunological balance in the long term as well. And what we need to look at is we need to look at generally how fit and healthy the patients are coming in.

So there’s a number of things that I’m looking for. If a patient comes in and they are at increased metabolic syndrome risk, so their blood pressure is elevated, they are looking overweight, they don’t do much cardiovascular exercise, is what I know is the level of systemic inflammation within their body is significantly increased.

If somebody is diabetic, they generally have low vitamin D as well. If somebody takes antidepressants, that can significantly impair how your implants are healing. If somebody’s got high cholesterol, then that can also impact with how your implants are going to heal as well. So, I think it becomes a little bit unreasonable that if somebody was to walk through the door, that you just turn around and say, well, hang on before we do anything for you that we’re going to, you know, check your vitamin D levels.

We’re going to check your blood pressure. We’re going to check your HbA1c levels. We’re going to do this, check that, check, we’re going to check your cholesterol, because you’ll just turn patients right off. So my point being is that if a patient comes in and I’m doing more complex work, so if I’m doing full mouth, if I’m doing zygomatics, if I’m doing big sinus lifts or large bone grafting, things like that. I’m more likely to do these checks beforehand and the way that I say-

[Jaz]It’s like a risk assessment. It’s like case by case-

[Pav]Risk assessment, systemic risk assessment. If a patient’s coming in, I’m a little bit worried, but it’s a single tooth. It’s just kind of like, well, I may pitch it to the patient, but if they don’t go ahead with it, then I’m not overly insistent on it.

Sometimes you get this odd patient where it come in and you put an implant in and it doesn’t take, you wait for it to heal. You put the implant in and it doesn’t take again. And you’re like, let me do a blood test. I’d say that 90% of the time. That blood test shows something undiagnosed, which has been impairing the healing for the patient. So we need to look at kind of like the general overall health profile of the patient and take it into balance with regards to what we’re doing as well. And the main thing-

[Jaz]I think, Pav anything surgery, like, I think even perio, just general perio, looking after periophile patients, these are often diabetic patients. There’s a rise in getting clinicians to take a step back and look the patient as a whole and look at their medical history and try and promote better habits and vitamin D and get checked out to boost even your perio outcomes. So it goes hand in hand with we’re doing if implants, and I saw one of your social media posts maybe eight years ago about how many patients are low in vitamin D and how it’s important to check this. I think I remember Hatem Algraffee also posted about this as well in his perio patients.

[Pav]Correct.

[Jaz]So these are things for healing. It’s all about wound healing.

[Pav]So in fact, all of these things link back to osteoimmunology. So vitamin D deficiency and diabetes are linked. And they are also linked to MetS risk, and they are also linked to osteoimmunology. So what we’re finding now is all of these random things, which is kind of like, wow, we didn’t understand that that would be linked.

Actually, when you trace them back, they’re all kind of like falling underneath this umbrella of osteoimmunology. This is why over the next, I’d say, five to 10 years. The paradigm shift is going to be more towards the osteoimmunology way of thinking as opposed to just pure biomechanics. And it’s the right way to approach things because it helps us treat and plan for the future and it helps us understand the risks of what’s potentially going on now as well.

[Jaz]So, these protocols are essentially what you, I see you talking about it, super Superosseointegration. I love the term. Everything’s sort of like superhero base, Marvel base. I like it at zone of death, et cetera. I just, these are cool terms for me. So I love what you post about Superosseointegration. Obviously, we’ve just crashed the surface. You’ve got a two-day summit coming up about it. Please tell us more about how you’re talking about Superosseointegration. What kind of format is it going to be this event?

[Pav]So it’s going to be a live two day event in the middle of September. It’s 15th and 16th of September and day one.

[Jaz]2023 in case you’re listening next year, 2023.

[Pav]And it’s going to be what we’ve discussed in a lot more depth. So we’re going to be going into depth about osteoimmunology, how we do things, why we do things, decarbonization of implants, I’ll show full disinfection protocols, osteotomy protocols.

So we’re going to basically flesh all of this out that we’re talking about. Day two is a full arch treatment planning masterclass with a heavy emphasis on pterygoid implants. We’re going to tie in the osteoimmunology and all of what we discussed on day one into the full arch treatment planning masterclass and we’re going to have like a round table as well where we’re all going to kind of like brainstorm. So if anybody has cases that they want to discuss bringing together that they’ll get to look at it kind of like as a group, I think it will be a good exercise for everybody. So that’s the-

[Jaz]That sounds very engaging and group work. I love that way going. But is this like, is it a two day package or can someone who’s not doing pterygoid implants come to day one only like, who is the ideal person at what stage of the implant journey should they be coming to learn about Superosseointegration and your day two kind of thing.

[Pav]So it’s not an independent package for each day. This is going to be best suited for those people who are placing implants and who are kind of like early on in their full arch career or are about to get into full arches and things along those lines.

Even if they’re not doing full arch, they’re still going to get a lot from the diagnostic aspects of it and from the Superosseointegration that we’re and the biological principles that we’re going to do on day one. It’s going to be really, really interesting because I’m going to take a lot of dogmatic paradigms and just throw them out the window Jaz and what’s the best way to describe it? I’ll take my fingers and put them into people’s heads mix their thoughts around a little bit. Yeah, that’s the way that we’re going to do it

[Jaz]Well, the other good thing about events like these is the networking, right? Implant dentists meeting other implant dentists around the country now, around the world who will be able to lean on for support set up, exchange WhatsApp numbers, keep in touch. It’s a great opportunity to meet like-minded people, maybe already doing full launches as well, or earlier on in the journey.

So it’s a good opportunity I think, even if it’s just some, if it’s a course that you’ve already done before, but it’s the ability to learn further from your protocols and also to just network. Networking is so, so important what we do and mentorship. So it’s always something to be gained there. I think.

[Pav]Yeah. Absolutely agree with everything you said there, Jaz.

[Jaz]Amazing. What’s the website so people can just log in? I’ll put it in the show notes, obviously, but please just let us know the website so that people can book on.

[Pav]So you can go to academyofimplantexcellence.com, reach out through there. Or if you go to Instagram and look for Dr. Pav Khaira, message me from there as well. And I’m pretty swift at responding to messages. So, because a lot of my time is now focused on the academy and mentoring. So yeah, I’ve got plenty of time to respond to messages.

[Jaz]What I’ll do as well is, protrusive.co.uk/AIE. Academy of Implant Excellence. So /AIE, it will take you straight to that event page. So when you share the event page with me, I’ll stick it on there. In case anyone didn’t get it, it will be a /AIE. And then that’ll just take you to the page. Cause I love to support you, get your people to network and mentored and do all the lovely things that you’re doing. So Prav, thanks so much for giving me time to talk about Superosseointegration, four ways that we can boost our osseointegration.

[Pav]Thank you, Jaz.

Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end, as always. Whether you are chopping onions or on your commute, I hope you found that useful.

If you’re new to Implant Journey, amazing. Pav’s a great guy to learn from. If you’re more advanced, and I’m hoping some of those tips are going to be applicable to you to really elevate and raise your game, sometimes the whole systemic factors of patient, it can get neglected a bit. So this is a great thing, even in the world of periodontology, as we discussed.

After recording a few episodes with Pav, I really get an idea that implants, like many other things in life, are all to do with marginal gains, right? Getting those one or two percent things correct, and overall, they add up to get you a good result. So it’s really paying attention to detail, so if you want to learn from Pav, please do go on the website /AIE, that’s Academy of Implant Excellence, and that’ll take you to the event.

And of course, if you want a quick win and you want to answer a few questions to get CPD for this episode, so half an hour’s worth of CPD for this episode, just head to protrusive.app. That’ll take you to the web app and then all my episodes there, all my premium content’s there. We’re doing live webinars every month now.

I think the next topic is about vertipreps, so watch out for that one. And if you are going to sign up to Protrusive Premium, whether it’s CPD you want, because you’re already listening to the podcast or for the premium clinical videos, my request is that you sign up via protrusive.app and not via iOS and Android, ideally, because Apple and Android, they actually take a really huge percentage.

So if you want to support the podcast, you go on protrusive.app, make your login. And the cool thing is, once you download the app from iOS and Android, the same login that you made on the web app. That’s protrusive.app website. You can then use on Android and iOS basically. So that will, you get all the premium features without anything going to Apple, Android and supporting the podcast the most.

So thank you so much for the hundreds of you who support the podcast so that I can continue to do what I’m doing. I’m always happy in the comments below. If you’re watching on YouTube, or if you hit me up on Instagram @protrusivedental to have your recommendations, what would you as a Protruserati like next on the podcast? I’m all ears always. Thank you so much. Once again, I’ll catch you in the next episode.

View Details

When and why should you use post crowns in contemporary Dentistry? Surely they are a thing of the past? Dr. Dominic Hassall, a restorative consultant, shares valuable insights on restorability and the essential concept of ferrule.

He highlights the significance of restorability and the role of fibre posts in dental procedures, emphasising the ferrule effect in crown and onlay preparations. The ferrule effect ensures predictable outcomes by transmitting occlusal forces through the natural tooth structure, reducing the risk of failure.

https://youtu.be/zQNReIIJCG8 Watch PDP154 on Youtube Protrusive Dental Pearl: How to Bone Sound for Ovate Pontics –Imagine you have a missing upper lateral incisor, and you want to use an ovate pontic for an aesthetic bridge. To achieve the ideal emergence profile, Jaz demonstrates how to assess gingival thickness using ‘bone sounding’ using a periodontal probe (please see video). This technique helps determine how thick the tissues are overlying the edentulous area and whether an ovate pontic is feasible (or perhaps a connective tissue graft is necessary).

Throughout the episode, Dr. Hassall’s expertise shines through, making it a must-listen for dental professionals seeking a comprehensive understanding of restorability and ferrule in restorative dentistry.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:0:25 – Introduction to Dr. Dominic Hassall1:27 – Bone Sounding Clinical Video6:25 – Dr. Hassall’s journey into restorative dentistry9:04 – Function of Post Crowns13:35 – Composite for Nayyar cores18:10 – Assessing restorability23:25 – Impact of ferrule position on treatment outcome30:30 – Advantages and disadvantages of post techniques38:55 – Post Crowns as Bridge Abutments?43:08 – Dr. Hassall’s teaching institute details

Dr Hassall gave a discount for his Diploma Course, head over to https://dominic-hassall-training.co.uk/contemporary-restorative-aesthetic-dentistry-online-blended-course-advanced/ and use the code “JAZ10”

Jaz has no financial interest in this product.

If you enjoyed this episode, check How to Save ‘Hopeless’ Teeth with the Surgical Extrusion Technique

Click below for full episode transcript: Jaz's Introduction: We are using less and less post crowns now, but is there still a place for them? Now, recently I had Dr. Pasquale Venuti on the show and he had some interesting opinions. He was quite a big advocate of the cast metal post crown in certain scenarios, where today's guest, actually Dr. Dominic Hassall, is well known restorative consultant, has a teaching institute, is a well-established educator, and he's very anti cast post crowns. [Jaz]He’s very pro COMPOSITE FIBER POSTS. So you’ll find out today what his views are on that. But we take a big, broader view of all things to do with posts in terms of when we should be placing a post. What about restorability in general? If you’re thinking about placing a post, then you are also debating, ‘Hmm, is this tooth even savable in the first place?’

We also cover the very foundational concept of the ferrule, which is so, so important when you’re considering if you can rescue a tooth or not. And also in terms of the long term outcomes for post crowns in general. Lastly, if you stick all the way to the end, we talk about this real world factor of communicating fees to your patient, because if your patient needs a root canal retreatment, and a post and a new crown, you’re kind of in the implant money territory, you know? So this is like a tough thing to help our patients decide which is the best scenario for their tooth.

Hello, Protruserati, I’m Jaz Gulati and welcome back to another Protrusive Dental Podcast episode. Every episode I give you a Protrusive Dental Pearl. Today’s Protrusive Dental Pearl before you join the main episode is about bone sounding.

So what is bone sounding? There’s a couple different scenarios we can use it, but let me give you a clear one because I’ve got recording of this that I want to show you on the screen. And a standalone video for this on YouTube just about bone sounding. So essentially, imagine you are missing an upper lateral incisor.

You have your central, you have a canine, but you’re missing the lateral incisor. Now, if you want to do a bridge there and you want to use perhaps the canine and you want to cantilever, let’s say a resin bonded bridge, or maybe if it’s already a crown, you can do a conventional cantilever bridge. For example, and you want the pontic to look as natural as possible.

Maybe this patient’s got a high smile line, right? So what you would want to do is choose an ovate pontic, like an egg shaped pontic that emerges from the gingiva and looks very natural. But to do that, we need to squish, we need to compress that gingiva, the gum overlying the edentulous lateral incisor area.

Now, what you need to establish and find out is, how much wiggle room do you have? How squishy is this gum? If there’s lots of gum structure and you’re very lucky and you can squish it a long way, you can really get your technician to make a lovely ovate pontic and it can look extremely natural. But if it’s very thin amount of gingiva overlying the bone, then how can you possibly create a decent ovate pontic.

You probably can’t, you probably need something like a connective tissue graft there. So this is where bone sounding comes into play. Now, what you do first is numb the patient up. You anesthetize the patient if you like them. Okay, now please, please, please anesthetize the patient. Anesthetize the patient and then you get your perioprobe.

And what you want to do is you want to sink the perioprobe all the way into the gingiva. So when the patient’s numb and you’re actually penetrating the gingiva. All the way until you hit bone. Now, sometimes you feel some resistance and you think that’s bone, but actually that’s not bone. That’s probably connective tissue.

It’s a bit tougher. You actually want to really go for it until you feel a hard bony block. So you can’t go any further. And then you measure how far into the gingiva are you before you got to the bone. So if you’ve got something like five millimeters, wow, happy days, right? You can actually make a nice three millimeter ovate pontic that sinks into the gums and emerges really beautifully and that’s amazing.

But if you’ve only got two millimeters, one millimeter for example, then that’s no good, right? You know you need to think about some grafting or you can’t do a ovate pontic, you have to do another type of pontic like a ridgelap or something.

So bone sounding is useful in decision making, it’s useful in treatment planning, and I just go into this a little bit deeper and I show you an example case in this standalone video that will be clearly on the app, also somewhere on YouTube which will be a lite version. Please do check it out if you want to learn more about bone sounding, but the importance of it hopefully I’ve explained to you, and now if you didn’t know this technique of bone sounding, now you know.

Let’s join our main guest Dr. Dominic Hassall, and I’ll catch you in the outro. Dr. Dominic Hassal, welcome to the Protrusive Dental Podcast. How are you, my friend?

[Dominic]Very well, thank you very much. Are you all right?

[Jaz]Fantastic. Thanks for making time for this. I’ve just done the school drop off this morning and now I’m in the zone. You saw me put everything to do not disturb. And this is, I love obviously recording podcast stuff. It’s just an opportunity to switch off from the world and immerse myself and the Protruserati in some good quality education, which I know you are brilliant at delivering. I’ve seen so much of your stuff before as well. So just tell us a little bit about yourself as a clinician and as an educator.

[Dominic]So really my background is kind of conventional NHS kind of consultant training pathway. So did the kind of full NHS consultant training pathway, worked part time as a restorative consultant for a while, but really wanted to set up my own training centre and really set up a centre where I could treat patients as well.

One of the problems of being predominantly in the hospital is you don’t get to see many patients and you don’t get to do a lot of stuff. And I kind of like doing dentistry because I like doing dentistry, so it’s good to be in my own centre. Kind of doing my own thing really as a restorative specialist.

The great thing with that then is because you’re doing a lot of it, you can pass on that knowledge through the training centre to other dentists as well, which is great and what I love doing. So the mix I have with the two is great, really. Love doing both things, really.

[Jaz]Great. And things have changed in terms of training pathways that are available now, which one perhaps available when you were making that decision about which pathway you should follow.

So you followed the STR training, restorative route, assumingly at the time that when you became a specialist you were on the register for all the specialties, is that how it worked? For restorative, for perio, endo, prostho?

[Dominic]Yes, so you could sit the MRD. The membership in restorative dentistry and then nominate a specialty with that, but then when you came out with your full consultant training pathway and you passed all the exams for that you then became a restorative specialist but you could nominate another specialty as well that was of interest to you.

[Jaz]Now, where I’m going with this question, Dr. Hassall, is if you were to do it now, if 2023 you’re applying for training, would you have gone down the same pathway? Would you perhaps have considered an MClinDent in prosthodontics, or would you have considered something different in terms of to get to the level that you are practicing at now?

[Dominic]Very much depends what you want to do, but I think there’s much more options now. So, the institute here we run a sort of intermediate certificate, then an advanced certificate, then a diploma and an MSc, and there’s lots of other places do that. And I think if you want to stay predominantly within practice, I think that is a better career route now.

Because it’s kind of, and with myself and other institutes doing the online blended, you don’t have to take as much time away from practice. The trouble with a lot of kind of traditional institutes is, yeah, they’re either full time, which just isn’t doable for a lot of dentists, or they are kind of significantly part time two or three days a week, which again isn’t doable.

And if your ultimate gain, sort of aim is to kind of do what I would say high end private practice, I think you’re better off going down a kind of different training pathway really. And certainly with my institute, everything’s very practically based, very evidence based. So I think there’s a lot more options out there now than just the kind of traditional sort of training pathway and ClinDent. There’s, there’s much more flexible options now for dentists, which is great, I think.

[Jaz]Agreed. And when I was at that crossroads and I was thinking, ah, should I go into specialist training? I really wanted at one point to be a restorative consultant, just like you, I want to be like that pathway. And then I did the hospital posts.

And I fell out of love with hospital and to be able to go five more years in hospital. I just couldn’t see myself having a fulfillment from that. So I went up the private route and lots of the more contemporary courses that you have, like yourselves, for example, and that has given me so much training, education and experience to be able to practice at a level I’m happy with.

Obviously, I still want to keep going, keep developing. I’m still a young dentist, but there are so many more options now than there were before. So you’re totally right on that. In terms of switching to the main topic today, which is Post Crowns. If we start with the very bare basics, we’re talking to dental students, let’s say, what is a post? Just start off with the general indications and how it comes into restorative dentistry.

[Dominic]Really, I think the thing to think about with posts that the simple facts of the matter is the post is simply there to retain a call. That’s it’s only role. We’ve got to forget that, I mean, this has gone a long time ago, but there was all this kind of myth that posts reinforce teeth.

Well, posts don’t reinforce teeth. Anything you do to the root canal that is removing what is left of that root dentine is weaking it. So the only thing your post is there to do is to retain a core. Now that can be a core for either a crown, or a bridge, more traditionally. Or it can be there to retain a core for a composite build up as well.

So that is the only role of the post, is where you have very little coronal tooth tissue left. It’s simply there to retain that core. Nothing more, nothing less. And I think, if you get that sort of basic fact in your head, then you can’t go too far wrong.

[Jaz]And when you were doing your restorative training, and compared to what you teach now, and what you practice now, tell us a little bit about if anything has changed in terms of either how much you’re using posts, or the types of posts you’re using, or the general philosophies and views on posts.

[Dominic]Yeah, I think from when I did my undergraduate training, things have changed just dramatically. So, now don’t anybody go and do this, but when I was a dental student, we were taught to use paper clips as a temporary post crown. Now, obviously don’t do that anymore because the G-, that’s not going to go down well with your GDC or your defense union.

But no, we were much more aggressive. I mean, some institutes would, we’re actually teaching for you to decoronate the tooth to put the post in.

[Jaz]Wow.

[Dominic]When I trained as well, we were doing quite technical procedures like split cast posts on molars. And that has all changed out of recognition.

So I think the first thing that I would say these days is we just basically, we do far less post. So, with posterior teeth, what predominates over post now is the Nayyar core technique. Now, traditionally, the Nayyar core technique is basically opening up the access cavity, opening up the first two to three mms of the canal orifices, and then basically you used to pack amalgam in.

Well, things have moved on from there because we now have bulk-fill, low-shrink, deep-cure composite. So you can actually do the Nayyar technique now with, with bulk-seal composite. So, you don’t really need to do posts on posterior teeth, and all the dangers that come with that, with trying to get the alignment right, trying to make sure you’re not perforating the canal.

So, I haven’t done a post on a molar tooth in I would say decades. Premolar teeth I don’t think I’ve done a post on a premolar.

[Jaz]Hey guys, it’s Jaz here interfering with a quick kind of testimonial or a positive comment that we received on Occlusion Basics and Beyond. So on our course platform occlusion.online, where we teach occlusion, Mahmoud and I, we ask for this bespoke thing whereby every lesson under every video lesson, we wanted to enable comments. So they didn’t have this before. So me and Mahmoud specifically requested it for this course that we want delegates to be able to comment under lessons. Now, we didn’t know how popular this would be, but we’ve been blown away about how many questions daily we get on the different lessons and discussions and debates.

And it’s been absolutely brilliant. And what Craig shared with us on July 1st 7:17AM is on a video where Mahmoud discusses the envelope of function. He said, ‘this was so well explained. You have a gift for this. I too always try to create some positive overjet with orthodontics, but with what you said made me realize, after you have assessed a patient for braces, you could well completely encroach on this envelope when you consider a maxillary fixed retainer.’

So what Mahmood says that if you’re planning orthodontics, you’ve got to have enough overjet for the envelope function, but also consider about how a fixed retainer will impact this. Could your fixed retainer be encroaching your envelope function? So I want to put this in A) to raise awareness about occlusion.online.

We’re super proud of it. We’d love for you to learn occlusion. If it’s something that you’re struggling with, let us make it tangible for you. And B) as a learning point, envelope a function. Have you got enough overjet? Have you got enough overjet? Once you factored in the position of the fix retainer as well. Let’s join again the main episode.

Before we move away from molars and go to pre molars and anteriors, just because people might be wondering, as you said it, is there a bulk fill composite that you like, that you prefer, like a brand that you use that you like for these purposes? I think often Protruserati are like, ooh, I wonder what Dominic’s using.

[Dominic]Yeah, I like the 3M, the bulk fill one. I like because it works well with the new kind of universal bonding system that 3M have. It’s a nice handling material. But the other thing I would say as well is what we’ve kind of pioneered at the Teaching Institute is heated composite as well. And heated composite works absolutely fantastic for core build ups.

Because you can get it into the canal orifices. You can then start building up into the pulp chamber. Now you can only go to about 4, 5mm with that. So sometimes you’ve got to go 1, 2, for really heavily destroyed teeth, even 3. But yeah, that’s the material that I like to use. But don’t forget, pretty much every composite out there can be heated and used. You’ve just got to remember, it heated about 20 times, and that’s the limit that It’ll take, really, for heating.

[Jaz]Are there any concerns about C factor, or is there any layering technique you recommend to minimize that if you’re doing, let’s say you’re building up a molar with a core with the composite dowels extending into the orifice, do you do it like the one sort of corner like a triangle’s or are you happy to connect walls with the modern composites?

[Dominic]I think with the modern composites, particularly with the new 3M, because with the modern composites, they are much lower shrinkage than the older composites. In addition to that, basically you’ve got to have, because your composites absorb moisture, you’ve got to have a little bit of shrinkage in them for when they absorb the moisture.

So the C factor worries me much, much less than it used to be. Because these materials are much lower shrinkage. They also with the cross linking within the 3M composites, they absorb the stresses better. With the heating and the modern bonding systems, you’ve also got a much better bond and adaptation to the tooth.

So I think C factor, for those of us who have kind of gone to heated composite, worries us much, much less. The only time I would say that the C factor tends to come into play is, bizarrely enough, with the much smaller occlusal composites. That’s the only time the C factor kind of has more of a significant impact. But I think C factor with the modern composites is far less of an issue than it used to be.

[Jaz]And if you follow the Bioclear protocols, they’re very happy to do that, the bond, and the flowable, and then the heated composite, and as they would also suggest that if you adapt your cavities correctly, then yes, C factor is much less of an issue with the modern composites.

Now you’re moving to, so basically the theme here is molars, you haven’t done a post in decades, and nowadays with the Nayyar core technique with composite. We probably don’t need to talk any more about molars and posts in this episode. You’re going to move on to premolars.

[Dominic]Yeah. Now premolars, you’re in that kind of transition zone now coming towards the front teeth. Is there still a role for posts in premolars? Yes, I’d say there is to some degree. Is there a role for posts in anterior teeth as well? Yes, there definitely is. Much less of a role, but if you have a tooth that just has no, virtually no coronal tooth structure, then you are literally forced into that decision as to, well, do, first of all, do I extract the tooth?

Or, do I basically then, I wouldn’t say do something heroic, because it’s not heroic, it’s just, it’s going to have a shorter lifespan and it’s going to be less predictable. Doesn’t mean you can’t do it, but yes, I think that really there is still a role for posts. Definitely. Yeah.

[Jaz]I think it’s all about restorability assessment and I think there are sometimes you look at a tooth and you think okay this one’s for the bin and that’s fairly clear cut and then on the other side this tooth is restorable with a Class IV composite.

We don’t even need to do an endo and it’s extremely restorable. And so when we get to the middle ground, the gray area is that, ooh, is this restorable? Is this not? Shall I use a post? Shall I not? So if we talk about those two things in terms of just quick and dirty guidelines for the dentist, in terms of at what point would you consider, okay, there is enough ferrule here, if you can expand on the ferule, obviously a big part of today’s discussion.

At what point is there enough ferrule to think, okay, let’s add a post on to retain the core and continue, versus, okay, at this point, the patient will be better served with an implant or something.

[Dominic]Yeah, what I teach to, this is a study they use in America a lot, the undergraduate clinics. There’s an article by Samet and Jotkowitz, and it’s fantastic.

It classifies teeth as A, B, C, D, and F with very good guidelines are what is the prognosis for that tooth. So I teach that a lot within my courses, that article. And basically what you’re looking at with the post, first of all, you’ve got to be able to get a decent root filling in it. Okay, so you’ve got to be able to get a decent root filling in it.

And then it is all down to how much coronal tooth structure that you’ve got. Now, the one thing we know about posts is the importance of the ferrule effect. Now, the ferrule effect essentially means that when you’re going to prep the tooth often for a crown or an onlay, that you can get onto sound tooth tissue.

The benefit of that is that when the tooth absorbs occlusal forces, those occlusal forces then go down into the tooth. They are less concentrated in the core, the post, or the interface. And it’s interesting, there are studies on the ferrule going back decades which show how important it is. Even up to recent times, there’s quite a recent article by Pascal Magne.

And that actually looked at the ferrule being the most important thing in terms of post success. And we haven’t even got on to post materials yet. So the ferrule is absolutely crucial. Now don’t forget, if we can’t get a ferrule, we still have at our disposal surgical crown lengthening. We also have the use of lasers and electrosurge as well. So sometimes you can borrow a little bit of gingivitis-

[Jaz]Orthodontic extrusion as well?

[Dominic]Orthodontic extrusion, yeah. Do you know what? It tends to be less popular with patients, but certainly where that is very useful is where I’ve used it a lot in the past is with trauma cases. So you’ve had youngsters who’ve had trauma.

They also need orthodontics as well as part of a malocclusion and then you can do the two together. And certainly, yeah, that’s something I’ve used a lot in the past, is extrusion of the tooth. But don’t, that’s one of the things is how much of a ferrule can I get? Then if you can’t get a ferrule, the prognosis for the tooth is looking far, far poorer.

The other things with treatment planning that I think it’s worth mentioning now is you’ve also got to look at the occlusion. And when you’re doing that post core and that post crown, you really want to start treating it more like an implant and be trying to get a protected occlusion on it. So you want to be taking that final restoration out of the occlusion as much as you can.

So very low slack cuspal inclines. And the prognosis is going to be obviously worse if they are patients who are bruxist. If you can’t take the tooth sort of out of the occlusion almost. Then the prognosis is going to be worse if you see what I mean.

[Jaz]That makes total sense, by the way, in terms of the first time I saw this was in North East, I was in, dental school in Sheffield, prosthodontist, and I was reviewing one of his patients and there was a canine which he did a post core crown.

It looked lovely. But it was slightly buccally positioned. It looked very natural. It looked like slightly crowded. And I had a look. I wonder why he’s done that. And I spoke to him. He said, ‘Oh, it’s because it’s a very compromised tooth.’ We want to treat it like it is just like you said, like an implant, which is like a novel thing to me at the time.

So that was an interesting use of that. Now, before we move to the next points, one, just touch back on the ferrule, how important is it in your opinion? Cause we don’t know that the full facts on this in terms to have ferrule a hundred percent all the way around, or is there a minimal percentage like, okay, I’ve got good feral, 70%, this will be enough, any guidelines on that?

And then exactly how much vertical ferrule is ideal for you? Obviously the more the merrier, but the papers say 1. 5 to 2 millimeters. Is that what you teach and what you follow?

[Dominic]Yeah, the papers very much are 1.5 to 2. So I would still go with that. I would say, yeah, ideally you want to have the ferrule all the way around.

Is that always achievable? No. Okay? The other balance is, yes, could I surgically crown lengthen it, could I laser it, or electrosurge it? But then don’t forget if you’re going to do that, the patient is going to accept at some point that the tooth is going to be slightly longer. Now that maybe is, that’s obviously more of an issue in the aesthetic zone.

So if they’re happy to accept a slightly longer tooth, I would go for a longer tooth to achieve the ferrule. But I think that’s very important. Also, if you’re going to be just lasering or electrosurge, which is always a whole kind of just topic in itself, you’ve got to-

[Jaz]I’m so sorry, Dominic, because it’s really important for the students listening to this, just to make clear for them, by longer tooth you mean at the gingival level, so, it’s going to be a higher gum line.

[Dominic]Yeah, you’re going to have a higher gum line which for say if the smile line is low and the patient is happy with that and you consented them it’s not a problem.

But say it’s an upper central incisor with a high smile line then that potentially isn’t going to be a starter for them really. They’re not going to go for that.

[Jaz]And what about the position of the ferrule? So you know I’ve heard some people say that if you’re missing mesial and distal ferrule and maybe it’s half a mil, but you’ve got three or four mils of palatal ferrule, we’re talking about an upper incisor, that is actually looked on more favorably. Would you agree with that sort of mindset?

[Dominic]Definitely. Yeah. I think really with the way it’s going to absorb the forces. I think, yeah, you can accept if there is a little bit of mesial or distal ferrule missing, but realistically, yeah, you want to have a full palatal and a full buccal ferrule, definitely.

So, ferrule predominates, okay? Yeah, and I think that’s very much, have a discussion with the patient, because I treat all sorts of patients. Some patients, that would be the end of the world for them, that aesthetic compromise. But, if our patient is more kind of functionally driven, then that is less of an issue for them and they’re happy to accept that.

[Jaz]So that’s restorability is very much hinges on the ferrule availability. And so you want as much as you can. But in terms of that decision, that tipping point of a post, any guidelines on that? Sometimes endodontist, they’re faced with a scenario where they’ve just finished the root canal and they’re looking at that tooth structure and they’re just about to put their core on and they’re thinking, should I stick a fiber post in at this point?

Because we know that endodontist generally are very much against cast post and we’ll come onto that shortly compared to some other dentists. But yeah, where they’re deciding shall I put a post in any guidelines that you could suggest to an endodontist, a young endodontist in terms of stick a post in this scenario, but perhaps you don’t need it in this other scenario. Any guidelines on that?

[Dominic]It’s tricky. What I tend to do with the course is we have a number of photos of teeth with different amount of, or different lack of coronal structure, and then kind of decide when you would need the post, if you see what I mean. But yeah, I would say much more these days, we’re kind of going much more for the heated composite and the direct Nayyar.

I mean, if the tooth is virtually completely decoronated, but you can get a slight ferrule all the way round. Then I think you’re going to have to go for more of a kind of traditional post, if you see what I mean.

[Jaz]By cast post? You mean, by traditional you mean cast post, yeah?

[Dominic]Oh, no. I’ll come on to that in a bit. What I would say is a kind of, an indirect post, basically.

[Jaz]Okay.

[Dominic]Yeah. Post materials, I’ll come on to in a second. The more buccal and the more lingual wall there is the less likely I am to go for what I would say an indirect post rather than a direct heated composite post.

[Jaz]Okay, brilliant. Well, this leads nicely into post materials So let’s say you find a situation where you have a doubt that if you do not place a post here you worry about what is retaining the core and you’re relying too much on the adhesion at that point, and the quality of tooth structure may not be so brilliant. So if you add post in that scenario, it could help to aid you in retaining that core so you can then proceed to placing a crown there.

So in terms of materials, what are your thoughts? Probably changed a lot over the decades in terms of what you were taught because you’ve got lots more new materials as well. What are the sort of decision making in materials that you employ?

[Dominic]Now, the other thing I would say is, again, I would not have done what would be termed a more traditional cast post in probably 20 years as well. So all the posts I do are composite fiber posts. The brand I use, because it served me well and the drill kit is quite straightforward, is the ParaPost. So it’s a composite post that they do. There’s lots of other brands out there, but that’s the one I use. And I think the next reason is why go composite fiber post?

Because I think the thing with posts, the first thing you’ve got to tell the patient, this is kind of last chance saloon. So when we do this post, you’ve really got to be thinking about in a number of years, where is this tooth heading? Which is going to be extraction, and then it’s going to be either a gap, an implant a denture or a bridge.

Why go with the composite fiber post? There’s a number of advantages to them over cast metal posts. Now don’t forget with cast metal it can either be just a cast base metal or it can be a cast gold post. So if you’re going to go cast post I would always go cast gold post rather than cast metal.

The aesthetics are better with it, there’s less corrosion issues with it. But, essentially, I would go composite fiber. They are a different concept to a cast post, because the modulus of elasticity, or the stiffness of the post, is similar to the dentine. So it will actually move with the tooth slightly.

Now, what are the advantages of it? Well, number one, if you’re going to go for a composite over the top of it, or basically an all ceramic crown over the top of it, you have no cosmetic issues, because you’re not trying to hide the dark grey post underneath. The other fact with them that I like, because as a restorative specialist, all of us are heavily involved in implants as well, the mode of failure of a composite fibre post is better.

Now, when you look at the studies, generally how they fail is they fracture at gum level. The other mode of failure, which I don’t see a lot, is that they actually fully de-bond. Now, the good thing about that is when it fails and it fractures at gum level, you can show the patient, this tooth is now unrestorable, you make them a little partial denture, just a little flipper partial denture, and then they can think about their options.

The mode of failure with cast posts is really troublesome, because what tends to happen with cast posts is they fail, but they’ve split the root. Patient comes in, you’ve got a quick emergency review. You’re like, oh crikey, what are we going to do? They’re going on holiday. You wash it, you clean it, you particle-abrade it all, and you recement it.

The trouble is, in the meantime, there is a crack in the root, you’ve now got bacterial ingress into the bone, and you start losing the bone. And I’ve seen instances where people have kind of nursed along failing posts for six months, twelve months, two or three years. They then decide, right, I’m going to have an implant now.

The implant is a lot more troublesome, because they have no buccal plate. And so they just don’t have the bone for simple implant placement. So the mode of failure with cast posts is much poorer. So I would rather go for a composite fiber post. Does it take less force to break them? Yes, it does. But then when they break, the mode of failure is much, much better, much, much better.

[Jaz]You mentioned earlier about indirect posts that you would use though, right?

[Dominic]Oh, yeah. The composite fiber post would be the only one I would use, to be honest now.

[Jaz]Okay. In my mind, that’s like a direct technique. I mean, indirect being lab work.

[Dominic]Oh, yeah. Indirect with an impression. No, I wouldn’t do that at all anymore.

[Jaz]Okay. Got it. Got it.

[Dominic]I haven’t done it for ages and ages.

[Jaz]Got it, got it. And then what I touched on earlier for those listening about endodontists, why endodontists worry is because if you’re going to go for a impression and a class technique and an indirect flow with a lab, then you have to put a temporary post and what the endodontists think is that temporary posts are the devil’s work when it comes to micro leakage. You’ve just done a beautiful root canal and now there’s leakage and that’s always been my concern as well.

[Dominic]Yeah. And I think the other thing with the composite fibre posts, what the studies show as well, Is they don’t need to be that wide, because certainly when I was at dental school you were taught to keep widening the canal to get the biggest post in.

No, you want to go for a relatively narrow post. And with all the current bonding technology we have, it doesn’t need to be extremely long either. Okay, because we were taught to widen out the canals. No, you can go for a fairly narrow post. So once you’ve got rid of the gutter percha, and once you are onto the root dentine, you can pretty much stop.

And then lengthwise, as long as you are going realistically, you’ve obviously got to go below the bone crest into the root. As long as you are doing that, you don’t have to have posts that are 13 millimeters long anymore. Because the risk of perforation is too great with those.

[Jaz]That’s true. And just to make clear to any dental students, the reason why you want to go beyond the bone is?

[Dominic]Basically, you’ve got that bracing effect. And you see with implants as well, sometimes implants that lose bone the top of the actual implant itself can break because it hasn’t got that bracing effect from the bone. So you really want to get below that level there. Yeah, definitely.

[Jaz]Have you seen or used some of the new posts? I haven’t used them myself yet, but the actual fibers that they place and they sort of are building up the posts as they go along by using sort of pieces, strings of fiber, if you like. And then they’re making this, I see the benefits because you’re essentially using a fiber and then you can adapt to the shape of perhaps an oval shaped canal. Have you used that yet? Have you seen it often?

[Dominic] I haven’t used them as yet, but I have seen them. Where I think they have a role is when you have an endodontically treated molar. But you’ve been quite clever, so you haven’t gone for straight line access down the canal, so you have a lot more coronal tissue.

And I think those sort of, what I have seen the endodontists doing, is kind of mixing those fibers with composite. rather than going for cuspal coverage on the tooth, essentially. But if you’re going to use those endodontic techniques, you kind of need to know exactly what you’re doing with it. They’re not the easiest to master.

[Jaz]Sure. So to summarize, your philosophy on posts is composite fiber posts. When you need one, then that’s what you’d go for. We don’t need to certainly we don’t want to prepare the canal any more than necessary because that’s going to weaken the tooth and that’s definitely something I was taught as well at dental school.

Pascal Magne, he’s quite a biometric group. They’re quite anti posts. I think you are as well, in a way, you don’t want to have to use them unless you really have to. What do you think about that?

[Dominic]You see, because I’m a restorative specialist and I do everything, I just kind of look at the bigger picture. Pascal Magne he’s very implant led, if you see what I mean. The trouble with some patients is, first of all, there might be contraindications to implants. They might be diabetic. They might have periodontal disease. They might have this, they might not be in the best health for implants.

So if there’s any contraindications to implants, that’s going to affect my decision to try and retain the tooth for longer, essentially. Also, I think the one that we haven’t touched on as well is, is the cost of it as well.

[Jaz]I was just going to come to that. In the real world conversations, because these are the, if you’re factoring in potential a re-RCT, a post, a new crown, and then you’re not too far off in implant territory, this is where it becomes a financial equation.

I’d love to hear what you think about that, also how you communicate that to patients. Ultimately the patient decides, but we need to lead and guide them as well.

[Dominic]Yeah, I think that’s the other thing, that when you start adding up the cost of saving the tooth, you want it to have a pretty good predictability.

[Jaz]That’s it.

[Dominic]Sometimes it’s very patient led because you have these patients who basically write, yeah, I’ll do anything to save the tooth. So those are easier to treat because, right, yes, we’ll try and save it. You then have the patients who are very much, well, what do you think? What do you think the best option would be?

And sometimes you’ll be like, look, you’re a smoker. You’ve got periodontal disease, you’ve got and I see this on a weekly basis, you’re diabetic as well. I don’t think implants are the best thing for you, okay? I think trying to save the tooth is going to be the very best thing for you, because you’re not a great candidate for implants.

Whereas with other patients, you look at them and they have immaculate oral hygiene, they have no medical considerations, and then when you start weighing up the costs of it, you’re leaning more towards extraction and implant placement often with those patients. But I think the other thing with the sort of Pascal Magne, it’s kind of what we’ve experienced with post crowns, and it’s the mode of failure of cast posts.

That they come and see you as an implantologist and you’re basically right. I’ll take the tooth out, I’ll clean it all up, but then you’re going to have no bone left. And then you’ve got this whole other issue of what are we going to graft it with? Are we going to graft it with an autogenous bone?

Are we going to use a bone substitute? And all the aesthetic considerations that come with that as well. So it’s tricky. But yeah, I’m definitely not anti post. I’m anti cast post. But I think, yeah, I think the cost is saying you’ve really got to factor in as well.

[Jaz]I’m going to make up a pretend scenario. Just, this is a play with me here. Patient, 34 years old, male. Has an upper left central, which has a shoddy root canal, and now it’s fractured. You’ve got two millimeters of ferrule to play with, 360 degrees. If you treat him, obviously you’ll need a re-RCT, post and a crown. But we can also go for, let’s take it out and go for an implant. He’s otherwise medically fit and well. Are you trying to save the tooth for this gentleman, or, are you suggesting implants as the first choice?

[Dominic]I would sort of say 50 50. I would say, if he was 20 years young older. Yeah, it’s how long the post is going to last because posts, there’s lots of studies showing on average how long posts last, but when you do a post, it’s going to have a compromised lifespan.

So certainly with an older patient, you’ll be thinking actually this might see you through if you see what I mean. This may be your final restoration. The younger patient, you may be better off doing the post because then you can delay the implant for 10, 15 years if you see what I mean. And there’s no doubt with implants that technology moves on all the time if you see what I mean.

So, with a patient like that, I would be to some degree more inclined to try and save the tooth. But it also depends what is happening around it as well.

[Jaz]The occlusion, the aesthetics, the gingiva. It’s a very open question, but it’s, without showing you a specific case, but, I think you touch really well on occlusal, the periodontal factors, aesthetic factors, low lip line, high lip line. We covered a lot there. Any final points for those Protruserati listening about posts in general that you’d like to add in there?

[Dominic]I’m just trying to think. I think we have pretty much covered everything, but yeah, I would kind of shed away, I think, the kind of anti post kind of movement with some endodontists, I think that’s justified to some degree because of old cast posts, but certainly with composite fiber posts, I think when they fail, no, you’re still fine for the implant, which is great. So I don’t think that, I don’t think they compromise the implant site as they used to because when mine fail, you know, and I’ve been doing them for 20 odd years, so I have had them fail, they tend to be fracturing at gum level.

Or, very rarely, they just completely de-bond, but it’s virtually unheard of that they actually kind of split the root and you can stick them back in. So I think in that respect, I think it’s just looking at it and thinking, well, what do you think is going to be the best thing for that patient? The final thing I would say about it as well is because also, the one that we didn’t touch on was using posts as bridge abutments, because that’s the other thing. And certainly what the studies tend to show is that if you can get a ferrule and control the occlusion, that basically a post is a reasonable support for a short span bridge. So basically three units.

But where they start to obviously just break down these longer span bridges. So that’s a question I get asked a lot is, Ooh, I’ve got this post crown three. Can I use that as a bridge support to a six? And I’m very much, no, basically. That’s a poor prognosis.

[Jaz]Let me throw a curveball in there. What about a cantilever off a post, crown tooth?

[Dominic]Definitely not. Cantilevers tend to be bad news, full stop. But yeah, you’ll see them occasionally. You’ll have a patient walk in, you take some x rays of them as a new patient, and they will have a cantilever, a cantilever bridge off a post crown.

And they do well, but statistically, posts don’t do well as cantilevers and cantilevers don’t do as well anyway.

[Jaz]Yeah, I’m not as brave now I mean if I’m going to be doing a cantilever It’s either going to be a resin bonded bridge with lots of enamel or it’s going to be a decent perhaps it’s an old crown that we’re taking off and you see lovely to structure inside that’s probably going to be a scenario where I would but otherwise I totally agree.

I can’t risk doing a cantilever off a post crown tooth, but it’s good you mentioned that. It’s perhaps a short span bridge. It can still be a consideration. I’m very glad you mentioned that. Dominic, where can we learn more in terms of, because you said you do a blended program. So it’s online and in person. Tell us more about where we can learn more from you.

[Dominic]Yeah. So I have the training institute in Solihull. Which is great, because we’re close to the train station at International Solihull, we’re close to the airport. And yeah, we run our courses in two ways. A number of years ago, we kind of moved away from just the traditional method, where people come once a month, or kind of once every two weeks to do the course.

And what we found was, we basically do sort of high quality, regular recordings of all the material. And so what people can do is they can effectively do half the course online. Now the beauty of that is you can do it when it suits you, on a device that suits you. You don’t need to take time away from clinical practice.

And then you can come and do that hands on component in a kind of five day block. And we do that very much for our Level 1 course. And we do it for our Level 2 course as well. You can still do it in the traditional method if you want to come more often. But we find that the blended format has become hugely popular.

And what I like about the blended format as well, if you’re not quite getting something, you can hit the pause button, you can rewind it, and you can watch it again. And then if people really aren’t getting it, we do an online forum, so they can just basically email you in and get the answer that they need.

And we did that, we kind of did that, oh, many years ago, about eight years ago now. And obviously COVID has kind of accelerated that kind of teaching now. So, it was popular before COVID, but it’s got even more popular now as well.

[Jaz]What I like about that is the maximizing the hands on. When you’re coming, you’re taking time off from work. You’re not just sitting, listening to lectures, which you could have done online at home. You’re really maximizing the hands on. Is that the kind of way you do it?

[Dominic]Yeah, we find people are just better because they’re better prepared. You can come in to do the practical, you do a short little recap, and then they’re straight into the practical.

And then you can have, just a really enjoyable time with people just getting on with what is the job of dentistry, which is the kind of, we can do practical exercises in diagnostic and then all the composite exercises. Or the inlay, onlay, resin bridges, conventional bridges as well. So we can do all of that.

Oh, and there was one thing yes, that, where people can come for all this information, if they go to dhti.co.uk, so if they hunt us down on dhti.co.uk, we have all the courses on there. But what we also have is we have what’s called the evidence-based toolkit. So what we have is a kind of wealth of all our materials on there.

Which I like because people can kind of get free CPD on there. But what is nice is that they can kind of see like is the courses that we’re offering the kind of course that they want to do if you see what I mean. Do they like the style? Do they like what we’re doing? And I think we have got running if i’m right, I think we’ve got a 10% discount or a discount on the courses at the moment. So if they use the discount code Jaz10, they can get a discount.

[Jaz]Wow. My guys love a discount code. So Jaz did all, all about Jaz10.

[Dominic] But yeah, if they head to the website, they can have a good look at the evidence space toolkit, pick out some of the things that they want to have a look. We’ve got practical videos, lecture videos. We’ve got some of my articles on there. So there’s a whole wealth of stuff that they can have a good look at on there.

[Jaz]Now, when they visit Solihull, is Solihull a good night out?

[Dominic]Not bad at all. And Birmingham is a great city as well, because he must said when I left Birmingham to go to university at the age of 18, Birmingham was not the best city in the world. But over the last few decades, Birmingham has absolutely transformed as a city. They’ve kept all the best they’ve kept all the best bits and knocked down all the horrible bits and redeveloped it, so it’s great now. And Solihull’s good as well.

[Jaz]Excellent. Dominic, thank you so much for your time today. I really enjoyed our chat. It was super clinical. I love these kinds of episodes. And we discussed real world scenarios about costings as well, which we said was really important to bear in mind. Very happy with that. Thanks so much for your time.

[Dominic]No problem. Been an absolute pleasure.

Jaz’s Outro:Well, there we have it, guys. Dr. Hassall is not a fan of cast posts, unlike Dr. Pasquale Venuti. So it’s nice to hear two different perspectives. You make up your own mind, listen to everyone and do what feels right to you. After all, I want to thank Dominic Hassall for coming on the show.

If you like his education, check out his course. He did mention the Jaz10 code and I’ll put everything in the show notes so you can always learn more. I always like to promote what our guests do because they’re giving up their time to have a lovely conversation with us so we can all benefit. If you want to gain CPD for this chat, then you can answer four questions on the app to get it.

You can even do a two-week free trial, rinse the CPD, and say goodbye. I don’t mind. As long as you’re learning, I’m happy. It’s on protrusive. app. So on your laptop, go to protrusive. app, or you can just download it on Android or iOS. It’s actually cheaper for you to get it on protrusive.app than on iOS, Android, and then you can use your login on iOS and Android as well. Basically, that’s the most cost-effective way to do it. You don’t pay any Apple fees. You don’t pay any Android fees, etc. The entire PDF transcript and the PDF show notes will be uploaded on the premium version of the app as well, alongside the CPD questions.

And as ever, if you enjoy the show, please do consider giving some thumbs up, some stars, wherever you’re listening. I’d really appreciate that. I’ll catch you in the next episode.

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Protrusive Dental Pearl: How to Bone Sound for Ovate Pontics -

Imagine you have a missing upper lateral incisor, and you want to use an ovate pontic for an aesthetic bridge. To achieve the ideal emergence profile, Jaz demonstrates how to assess gingival thickness using ‘bone sounding’ using a periodontal probe (please see video). This technique helps determine how thick the tissues are overlying the edentulous area and whether an ovate pontic is feasible (or perhaps a connective tissue graft is necessary).

Throughout the episode, Dr. Hassall's expertise shines through, making it a must-listen for dental professionals seeking a comprehensive understanding of restorability and ferrule in restorative dentistry.

Highlights of this episode:

0:25 - Introduction to Dr. Dominic Hassall

1:27 - Bone Sounding Clinical Video

6:25 - Dr. Hassall's journey into restorative dentistry

9:04 - Function of Post Crowns

13:35 - Composite for Nayyar cores

18:10 - Assessing restorability

23:25 - Impact of ferrule position on treatment outcome

30:30 - Advantages and disadvantages of post techniques

38:55 - Post Crowns as Bridge Abutments?

43:08 - Dr. Hassall's teaching institute details

If you enjoyed this episode, check How to Save ‘Hopeless’ Teeth with the Surgical Extrusion Technique

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As promised – the 2nd episode in a week specifically for new graduates looking to map out their career.

After last week’s episode on making a Dental Portfolio, this time we are joined by Dr. Ajay Dhunna, a soaring young dentist who graduated in 2018. Join us as we uncover his journey from dental school to becoming an associate, and gain valuable insights on how to excel in your dental career.

https://youtu.be/QP8ggPjqYxc Watch IC042 on Youtube Communication and collaboration are crucial aspects of dentistry, and Dr. Dhunna emphasises their significance. We look at the value of shadowing clinicians in different areas of dentistry, attending conferences, and networking events – discover how these interactions can sharpen your language and communication skills!

Work-life balance and well-being are essential for a successful dental career. Dr. Dhunna and Jaz discuss practical strategies for managing stress, taking breaks, and maintaining a healthy personal life.

Learn from his experiences and gain valuable tips on reflection, communication, dental photography, career development, and work-life balance.

Here are some resources we promised:

An Introduction to Dental PhotographyTrinity Dental Courses

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:

01:12 An introduction to Dr. Ajay Dhunna06:46 Going from a newbie dentist to an associate08:28 Reflection and the importance of clinical photos09:10 Attending courses12:09 Photography and setup18:41 Communication26:43 Planning your next career move33:37 Being proactive and portfolio presentation38:40 Maintaining your personal life and managing stress42:50 Trinity Dental Courses

If you enjoyed this episode, you will love Not Your Average Young Dentist Journey

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

Click below for full episode transcript: Jaz's Introduction: Hello Protruserati, I'm Jaz Gulati. And earlier this week, we had James Murray on the show. He was a new graduate talking about his first year and how he effectively used some tactics to get his first associate position and primarily the use of an effective portfolio when applying for jobs, what should be in a portfolio. [Jaz]So we delve deep into the transition from dental school to your first associate position and making an effective portfolio. Now in the same vein, I’m joined today by Dr. Ajay Dhunna. So he’s a little bit more qualified than James, and he has a different perspective to offer. And whilst we do discuss portfolios here as well, and actually Ajay shows an example of his portfolio.

For those watching the video, I highly encourage for you to see this bit if you want to see what an effective modern contemporary portfolio looks like. But Ajay gives his own unique perspective on his top tips to help new grads navigate, because often we feel lost when you’re qualified. We feel overwhelmed. It is a tough gig dentistry and when you lack experience it is way more difficult.

I promise you dentistry becomes easier and easier and easier with more experience. So those first few years are so important to develop resilience and a growth mindset. So we’ll join now Dr. Ajay and I’ll catch you in the outro.

Main Episode:Dr. Ajay Dhunna, welcome to the Protrusive Dental Podcast. How are you, my friend?

[Ajay]Yeah, very, very good. Thanks, Jaz. It’s been a bit of a hot one these last couple weeks, isn’t it? But looking forward to this chat today.

[Jaz]Absolutely. It’s a big, big topic. It’s a huge topic when you feel lost, when you qualify. I remember feeling very lost, doubting career choices. Having those tough days, feeling like you just know nothing. Right. And before we delve into those topics, just give us an introduction, my friend, when did, where did you qualify, what your interests are and what keeps you going?

[Ajay]Yeah, yeah, sure. So, I qualified in 2018 in Cardiff University. That seems like a lifetime ago now, only four and a half years ago, but that was the best five years of my life. I can’t say that my wife’s listening, but yeah, ever since then kind of went on a journey just to try and be as good as I can clinically. Went on a journey through a couple of courses, but not trying to be one of the course junkies trying to implement it throughout practice.

I had a really, I was very lucky early on. I had very good mentors throughout my FD training and going forward into associateship, it was like kind of not today’s lucky streak, but also you kind of make what you want from it as well. So the FD kind of, I put myself into situations where I wanted to do more difficult cases.

I had the opportunity to do some oral surgery training in my FD as well, because the practice was partnered with a tier two oral surgery contract provider, which was great. And then straight out of FD, I completely restarted the course.

[Jaz]Let me just probe you on that, Ajay, if you don’t mind, just because that is a really good point, right?

So the oral surgery is, I mean, one of the things that we’re going to discuss is one of the questions I will ask you is what should we be focusing on when we qualify and that I think oral surgery will definitely come up as one of those things, so it’s very apt that you mention that, but is that something that just you fell into by accident, or did you feel as though you had to knock on the right doors, you had to show that you were keen, or you had to grasp the opportunity to make it happen? How did that actually come to fruition?

[Ajay]It’s like I said, I was a bit lucky in my foundation year, because the practice I was with was partnered with the another practice that had a Tier 2 oral surgery contract, the provider there absolutely incredible surgeon, his name is Tsukiyate (unsure), he actually, he’s a lecturer at Birmingham University, but he helped me a lot through that.

And they kind of scheduled me once a month to go and observe him and shadow him. And that was for the first couple of months. After that, he allowed me to kind of help him out a bit. Initially, it’s that kind of thing where you start off just placing the ID blocks. Then he kind of teaches you how to basically just simple stuff, like assessing X-rays of how you’re going to get an extraction done in the first place, and then going from going on from there to actually do the extractions that are a bit more complex.

And to be honest, I keep that learning with me to now touch wood. I don’t have, I don’t struggle with many extractions these days, but it also helps know your limits as well, but going on from that, like I said, I was scheduled there to be there once a month. I enjoyed it so much. I kind of became proactive myself and I asked to be there like two or three times a month just so I could step up the game there because as dentists generally we are restorative dentists.

There’s the other skills that are involved with it that other skills involved with dentistry that you need to kind of get a stepping stone with and I found this was a really good experience for me that not many of my peers would have had. So I thought I need to make the most of this.

[Jaz]Well done. And then how do you, obviously you’re really brilliant at restorative dentistry, adhesive, that kind of stuff. What attracted you towards that?

[Ajay]It’s one of those things where I started getting involved with dentistry, like kind of wider dentistry quite early on. From my final year of uni, I joined the BACD as a student member and then that kind of led me on to meet a lot of other people. I joined Dentinal Tubules in my foundational, foundation year and that was absolutely incredible as well. It’s just getting exposed to a lot of extra, extra dentistry rather than your just foundation year.

I’m a massive advocate of everyone learning their basic skills, but there’s no harm in knowing what’s out there early on. So you can kind of delve deeper into that and know where your interests lie. So that’s what basically sparked my interest in restorative because the idea of taking someone, I think what really sparked the interest was seeing the tooth wear cases, which is what I’m kind of really interested with at the moment.

Your teeth are just so broken down due to a reason. You find out the reason, you deal with it, and then you go on to kind of the massive journey of rebuilding someone’s mouth. It’s almost like dental architecture. And it’s kind of really interesting to me of how we can get from baseline nothing, to rebuilding a whole mouth, not just improving the teeth, improving airway, improving function, improving speech.

It was incredible. So that kind of led me on a journey and which is why yeah, I joined a restorative course with Chris Orr.

[Jaz]Amazing.

[Ajay]Yeah.

[Jaz]I mean, I remember being a final year dental student and I think I accidentally saw this patient who was treated by postgrads and he had these most beautiful gold onlays and just the way that everything just fit together and was rebuilt.

This was like, wow, how do you even begin to do this kind of dentistry? That really made me think just like you did, you see them tooth wear cases being treated and the question becomes, I want to do this. How can I do this? And if you don’t go to outside your comfort zone, if you don’t go to the BACD, if you don’t go to AACD, wherever you are in the world and you start to see what is possible out there.

You don’t get that spark. You don’t get that sort of inspiration, that dose of inspiration. You need a, ‘Hey, I can do this. Can I do this? How can I do this?’

[Ajay]Yeah, that’s the question, isn’t it? It’s always, how can I get there? It’s not like I want to do it or, oh, it’s impossible. It’s too, how do I get to that stage?

And that’s kind of, that’s a real big question for a lot of the young dentists like these days, because mainly because of social media, but I think that’s, they’re seeing a lot more. And they want to do a lot more, but I think they need to understand how to do it.

[Jaz]And how did you evolve from your sounds like a very positive first year out of dental school for you. To going into practice and how soon did you go into, I’m only assuming, practice or mixed practice. Tell us about your sort of working environment.

[Ajay]Yeah, sure. So I was lucky my first year at my foundation. Yeah. I keep saying lucky. It’s like you are what you make it, but I was lucky because I had great mentors.

My foundation trainer was great. He supported me really well. He let me carry on with what I wanted to, as long as I had justification and showed him that I knew what I was doing, basically not as it was that standard thing in foundation dentistry, you’re a safe beginner. But you have to be so, that was kind of the stepping stone through foundation dentist, the dental year, and I just kind of incorporated all the knowledge that I’ve learned from BACD short courses, the internal tubules webinars and their online learning as well as just going to also the foundation kind of scheme.

Talks were great. I mean, I was lucky to have, at that point, Lewis McKenzie was still doing the foundation teaching. So we had Lewis McKenzie teaching our composites. So that was incredible to see that. And he did the adhesive onlays. So I had great inspiration early on.

Going on from that, I stayed in my foundation practice for another two years, actually, which is great for me. It’s that thing that a lot of dentists kind of, young dentists, they kind of skip from practice to practice to practice. Sometimes circumstances don’t allow anything else. But I was lucky to be able to see my work from foundation.

You come back maybe a year later. This tooth chipped there. That cusp has broken off. This is just not comfortable for patient. This tooth devitalized even because it was a deep feeling that this kind of thing. And I was lucky enough to see this progression of my patients and then my own patients that I’ve done the work on.

So then I can reflect back and that’s always a word that I love using. I love using reflection because you probably see in Jaz, me and Ferdie, my business partner, we take loads of photos and it’s the biggest thing for reflection. So I used to take loads of photos and that was a massive stepping stone.

That was really the key factor for my progression in an early stage is taking photos, didn’t have a great setup at the start. I took the photos that I needed to take, look back at them in a few months. If a patient came back, I was like, what could I have changed? And it’s that question again, how could I have got better?

I look back at what I did, I know I’ve got better knowledge now, incorporate it into the next patient, and there we go. Kind of improved for the next patient. It’s that self awareness of where you’re going wrong so that you can reflect on that and get better in the future. That was one of the biggest things for me, kind of, as part of my progression.

That was through my, kind of, next two years in, that was in Telford in my foundation practice, and then that was in conjunction with me doing a year long restorative course with Chris Orr. And I say this to everyone who has asked me, that kind of, that I even tell him when I see him at BACD I was like, that literally changed my career from a very early age.

It’s probably because I did it straight out of foundation training. I didn’t have time to get bad habits. So I was learning in quite comfortable environment with Chris teaching me being around other dentists that are in a very similar circumstances Some of them had been qualified for 20, 30 years even some of them are just in my a couple years ahead of me. So we’re all in the same boat, but we’re learning-

[Jaz]And I bet those guys were 20, 30 years qualified They probably said to you Ajay. Hey, AJ you actually It’s really good you’re doing this now, because some people think that, hey, you don’t even know how to do the basics yet, but you’re different, Ajay, you’re very, very switched on you’re very keen, and I know your experience is very, very positive, and there is an element of luck involved with getting the right supportive mentor and trainer, so yes, I agree, there is always an element of luck, but it’s good often to, especially something like Chris Orr’s course, so restorative focus the whole thing about aesthetic dentistry, all dentistry should be aesthetic anyway, right?

We’re not doing Class IV composites that are ugly anyway, so I think a foundational course like his, I haven’t done it, but I’ve got all my, so many friends, obviously, that have done it, have always said wonderful things about it, and so it’s good to hear this perspective that actually you weren’t disadvantaged for anything, it propelled you by doing it early on, and you didn’t get those bad habits, so that’s an important reflection point.

[Ajay]Yeah, so literally it was that. I didn’t get into bad habits early on. I managed to pick up kind of techniques that he did himself. But I say this to a lot of people that, especially young dentists, kind of classed as course junkies. They go from course to course to course. You need to go on courses, but you can never really copy exactly what the course provider does.

You need to pick up your own technique because some, what’s comfortable in someone else’s hands is not going to be comfortable in your hands. So obviously Chris taught us the techniques and taught us the protocols of things. I took that and I was like, okay, this is what I can do with my hands and this is how my brain thinks.

I’m a bit more, I’m not more, my brain works quite logically. Probably similar to Chris’s, but it’s the fact that he’s got so much more experience and stuff that he does, I can’t do. He’s just a wizard. But so I needed to kind of adapt the teaching to what I could do. And I do this, I did this with quite a few courses.

Like I said, with Lewis McKenzie’s, I can’t do composites like he can. So I adapted my way of doing things to make sure that it’s comfortable for me. And it’s worked out in a way that it’s kind of, it’s done well. Like, I’ve got the right protocols. Patients are coming back happy. There’s no sensitivity.

Yeah. It’s all going well like that. And doing one of these courses really early on has really, really helped. And I do recommend that for young dentists quite early on, not just to kind of do it because your mate’s doing it. Your mate’s uncle’s dog is doing it or whatever, but it’s one of those ones where you just need to get good habits early on.

And because when you come out of dental school, essentially the phrase is you don’t know what you don’t know. So just try and learn what you need to know.

[Jaz]One of my favorite quotes, man. You don’t know what you don’t know. Well, you mentioned a really good point about photography, but it’s one of those things.

It’s kind of like We sound like broken records on this podcast, like, if you count all the podcast episodes and anything on the theme of career development and mentorship, always photography will come up, but it cannot be emphasized enough about how many of our colleagues do not take enough photos, and so I’m going to be a little bit savage now, and I might upset some of my Protruserati, and I apologize if you’re affected by this comment, but it’s for your own good if you need to hear this.

I hate it when on our Telegram group, or on the Protrusive group, or any dental Facebook group, or any WhatsApp message I get, or any email I get, I get an essay describing the clinical scenario.

[Ajay]Could I just take a photo?

[Jaz]Where one photo, just one photo, literally all it took was one photo to describe everything. The exact scenario. I think what I found is that these colleagues are just not in the rhythm of taking photos. They don’t have their camera nearby. There’s too much out of their comfort zone. And I see this is why there is a stumbling factor. And it’s just about when you’re, it’s very noble and good to ask for help.

And I’m always happy to help everyone. But the advice you get out is so dependent on the input. So good input, i. e. good quality records and photos, even just photos, good quality photos, you will get good advice. If no one wants to read an essay. Right, saying this happened and that happened and this and this and can you give me some advice?

And you see those posts get the lowest engagement in terms of help. When you’ve got photos, you get the best opinions. Obviously, you’ve experienced this as well because you’re in education, you’re teaching young dentists and what not, you’re helping out with the lovely things that you do. Is this something that you’ve found as well?

[Ajay]Oh yeah, a hundred percent. We get questions like this, they, oh, how do I do this? What should I do for this cavity? What or which matrix should I use for this kind of thing? And we get a massive-

[Jaz]I was using, I was, yes, I was drilling a cavity. It was an MOD it had a two millimeter crack, and it just completely vividly described. It just needs one photo.

[Ajay]It literally just need a photo of the single tooth there. Just quickly, just bang, shoot there, done send it over. And it sorted. It’s one of those things where you can’t tell people enough times. They just won’t listen. Some people are, I wouldn’t say they’re stubborn, it’s just they haven’t got into habits.

They haven’t got into good habits going back to my kind of early career. I literally, as soon as I got into the practice, I set my camera up by the side of me. So it was always there. It was a back then it was a really light set up actually, it was just, it was a very simple setup. It was a Nikon camera with a ring flash.

The workhorse camera basically just grab it, point, shoot, taken, photos taken, add it to the clinical records, ask for advice from my mentors, ask maybe even for case report, even for my foundation, yeah, but it was there quickly, I could just quickly take it and I got in habits of doing it. My nurse got annoyed with me because I started practicing taking photos on her, so, but it got me in it, it got me faster at doing it.

[Jaz]That’s a hallmark of a good dentist, practicing a lot on your family. So I did it on my mum, my wife, then fiancé, and then yeah, loads of patients. Running a little bit late at the beginning because you’re just trying to perfect your photos and trying to get more photos and stuff. And some patients will say to you that you’ve taken more photos.

Literally, the other day a patient said to me, you’ve taken more photos in my mouth than anyone’s ever taken me outside my mouth, actually. So, you get comments like that. But patients notice that you’re into it, you’re dedicated, you’re interested in what they’re doing. And patients always have responded positively to that, I find. So if anyone out there is still not made the plunge yet, just please, it’s the most basic thing you could do, most fundamental thing you could do for growth is get into photography. How soon did you get your access to a camera after qualifying?

[Ajay]So I was actually into a bit of photography before I finished dental school. So I had a camera just for holiday photos. So I had the camera body, but I actually got into dental photography two months before I started foundation training, just because I met Ferdi who is now my business partner. So we were just chatting because we met on a course when I was in final year, he was in foundation dentist, and we just started chatting about photography.

And I was like, I’ve got this camera. I need to start taking photos. We bounced ideas off each other, came up with a setup for ourselves. He was taking photos for his case reports and everything. And I was here. I didn’t have any teeth to take photos of. I was taking photos of a Kung Fu Panda model. Just to try and practice the zoning and everything and taking photos of my sister’s teeth, my mom’s teeth.

I’m just getting in the habit. So yeah, I bought a secondhand lens. I’ve still got this set up today and it’s actually used for our course now, the photography course that we teach. It’s actually used for that course now, but it’s still fully working. The setup I got was a secondhand, I had the body already, it was a Nikon D50300.

That’s really old now. They don’t even sell that. I had a secondhand lens, secondhand flash actually from someone at the practice. Still got that, still got the lens. It still works really well. Still takes great photos. I just upgraded it to different camera, different lens, different things, different setup.

But that still works. And this is one of the things, it’s maybe a stepping stone for not stepping stone. It’s maybe a learning point for dentist is, young dentists is they say everything’s so expensive and it is expensive, but you need to see the kind of the value of the investment. It’s not kind of a cost to me.

It was more of an investment. And so the value of the investment has turned over a lot more kind of in terms of that, because taking the photos is patient education. You’re not selling treatment, it’s co diagnosis. And then you’ve got your clinical records, you’re protected, things like that. There’s mountains of benefits of taking photos, but that was my setup back then.

Still got it now. And for anyone listening, I would just say that you need to get a camera straight away, as soon as you can, as soon as you can in foundation training. The foundation dentists that I know in Birmingham that we’ve chatted to, I’ve drummed this into them so much that they’ve actually started asking it for presents for birthdays and Christmases because it is essentially, yeah, it’s a camera to me is a toy.

To someone else it might not be but it’s because I enjoy photography so that’s it’s a good present to be honest because they can be expensive but the earlier you get it the better your habits you’re going to get in early and just quickly on that if you are looking to find some kind of tips of photography Ferdi’s actually written an article for the BACD which outlines a basic setup so anyone can check that out really.

[Jaz]Amazing just pass that over I’ll put in the show notes for everyone to check out below that’d be good.

Occlusion is just so confusing. Does occlusion even matter? Wait, don’t you just grind away all the blue marks, right? You mean like plant it low, let it grow or leave it high and let them cry? Listen, what are these interferences even interfering with?

Is it safe to lengthen teeth? How much can I raise my patient’s bite? How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs? Is canine guidance always better than group function? Why can’t I just use the dial technique on all my wear case? Can I stop my patients from grinding?

What the bloody hell is crossover? What should the occlusion look like after orthodontics? How and why do you check for fremitus? What on earth is a custom incisal guide table? How do you use a leaf gauge? Do you always need to use a facebow? Does everyone really need perfect occlusion? What is the difference between edge wear and pathway wear?

Is it naughty to adjust the opposing tooth? What the f*** is centric relation? Occlusion is coming. One does not simply just open the bite. May the force of mitigation be with you.

If you want to do a deep dive 30 plus hours into occlusion online, just like in this format, but actually individual videos, lessons that are five minutes long, 20 minutes long, a few odd half an hour lessons, and lots of clinical videos and case walkthroughs, then check out occlusion.online. It’s Occlusion Basics and Beyond online course with me and Mahmoud.

If you are looking to take the next step in learning occlusion, that’s going to make your restorative dentistry predictable. Yeah. My first paycheck as a foundation dentist went pretty much towards a camera set up all on gumtree, secondhand, pretty much used, purchased from photographers who look after their equipment so I didn’t have to break the bank.

Although, yeah, it cost me a lot, but I was living with my parents at the time so that I could then buy this camera and start taking photos, thousands of photos in my first year.

[Ajay]Oh, yeah.

[Jaz]And I think this is when you speak to dentists who are really showing their work and they’re taking really good quality photos, okay, and showing good quality work.

I speak to them and the trend is the same. They started very early on and it was a relentless pursuit of trying to improve their photography and reflect on their work. So that, I know we’ve banged on about this but it can’t be emphasized enough. So you qualify for dental school, you have to now manage emotions.

You have to learn how to consent. You have to learn how to talk about money to patients. You have to learn without, yes, I know you have your trainer if you’re in the UK and you’re having the scheme or wherever you are in the world, your first year dentist, you’re not in that protected, as protected environment as you are in dental school.

You are your own person, you are your own man, your own woman. It can get very stressful, failed extractions.

[Ajay]Yeah.

[Jaz]Perforations, separated files, all these things basically. You end up feeling quite dejected, you end up feeling like you’re rubbish, you end up blaming yourself. How does one navigate this? What kind of ideas have you had for this?

[Ajay]Dentistry is stressful. It’s a very stressful thing, but the thing about dentistry is that it’s not a single person’s sport. It’s a team sport. If you’ve got a problem in practice, if you’ve got a problem with anything you’re doing, or if you don’t even feel confident in yourself, you need to communicate to that to someone and whether that be your trainer, like you said, be that your trainer, even your nurse, even your kind of your family, you need to be able to communicate. I think the first stage of getting through the stress of dentistry at an early age is talking to people about it. And it’s not even talking to people about saying, Oh, this feeling didn’t go so well.

Cause people aren’t going to want to hear about certain feelings, especially if they’re not dentists, just talking to them about your day, just talking to them about, this patient talked to me like this, or I didn’t know what to say to this patient when this happened. And it’s just talking to them because even if you’re not, even if you’re talking to a non dentist, they will still give you, have invaluable advice about communication, about how to deal with situations.

And this is how I think in my perspective from my early career, I actually improved a bit because just talking to a lot, not many of my kind of immediate family are dentists. There’s a couple of dentists, but all the same age. So the older lot, they’re all in business, they’re doing other things, IT, things like that.

So they’re customer facing as well. Talking to them about how they interact with other people was really helpful at an early age because you can really see how, like you said, emotions are portrayed, how situations are dealt with, and that was very helpful. I think what one mistake a lot of young dentists make is not talking to enough people.

And that sounds really stupid, but just talking to enough people, not in a dental environment, and also in a dental environment outside of the practice, because one of the early things that helped my communication, just side note is that I, I’m naturally kind of from back in the day, naturally I’m an introvert.

So, but that kind of came, I came out my shell in the, my final year of foundation, final year of university and my foundation training year, because I started attending more conferences, more networking events. And I started chatting to people, talking to people and I realized that I’m not alone in this situation.

There’s hundreds of thousands of other people in the same situation with me. They didn’t know how to deal with a certain patient. They’ve also had someone complain about maybe a fractured file, maybe the tooth didn’t come out as easy as you wanted to, things like that. And at the end of the day, it’s fine.

I don’t know if I should be saying this, but there’s that saying in dentistry, but you never killed anyone. It’s a tooth at the end of the day, but you always want to treat them as best as you need to do. But you need to understand there’s a patient at the end of that, and if you talk to them like a person, then great, you’re going to be getting along with your patient well. And the only way to talk to, kind of, people in general is by talking to people in general.

[Jaz]Very true, and you said that you went on lots of conferences, networking events. Did you follow this up with any non clinical courses? Communication type courses.

[Ajay]I did a one communicate, I did a communication course, not in my foundation training.

Well, the foundation training had the communication courses inside. The non clinical communication courses came after my foundation training because I felt that my foundation training didn’t kind of cover everything that I wanted to, such as like the standard thing of ethical selling. Because you’re an associate now, you need to be able to kind of convert or just basically, I don’t like using the word convert or upsell.

You basically want to be educating the patient on the best thing that they need. And the patient needs to have, needs to kind of understand that at the same point as well. And that is a quite a difficult thing to get through your head early on because at the start, when you’re young, you’re just thinking, ‘Oh, it’s a private versus NHS crown’.

It’s this much money versus this much money. You’re not thinking about the benefit for the patient of using say, adhesive lithium disilicate rather than metal crown on band three NHS. So it’s things like that where the benefits need to be explained properly, but so the patient sees the value in it as well.

And I think that’s really important as well, for sure, non clinical communication courses are without shadow of doubt, kind of very, very underrated. Because I think that the point is when you go on that course, you don’t see an immediate result after the course. You have to put it into practice.

It’s that same thing with patients with perio. They don’t see the benefit of perio until six to twelve months down the line, but it’s the same with communication. You won’t see the benefit of your communication courses unless you put it into practice and then go down the line of talking to the patients in a certain way and then six months down the line you’ll see your books are full of what you want to be treating because you’ve told the patients the value of what you’re treating them for.

[Jaz]Very true, and you already mentioned about visiting this oral surgeon as part of when you’re in DF1 and learning so much from them clinically, but I bet you, you learned so much about the communication and consenting and patient mannerism, right?

So there’s a dual benefit. So even though yours was like, you got lucky in a way that this was, they had this like a link and you had like this once a month thing, but there’s nothing stopping anyone right now, okay, to contact a local specialist or a local colleague that you respect and going in and shadowing.

And yes, you think you go in there who’s, oh, I’m going to learn how to do these composites and stuff by watching them. But I bet you you’ll come away thinking, wow, I like how he explained this to this patient.

[Ajay]Oh yeah, a hundred percent. Like I said, it was a tier two or surgery referral practice that I got to shadow once a month.

And because it was a referral practice there, the oral surgeon, Dr. Atif he got referred all the nervous patients, the difficult teeth and things like that. All he got, he also got referred teeth that are actually easy to do. But dentists didn’t want to do them just because, I mean, we’ve all been through that where we’ve seen referrals of teeth that should have been taken out in practice, but they’ve been referred because I don’t know, X, Y, Z, but then that kind of, that leads on to kind of patient’s emotions just because in their head, they’re thinking, oh, this, this is too difficult to be done in practice. So they walk into that situation thinking, oh, this is going to be a really difficult situation. I’m going to be coming out of here in loads of pain.

My face is going to be out here. Just hearing how Tsuki (unsure) talked to the patients just to put them at ease. I mean, to be honest, he would have been talking to them the same way he would be talking to mates. It was a very good rapport he built up within probably about two minutes of them walking through the door.

He would have commented on something saying something nice, just, ah, you’ve got a nice scarf on today. It’s a bit cold outside. I’m glad you’re keeping warm and things like that. Just relating to them, taking their mind off the actual treatment, taking their mind off why they’re actually there. And that’s all about communication.

Just making the patient feel at ease. And by the end of it, the patients are saying, like, it’s a strange one, isn’t it? They’re saying thank you for taking my tooth out, even if they’re not coming in in pain, they just need the tooth out. They’re saying thank you for making my experience feel good. Having a tooth out was never a comfortable experience, but if you can make the patient feel good about it, then yeah, that’s a win win situation for you.

And yeah, he was a wizard with his hands. It was like a magician with his tongue goes, oh, he could literally just, that’s a very weird phrase. But, no, he could literally talk through anything, but it was a great way to learn for myself because when I see a tooth kind of that’s on the books to extract now I can put a patient ease in one of the practices.

I literally get all the anxious patients referred to me now just because I’m nice. I’m nice, apparently, but in reality, I’m just listening to patients.

[Jaz]You make them feel listened to and respected. And so the lesson here, guys, is, sometimes you’re not in the best environment. Sometimes you may get in a place where you don’t have enough mentorship, but what you need to do is be proactive and seek that. And one of the great ways to seek that is by shadowing, because you will learn not only clinical, but the non clinical. Now, I’m just going to switch gears, Ajay, and talk about the desires of the dentist when they’re in DF1 and moving away and gearing up for the next level from there.

Yes, let’s say they’ve been, they’ve got a camera taking photos, let’s say they’ve been shadowing and stuff. Quite commonly nowadays, trajectory seems to be, I want to specialize and therefore they do these hospital posts, or going into private. Now, we’ve talked a little bit about this previously on the podcast, in those countries where they have a public system and a private system and a bit of a mixed system.

It’s not a given that just because you’re going to go into the fancy private system, that’s your ticket to happiness. I know plenty of dentists who’ve not had that experience and they are very, very happy in mixed practice. What advice would you give to the young dentists listening very early on about planning their next career move and the whole debate of specializing and what kind of practice they need to go into?

[Ajay]Sure. Well, I think from the young dentist I’ve spoken to kind of recently, it’s changed from what it was a couple years ago during the COVID years. Okay. And that’s, I think a couple of years ago during the COVID years, a lot more people were looking towards specialism, staying in hospital and going through that.

However, saying that, obviously during COVID, the COVID years, the private practice boomed and there was a lot of kind of a social media boom on that as well. So a lot more dentists are seeing what can be done in private practice, which is dangerous, in my opinion. Because they’re seeing things like people, they’re seeing people do these cases that have been in practice for literally 10, 15 years and they think, oh, I can do that when I finish next year.

And I was like, no, okay. And it goes back to that saying, you don’t know what you don’t know. And that’s a really important thing. And Jaz, have you heard of the Miller’s Triangle, the Miller’s Pyramid? The competence pyramid.

[Jaz]Ah, yes. Unconsciously incompetent.

[Ajay]Yeah, yeah. So that’s kind of very relevant to dentistry, in my opinion. When you finish dental school, you might be unconsciously incompetent at that point very early on, but you don’t want to be consciously incompetent because that’s a bad phrase, that’s a bad position to be in. You don’t want to be bad and know you’re bad and not do anything about it.

So in my instance there, kind of following on from your question is, I know it’s a long-winded answer, but I think at this stage they need to get focused on foundation training, straight outta uni, out after foundation training. They need to pick up from on foundation training what they’re not good at first.

And if they’re not good at it, find out why they’re not good at it. And it goes back to that kind of thing on reflection. And you might not be completely good at it, you might be mediocre at it, you might be great at something, you might be bad at something else, just try and be, in my opinion, you need to try and learn the basics of what you’re not good at first, so that you can go on to be good at what you want to be good at, and this is a kind of convoluting topic there, but it’s because you want to be, in my opinion, dentistry from an early stage is single tooth dentistry.

Like, in the NHS, in foundation training, you’re treating a problem. You’re dealing with this problem, you’re dealing with that problem. Essentially, you want to get to doing multi teeth. You want to be doing whole mouth holistic dentistry. That should be the end goal. Kind of general, if you’re going to go down the restorative route, dentistry route, things like that.

And if you need to, if you’re going to go down that route, you need to know what you need to improve on. And like I said, it goes back to your reflection. So there’s not one answer for saying specialism versus going into private practice. But I do think, however, that there should be no rush in doing any of those things.

If you are going to go down the specialism route and then great, you do that, but you need to, it’s a very strange one because you need to decide what you want to specialize in quite early in that sense, don’t you? From what I know of the specialism route, you’re going to be staying, you’re going to basically dedicate the next few years to being in hospital to go in the DCT post and then get into your specialism training.

So that’s kind of a big task, really. It’s quite daunting when you think about this is what you’ve dedicated your life to now. From that stage early on, where you might not have even given something else a chance.

[Jaz]I mean, that’s the hospital route. There are obviously the paid routes of playing for the MClinDents and stuff. Those options do exist, obviously. And sometimes people are 10, 15 years in practice, then they go into it. So the ship has never sailed.

[Ajay]No, definitely not. But I think that point of view, from 10, 15 years from then, you’ve kind of gone through the motions of finding out what you’re interested in and finding, and you’ve done your single tooth dentistry on every single tooth in the mouth multiple times.

You’re going into multi tooth dentistry, holistic whole mouth dentistry, and you want to get better at it and formalize your education in that, which is great. I think that’s a great scenario to be in. And then kind of looking back to the other route is, and this is a kind of a double edged sword, in my opinion, it’s like you said, the grass is that isn’t always green on the other side.

I’m lucky kind of going from my mixed practice. I still work in the NHS kind of mixed practice at the moment, just because I’m a foundation trainer now at that practice as well. I still do a lot of quite a bit of private work because of that communication thing of patients, but in my private practices.

I’m very lucky, again, because I’ve put myself in a situation where I’m surrounded by people that are like minded people that want to get the best for their patients. Whereas I know for sure a lot of my friends have not been in that situation. They’ve been advertised jobs. Which kind of promise things that aren’t actually in their practice and everyone’s heard this we all seen on kind of the dentistry forums on Facebook. People in kind of contractual issues because they want to get out of the practice because they thought I was promised this I was promised all these patients I was promised all this equipment I was promised this XYZ kind of pay or whatever, but I’m not getting it so in terms of private practice, the grass is not always greener on the other side. I do however feel that if you get in the right private practice then a hundred percent, you’re going to have a better experience for yourself.

That’s a bit of a kind of double edged sword statement in itself as well, because you can’t get that in a mixed practice, but just focusing on the private practice. If you get in the right one, you’re going to be much less stressed, in my opinion, from my own experience, you’d be less stressed in terms of you don’t have targets to reach of a certain kind of UDA target.

Okay, you’re going to have other targets to reach from the practice point of view, but that will be doing the treatments that you want to do. If you don’t want to do something or you find out firstly why you don’t want to do it, and then you might have to refer it. But it’s great if you refer it in house to a practice like that, then great, you can go and observe the person.

I mean, the private practice I work at, I don’t do any endo at that practice, but I found out why it’s because I don’t feel like an offer endo to the best of the ability that’s available at that practice. So there’s been times where I’ve gone to shadow the endodontist. And I’ve learned loads, like I said, just shadowing even now.

And I say even now, it’s only four and a half years since I qualified, but it’s great. And because I can learn, I can pick up tips and ideas from learning something that I’m not confident in to give to the best of my ability. So I think private practice itself is going to be the goal of most dentists, but getting into the right private practice, there’s a way to do it.

I think. And I don’t think dentists should go just straight for the first thing they see on a Facebook forum. They shouldn’t go for the first thing they see come through the door. The way I got into the private practice I work in where it was a kind of non traditional way is I actually saw this practice down the road that I really like the look at and they weren’t advertising a job.

I essentially posted well, I sent them my CV and portfolio. And I said, I really like the work that you do at this practice, and I would love to be part of the team. Here’s the work that I do at the moment. I’m really happy to talk about kind of anything else that you, anything, any questions that you have about the work or kind of, even if there’s any opportunities coming up in the future, I would love to be considered.

[Jaz]And this is a letter that you posted addressed to the principal? Yeah?

[Ajay]Yeah. So that was led, that was sent to the practice and say, and then this wasn’t an advertised job. There was a job going at another one of his practices. But not this one, but I wanted to work here because it’s, I mean, me being lazy, it was down the road, but it was an amazing practice.

Like the work coming out of the practice was great. I know for a fact the principals had great ethoses and they had the right frame of mind and it was great. It was what I wanted to achieve from, it was a practice that I wanted to be in and that’s how I got that job. And it wasn’t even advertised.

[Jaz]So be proactive. It’s that lesson right there. It’s like a few times we’ve had a guest on. They talk about how they got their first job. And it’s a very common theme. To put yourself out there. So you put yourself out there. There was no job advertised. But you created that job. You created that position for yourself.

Yeah, going out of your comfort zone and showing someone your portfolio, which is a topic we can talk about, how long should it be? What should be in your portfolio? We had an episode about this recently, actually. They’re going to come on these trips and come about the same time. So we won’t talk too much about portfolio, but anything that you want to add regarding portfolio?

[Ajay]But I think your portfolio as a young dentist should have absolutely everything in there. It should even have the things that haven’t gone so well. And by console, I don’t think you should say like, ah, this has completely just gone wrong. I mean, like you should have in there kind of reflections of what you could have improved on.

I mean, I’ve got my portfolio on my computer. I don’t know if I can share the screen or whatever, but am I able to?

[Jaz]Yeah. Do you want to share it? Yeah, you should be able to.

[Ajay]I’ll just quickly share just quickly. So yeah, essentially I printed this out and I sent it to the practice, but essentially it’s just a portfolio of work that I did early on.

This hasn’t been updated since 2020. So 2021 or something like that. But yeah, this is just an example of my early portfolio. So contents page, just everything there. About me page. I mean, it’s very word heavy at that point. I would change things now, but this is just early cases go through author cases.

My just basically case reports of my cases and the best thing I think that was the best thing is this bit, the learning points and reflection of what I could improve on because I know that I’m then reflecting back on work. And if I have a similar case come through, Then great. I know exactly how to plan it out.

I mean, you can see here the kind of smart design thing that was left from Chris Orr but this was all kind of my thought process. This is how I plan cases at that point. Things have changed differently. Now this is some also rest of stuff at that point, me showing rubber dam skills, photography skills, just going through all these and literally just going through this. It’s showing exactly what I did at that point.

[Jaz]Very good. I mean, that was really, really great. If you show the example for those audio listeners, I would encourage you to check out the video to see Ajay’s example of a portfolio, which is a little bit dated now, but it looks stunning and brilliant. And I can see why it was so effective in getting the job. You did get the job, right?

[Ajay]Yeah.

[Jaz]Definitely. Yeah, no surprises there. The main question I want to cover, obviously, about how lost you feel, and how you need to like I said, go to gain that network, identify your weaknesses. I also think you should identify your strengths and play to your strengths as well to try and develop into your niche.

That’s important. The importance of photography, which we emphasize, look, if you don’t have photography, you don’t have a camera, you don’t have a portfolio, right? So one leads to the other. It goes out saying, and we talked about your example of you being very proactive with the CV. Are there any other points you want to mention to dentists in terms of helping them navigate the first year or first two years?

[Ajay]You need to make sure that you have a personal life. You can’t do dentistry just like I said, dentistry is a stressful thing. Not something you can just focus on yourself. You need to have a team behind you, where that team is your family, where that team is your practice, your nurse, your friends, your peers.

You might not have, you might be the only friend in your friend group that is a dentist. That is actually a very, like, hard position to be in because firstly, you don’t really have anyone not to compare but to kind of grow with. At that point. So you need to make friends within a dental circle as well.

That’s why networking so good, but on a personal level, you need to make sure you’re making time for your personal time. Dentistry is a very hard thing and it can be a very dark kind of career if you make it that way. You need to deal with your stress levels. You need to deal with your kind of physical restraints, your mental restraints, physical restraints, treat yourself, go for your massages, just loosen up your body, join a gym, join that class you always wanted to join.

Just literally make sure you’re enjoying yourself as well. And then mentally wise, like I said, just talk to people, talk to your friends, get out there, do something different. Dentistry isn’t the be all end all. You need to enjoy your career. You need to enjoy your life. You need to enjoy your career.

So you can enjoy your life. It’s kind of kind of goes to hand in hand, but I think this is something that a lot of young dentists, they don’t keep in the head very well. And I know that for a fact because I teach them and I talk to them and I hear their their qualms. The same with you Jaz, you do the same thing you hear all their qualms, you hear all their problems and even from the foundation dentists coming through their main stress right now is worrying about oh, have I done, have I done this feeling too high?

Is the GDC going to sue me for having a feeling too high? Am I going to get sued? Is the GDC going to strike me off or missing caries here I call the patient. Yeah, you might miss caries people miss caries early on. You call the patient up, you get them back in, you tell ’em, oh sorry, this just missed that.

Then shouldn’t be missing caries. But yeah, this is one of those things. But you should be stressing about things where you’re not able to sleep, where it affects your daily life. And I think that’s a really important topic, really important point to get across. It’s not an easy career, unless you’re proactive, like we said, that word proactive, unless you’re proactive to make it an easier career for yourself.

And you need to look after yourself as an individual, mentally, physically, and just to have fun. And I actually put this in my lectures when I teach, when I talk to fifth year dentists, I actually say to them, go on holidays, literally, you feel better, save some money every month, even if it’s just 50, 50 quid, a hundred quid every month.

If you’re able to save some money, you just get away for a couple of days. De stress. Decompress, sit by the beach. Vitamin D is healthy for everyone and everyone knows that. Just get some, just enjoy yourself, have some fun.

[Jaz]Well said and I’m a big believer and an advocate and I say this to my colleagues that try and book out your year of holidays in advance so you know where you’re going in March.

Where you’re going in September, you’re going to Cornwall in December, wherever you’re going, whenever. It’s nice to know, even if you’re not going anywhere, you have this week and a half booked off in October, okay, to be filled. It’s just nice to know and to try and strategically place your breaks to that, evenly, so you don’t burn out.

I’m a huge believer. I love the fact that I know exactly what I’m doing in the next 12 months and I exactly, I know when my time off is, this is how I can stay focused and I can stay energized. Ajay, tell us about the teaching you mentioned about the photography course. I know you do some adhesive stuff as well. Is it online? Is it in person? Give us a flavor of that.

[Ajay]So, the course, me and my business partner, Ferdi Chum, he’s based up in Newcastle, we teach a course called Trinity Dental Courses. It’s basically aimed at dentists trying to improve kind of basic skills. So it’s photography, rubber dam, and posterior resin.

The reason we call it Posterior Resin and not just a composite course is because we’re trying to build the foundations of what you need to do to say, build up a core, to build up a strong foundation for a tooth for the future, so, those are kind of three basics that we’ve kind of dealt with on that, just because those, and I always start the course by saying.

And adhesive dentistry isn’t the future anymore, it is the now. Like five, ten years ago, it was the future. Now, it’s happening now. We need to know how to do these things as best as we can. You’ve got rubber dam teaching how to isolate properly, and this is because people take ages putting rubber dam on.

I mean, the nurses always get fed up with it, taking 15 minutes, half the appointment to put rubber dam on. The protocol that we teach for rubber dam actually. It has worked pretty much 90% of the time for delegates just to get them really fast. And the great thing is it’s a safe way you never, there’s no risk of aspirating the clamp or anything like that.

That’s a really good way. Then the photography course is basically teaching, going to masterclass of photography for you to understand, not just giving you settings and go away, take some photos. It’s really teaching you how to use a camera. The teachings that we give on that course will actually be able to help you take photos in kind of holiday nature landscape photos because you understand how to take a photo and kind of taking the photo isn’t about click and shooting with settings. It’s about controlling light at the end of the day and after the kind of the session that we give you, you’re going to know how to control the light.

Just like that really quickly you’re going to know how exactly how to change the settings and we’ve had really good feedback from that because again going back to foundation training. It’s these days it’s only half a day of foundation of your foundation training study days It’s not enough for you to learn and practice.

So we give hands on training for the photography for that. And like I said, the third day is posterior composite, posterior resin restorations We go into different types of matricing so to cover basically I think it’s five different scenarios. You’re placing a rubber dam, we show you kind of how to build up deep margins, et cetera, but basically basic, simple principles that every young dentist is now seeing on Instagram, trying to copy, but not knowing how to do.

And we want to basically give you that knowledge. So you’ve got that in your head of house, how to do things properly, which is the best thing. It’s one of those courses. I think it’s kind of that stuff that you’re meant to know that people never actually learn. And it sounds so stupid and simple, but you’d be surprised how many delegates come on our course that don’t even know which bonds they’re using, which generation of bond they’re using, how to even use that bond.

And it’s a big common factor. So it is mainly aimed at kind of younger dentists coming through who just want to up their game. And this is a great way to kind of build your portfolio, your CV. And to be honest, we always talk about courses being an investment, but the investment for this is actually a lot cheaper than most other courses because we wanted to make it accessible for young dentists.

And plus me and Ferdi both really enjoy the teaching. So it’s not about the money. Check it out. It’s called Trinity Dental Courses.

[Jaz]It sounds, yeah, it sounds foundational. And just tell the website and I’ll also put in the show notes as well.

[Ajay]It’s called trinitydentalcourses.co.uk.

[Jaz]Great. I’ll put down the short show notes and your next dates and stuff. You and Ferdi met you guys at the BACD together as well. Very switched on guys. Very, very fun to speak with and big time dental geeks. So, please do show your support Protruserati. If you’re looking for rubber dam photography, the foundational stuff, then do check these guys out.

Well, there we have it guys. Thanks so much for making it all the way to the end of this episode. As usual, there will be some links for you to click on in the show notes. If you found this useful or you know someone who will like this episode, please send it to them. This one and of course the one we did earlier this week with James Murray on portfolio building.

If you know a new grad or someone at the end of dental school who will benefit from this, then please don’t hesitate to share this with them and I’ll catch you back on the more clinical episodes next week.

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As promised - the 2nd episode in a week specifically for new graduates looking to map out their career.

Communication and collaboration are crucial aspects of dentistry, and Dr. Dhunna emphasises their significance. We look at the value of shadowing clinicians in different areas of dentistry, attending conferences, and networking events – discover how these interactions can sharpen your language and communication skills!

Learn from his experiences and gain valuable tips on reflection, communication, dental photography, career development, and work-life balance.

Here are some resources we promised:

An Introduction to Dental Photography

Trinity Dental Courses

Highlights of the episode:

01:12 An introduction to Dr. Ajay Dhunna

06:46 Going from a newbie dentist to an associate

08:28 Reflection and the importance of clinical photos

09:10 Attending courses

12:09 Photography and setup

18:41 Communication

26:43 Planning your next career move

33:37 Being proactive and portfolio presentation

38:40 Maintaining your personal life and managing stress

42:50 Trinity Dental Courses

If you enjoyed this episode, you will love Not Your Average Young Dentist Journey

View Details

Are you a final year dental student or a recent graduate looking to kickstart your career as an associate dentist? In our latest episode we sat down with Dr. James Murray, a passionate foundation dentist who shares his recent insights and experiences on how to land a job as an associate dentist.

Dr. Murray understands the challenges that come with transitioning from dental school to real world practice. He discusses the importance of building a strong portfolio and reflecting on your work to overcome imposter syndrome – embrace the learning process, seek feedback, and use every situation as an opportunity for growth.

But what’s the best way to showcase your skills and make a lasting impression on potential employers? Dr. Murray reveals his secret weapon: an online portfolio accompanied by a thoughtful cover email. In this episode we also delve into tips for approaching dental practices that align with your values and interests.

Struggle with taking clinical photos? Don’t worry, we’ve got you covered! Dr. Murray and Jaz provide helpful advice for improving your photography skills. So, if you’re ready to take the next step towards a fulfilling career, tune in to our podcast and unlock the secrets to securing your dream job!

Access premium clinical videos by Jaz and gain CPD for Podcast episodes via the Protrusive.app

https://youtu.be/AVREWCa8VN0 Watch IC041 on Youtube Need to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:

03:14 Dr. James Murray04:02 Dental school experience06:22 Imposter syndrome08:02 Curriculum vitae09:09 Covering emails11:01 Do the research11:30 Portfolios14:14 Having the right attitude19:37 How to make your portfolio20:45 Photography in dentistry23:52 Photography tips and tricks26:30 Resources for photography27:56 Advice to new graduates31:22 Just-in-time learning

If you enjoyed this episode, you may also like Young Dentist Thrival Guide – First Few Years.

Click below for full episode transcript: Dr. Anonymous: This episode is one of two being published this week, all about the topic of career development, your first few years after qualifying, making an awesome CV and portfolio, and the most important things you should focus on as a new graduate. So think of this as a new graduate week, two episodes this week. [Jaz]This episode is aimed at any student, any newly qualified dentist. Or someone who’s just ready for a career change, i.e. either you’re applying for your first ever role as an associate dentist perhaps or you’ve been stuck somewhere for a while and you want to broaden your horizons and elevate your dentistry and so now you need to start thinking about a portfolio.

Back in the day dentists would hire other dentists by a handshake. Then things evolved into curriculum vitaes or CVs. Of course, there’s always a place for a cover letter in an email, for example, to complement your CV, but nowadays it’s all about the PORTFOLIO. Portfolios are a great way to show that you are a caring, reflective practitioner, and they really help you to stand out against the competition.

I’m joined by a newly qualified dentist, James Murray. Who’s going to give us a guide about what it takes to make a decent portfolio. Not because he’s the most amazing portfolio in the world, but he’s been in this space. He’s been thinking about this a lot because he’s in exactly the right stage of his career, newly qualified and has been very proactively.

I’ve been very impressed with young man, very proactively building his portfolio, which helped him to get his associate position. Hello Protruserati, I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. This is an interference cast, which is like a non-clinical interruption. The themes covered in this episode are the portfolio, but everything that goes into the portfolio, what kind of stuff should you put inside there?

What kind of photography should we be taking? And lots of photography tips in here. And it gives you a good insight into the challenges of being a newly qualified dentist. One thing we do talk about in this episode is COMMUNITY. And if you want to join a community, we have one on Facebook called the Protrusive Dental Community or on the app, protrusive.app. Once you’re a Protrusive member, you can access our secret telegram group. Let’s join the main episode with James and I’ll catch you in the outro.

Main Episode:James Murray, welcome to the Protrusive Dental Podcast. How are you, my friend?

[James]Yeah, really good. Had quite a quiet day today. A little bit of exercise. A little bit of work, a little bit of preparation for the podcast actually does just making sure making sure I can get all of my experience portfolios and deliver it in a way that, as you say, it’s quite tangible.

[Jaz]Amazing. I love the use of the word. I appreciate it. Well, I could have got someone on, James, who was 15 years qualified. Right. But the problem here is the problem with that, James, is that when you get someone who’s 15 years qualified and we start talking about CVs and portfolios, they’re like, what are you talking about?

I haven’t had to make one for like 12 years. Right. So they’re completely out of the loop. So who better than someone who’s like really, really thought about it? Because when you’re in the position where you’re just out of dental school. And you’re in your training year and then you’re having to have almost like a pressure to think about the next step and then you’re thinking about it and then nowadays with the world of social media, we’re seeing where everyone else is up to.

We’re thinking, okay, I’ve got to get ahead of the curve and therefore, there used to be a back in the day, there weren’t no CVs necessary. You just shake hands on it. Then CVs became a thing in dentistry. Then it became two pages and more then the cover letters. Then now we’re going to talk about is the portfolios.

Now, before we dive deep into that, James, just tell our good friends, our listeners a little bit about yourself in terms of where you qualified and what got you interested to talk about this kind of topic, which I’m sure is going to be very useful to anyone who’s thinking about applying for a job.

[James]Yeah, so currently a foundation dentist. I’m working up north in the Newcastle region at the moment. Currently I’ve been applied specifically if you know the area, and yeah, graduated in Newcastle Uni in 2022 and always had a keen interest in restorative dentistry and actually delivering just the best care and the best quality of care that I can.

And once I graduated, I found out quite quickly that one of the ways to do that was through taking photos and developing a portfolio, reflecting on my work. So that’s how I sort of came about trying to focus my work and focus this year on developing myself.

[Jaz]Yeah, well, James, every time I have a fresh graduate on the show, I like to, if you don’t mind, I just like to ask about the current state of affairs of dental school in terms of totals, right?

When I say totals, like how many procedures do you get done now? Right? So famously certain dental schools during my time, this was 10 years ago, would qualify with very few extractions. That was like a thing. I’m not going to say the name of the dental school. That was very low on extractions.

It’s not mine. It’s not yours either. So don’t worry. But certain dental schools have the requirements of just doing six canals or something like that before you can qualify, et cetera, et cetera. Now, you we’re kind of part of the COVID year, but I’m thinking the COVID was kind of like, didn’t disrupt your clinical so much because your clinical was probably more towards 2021, 2022, but you can correct me. What were the totals and requirements like, and how much experience do you think you got or didn’t get?

[James]Specific numbers. I would-

[Jaz] Rough guide.

[James]Rough guide. I would probably say there was about 70 extractions, 50, 60 fillings, and maybe four crowns, four endos. So, to be perfectly honest, going out of dental school, I didn’t feel like I had the most experience, and my third year, which was the COVID year, was disrupted.

Currently in dental school, the look of the draw with patients, if you get a patient where they have absolutely loads, they have no time commitments, and you can call them in when you have a cancellation, that’s great. But for me, I didn’t until about end of fourth year, middle of fourth year, start of fifth year, really. So getting those numbers was a big stress.

[Jaz]Huge. And the issue is, even when I was qualifying, I think I must have done like 12 crowns. And even then that was that kind of average, I think it wasn’t that much. And one thing I remember actually, James, is being really stressed or anxious about even qualifying first few years is, and tell me if you can relate to this, is breaking contact, i.e. if you’re doing crown prep and the interproximals try and break it without touching the adjacent tooth, distal of the upper molar, that was extremely stressful. It took me years to not have an escalated heart rate when I was doing that bit. Now, when you speak to experienced dentists, like, what are you talking about? Cause they forget, right? Is that still a thing? Do you have that as well?

[James]Oh, I have that. I would say on every procedure, no matter how simple it is. Even this year, you can do every procedure you can in an hour and a half, do that in 20 minutes. And there is that imposter syndrome in your FD year and in dental school.

There’s always going to be someone better than you, someone quicker. I worry on a daily basis thinking, is there a dentist who could do this job better than me? And the way that I’ve tried to reframe that, is by taking my photos taking my developing my portfolio and actually asking for advice from these dentists rather than being fearful or jealous or anxious about what they might think of the procedure that I’ve done. And I think that really helped set me up on the right path.

[Jaz]Yeah. And any student listening, really, really key advice there. And I would say it’s extremely steep learning curve when you’re at dental school. And even just, especially in the year, last year that you’ve had basically in the big bad world, trying to do a lot of things still for the first time and first few times.

And the advice I want to give to you, James is not even advice, the reflection I want to pass on to you is I admire the fact that you feel nerves. I admire the fact that you worry because, the dentist I’ve seen in my career so far that I’ve worked with who were same level of experience with me or less, whatever, that didn’t have the fear.

They were reckless and they just didn’t care about the patient. It’s very few, thankfully very few. Right. So what you’re saying is, I think it’s completely normal and just shows that you are caring and you want to the best possible. So that will serve you well. Keep that up. That’s amazing.

So let’s go into portfolios, which is the main thing. And the first question I want to ask you is CVs, cover letters, portfolios, 2023. What kind of stuff are you and your cohort of colleagues preparing? What do all these things look like as a snapshot for your generation?

[James]So I think their previous thoughts were to write a CV, write down all your postgraduate qualifications. Write down all of your experience and things you’ve done outside of dentistry as well. However, coming out of FD and my cohort have very little postgraduate training. So when it came to it, I was very resistant to do a CV to be perfectly honest. I felt like it was a waste of time because the first thing is what would it actually achieve?

And then highlight to the principal that I haven’t done those qualifications. And the second thing is that would it make me stand out? And the answer to both of those was NO. So the two things that I currently do or did do when I was applying for jobs was write a cover and email. And at the end of that cover and email, have a small link to my online portfolio that the practice principal could quite easily access. And that’s just how I’ve done it and there’s no right or wrong way to do that, that’s what I’m currently doing at the moment.

[Jaz]And just to help someone maybe in your position in years from now, what kind of, some people get confused, I don’t know what to include in the cover letter. Can you give us a flavor of what, because you’ve thought about this a lot, you’ve done it a few times now.

What kind of thing do you think is important to include in a cover letter? And is this to a cold practice, i.e., you don’t know the principal there, you don’t know anyone there, you’re just like, okay, you like this look of the practice, or was it a warm practice?

[James]So, I think you can apply the same principles to every cover email, depending on whether you’ve had a recommendation to go there, whether you’ve seen it as an advert on Facebook.

I don’t think that matters. The key principles to me in a cover letter, especially from the perspective of a foundation dentist, is willingness for mentorship, willingness to learn. And I think being humble and being open about where your weaknesses are as well. So just to really give you a flavor of a few of those things and how that might look in a cover and email.

I think the first thing would be one of the phrases that I use is, I’m just a foundation dentist and although I may not have the postgraduate qualifications and experiences that you may require. I do have the willingness to learn and the willingness to develop. And I would say that’s definitely something that I would include in my cover and email.

I think having a look at the website. But yeah, having a look at the website before you apply for the job. So that you know what the practice principal can offer you. But also the practice principal is the right type of person for you? Does he have the same interest and if you do share interest highlight that on the cover and email so I would say that That’s definitely one of the things that I would include.

[Jaz]Well, I’m hoping that the Protruserati are cut above the average, right? And they’re very intelligent people. But now and again, we get colleagues who may send an email that reads a bit like this. Dear Principal, there’s no personal touch. You should know who the… They should know their name, right? Little basic things.

And when I look at, I get lots of emails and stuff from people who want podcast. Like, Dear Host, or whatever. Dear Host of Protrusive. Piss off, right? Come on. There needs to be some sort of personal touch to it, right? So, that’s just basics, but I guess that is to, that is a hook for them to be like, okay, this seems like a genuine person.

Let me now look at the portfolio. And I do think that the portfolio really is where you get to shine. Not necessarily because you’re an awesome dentist and you got all this cases, but a reflection, which we’ll come to. So. What did you use to build a portfolio? And what does a portfolio look like? How many pages is it?

I mean, I’ve seen some portfolios because people email me their portfolios to check and whatnot. Please don’t see this as a license. Everyone to email me your portfolios. I’m already swamped, but to see what some of the ones I saw absolutely brilliant, but what they were is they were almost brochures, like 28 pages. I mean, very luxurious, very fancy. Does it have to be that way? Give us a flavor of that.

[James]Well, I can only speak from my experience and currently I’ve only seen my own portfolio. My portfolio is currently 12 cases long. I’m a foundation dentist as well. So my cases that I’m presenting are not complex.

They’re a simple adhesive onlay. They’re a direct composite, they’re a distal composite. I have a wide variety of things that I planned at the start of the year that I wanted to include. And I think when compiling a portfolio, you have to be asking yourself the question, what do I want to show the practice principal in this case?

Is it a new matrix technique that you’ve learned? Is it the anatomy used following the Style Italiano Anatomy Guide? Is it improvement from one case to another? So, actually in my case, and I think it’s case 3 and 4, in mine that I’ve compiled, showing the improvement of my anatomy on a premolar. Something that I really struggled with, and it’s not the hardest thing to do.

And I just printed off the Style Italiano guides and reflected upon that. I think it doesn’t matter how many cases a portfolio has. For me, it’s just about having a portfolio. It shows the practice principal willingness to learn. Willingness to develop. And I think ultimately it shows that you’re caring for your patient.

[Jaz]I think that the best principles that I know, most forward thinking, they have been often the ones that hire young blood with less experience because what they do is they hire for attitude, right? And really you just need to be good enough. You don’t need to be like, at your stage, you don’t need to be like all this singing, dancing, doing veneers and stuff.

It’s unlikely. It’s just dangerous, I’d say, right? You need to show that you’re a safe practitioner. And make your attitude shine across and that attitude comes from the reflection. Just like you said, I think a really great way to do it is here’s a premolar from the start of my year. Here’s a premolar from six months later.

Here are the areas I focused on and I was so pleased that I managed to do it. I’ve got a little bit more to do, obviously. I’m not the finished product. But what you get with me is someone who keeps trying and wanting to do the best I can. And maybe a couple of radiographs showing the nice seal that you can make as well.

Might add some good value. And I think if a principal sees that, they say, yeah, this person, A, tries B, reflects and tries to improve and C, they’re good enough. Their clinical dentistry is good enough. Now I want to invite them to interview to see if I like this person or not. What do you think to that?

Occlusion is just so confusing. Does occlusion even matter? Wait, don’t you just grind away all the blue marks, right? You mean like plant it low? Let it grow or leave it high and let them cry. Listen, what are these interferences even interfering with? Is it safe to lengthen teeth? How much can I raise my patient’s bite?

How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs? Is canine guidance always better than group function? Why can’t I just use the DAHL technique and all my wear case? Can I stop my patients from grinding? What the bloody hell is crossover?

What should the occlusion look like after orthodontics? How and why do you check for fremitus? What on earth is a custom incisal guide table? How do you use a leaf gauge? Do you always need to use a face bow? Does everyone really need a perfect occlusion? What is the difference between edge wear and pathway wear?

Is it naughty to adjust the opposing tooth? What the f*** is centric relation? Occlusion is coming. One does not simply just open the bite. May the force of mitigation be with you.

If you are looking to take the next step in learning occlusion, that’s going to make your restorative dentistry predictable.

[James]Yeah, there was one thing that a practice principal actually said to me that really stood out. They said that skills can be learned, but your attitude is very difficult to change.

So if you’re going in with the attitude that as a foundation dentist going into associate year, you are brilliant, you can do your composite veneers, you know your anatomy, you can do your root canals in 30 minutes, for example. I think it’s just unrealistic and it shows that you’ve got the wrong attitudes because there’s always someone better than you and there’s always something you can learn from that person.

And I don’t think any practice principal wants a dentist who isn’t willing to take advice and suggestions because it’s just a recipe for disaster. Well, that’s definitely what I’ve found anyway.

[Jaz]Agreed. And the hard skills dentistry, as a long career, it can all be learned, but a big thing that principals think about when they’re hiring is, will this individual fit into my team? Will my patients like this individual? Do I want to see this individual every single day? Do I want to conversate with them? Will they get along with my nurses? Because all it takes, right, is one bad apple to completely ruin the taste of the entire practice. I’ve seen it done, usually it could be a new nurse, it could be a new dentist, whatever, and completely mess the dynamic of the practice.

So yes, they want someone who’s good enough and that’s what your portfolio shows. When they see you at the interview, they look in the eye and and you show your human side. That’s what’s going to show them that, you know what, this person is a nice, caring individual. They’re enthusiastic. It’s good to have a pulse, right? It’s good to have some enthusiasm. And they think, yeah, this person is going to fit into my team.

[James]I would completely agree with that. And I think it’s really important, not only for the practice principal to know that you’re a good fit for them, but that you’re a good fit for that practice. And making sure that your ethos really matches that they’re willing to invest in materials.

They’re willing to invest in matrix bands, clamps, to give the best to their patients. And if that’s not the case, I think in my position, I would have been considering whether I’m the right person for there, and whether I can provide the best dentistry that I can to my patients. And I think that’s always something really important to have in mind.

[Jaz]What did you use, James, to actually make the portfolio? Like, do you use Keynote, use, Google Docs? Just give us a flavor. Some people like, technology. They, it’s a hurdle for them. Just give us a flavor of what you used.

[James]Yeah. So I actually asked for advice from a few dentists who are on Instagram. I chatted with dentists like Chris O’Connor, ones that I really respected. And the advice that they gave me was a website called canva.com. It’s a really simple software to use. You can drag and drop your images. You can reorder your boxes. It has lovely set templates. I don’t think it particularly matters what template you use, how it looks.

You can do it however you want. But what I would say is that just choose a software that you feel comfortable with using. But I do find Canva really useful.

[Jaz]Agreed. Canva is an absolutely brilliant tool. We use it for Protrusive as well. Thumbnails, artwork, that kind of stuff. It is fantastic and doesn’t have to be all this really, really pretty thing. It just needs to make it clear and easy to read and easy to follow for the person who’s reading it. And I mean, in terms of populating it with the photos, here’s an interesting one for you.

Like a lot of dentists I know still don’t take photos, they go through their career that without taking photos. Obviously no one wants to read a portfolio as an essay like, Hey, I wanted a composite and I thought I actually well, and I produced a good result without any photos. That’s BS, right? So, what kind of photos are you taking? Are you taking intraorals? Are you taking DSLR? And tell us about your journey into photography.

[James]So journey into photography, I had absolutely no. journey to start with. I started never being able to use a camera, getting all photographer in Newcastle University, take all my photos, my final spaces. But when I started, we had a brilliant study day and it was recommending and while just chatting about the sentence and the best thing that I did and the best thing that I can advise for any foundation dentist would be to buy their own camera and the settings get changed on your practice one in your foundation

year, the settings got changed. The batteries on charge, the memory cards full photos get lost what was getting needed.

[Jaz]And when you need it and when you need the camera, it’s in use or you can’t find it. And what it is when you’re ready to take a photo, it has to be there ready set up and ready to go. You never own a camera in dental practice, in a case, you don’t have to, if you have to actually assemble your lens to the body every time you use a camera, it’s not going to work beyond one day of your practicing career. So great advice there, James. Have it or have your own one. Have it ready to use.

[James]Yeah, and that would actually say, well, I plan on a Sunday, all of my patient that I have. I look through my diary for the week and I think especially it’s important as a foundation dentist to maybe do a little bit of research before seeing that patient. You haven’t done a fiber post before, but ultimately I use it to identify those patients where I’ve got a little bit of type.

I’ve booked out that hour and a half or that hour for a nice composite. And I know my camera’s going to be settled. I know my accessories. I bought the Focus Flex accessory kit from Minesh Patel’s website just with a little buccal mirror to take my intraoral shot for the camera. And I know you mentioned what photos do I actually take?

The photos I primarily take are completely dependent on what I’m trying to highlight in my portfolio. So if I’m trying to highlight a matrix technique or it’s a posterior, I’ll be using the buccal mirror and I’ll be taking an in the mouth before shot, photo with rubber damp, photo with the cavity prepared, a fill in. So the photo with the filling under rubber dam and then the photo in the mouth without rubber dam and that’s my treatment sequence. Now if I wanted to highlight something else, maybe it’s a new wedging technique that might be something that I want to take a photo of and highlight in my portfolio in addition and some of my cases have two photos. Some of them have ten and it doesn’t matter.

[Jaz]Agreed. And when you started to take photos, I think one advice I give to everyone is make sure whichever nurse is supporting you, you just get them in on it. Hey I’m a dentist who likes to take photos and therefore, let’s make sure the mirrors are warm to prevent-, prevent them steaming up, have some retractors.

Like you said, so, so important, dentists have cameras and then they like have these horrible rubber, not rubber, the plastic retractors which don’t allow that from the mirror to go in so you can’t take an occlusal one. So you need one that she’s going to work in that sense. Tell us about your occlusal photos nine months ago and your occlusal photos now.

[James]All my occlusal photos are not insistent Jaz. Previously they would have been steamy They would have been over or underexposed, so too light or too dark. They would miss off the tooth that I was trying to highlight. But ultimately there’s a few things that I found really useful. I think having some light already on the mirror from your overhead dental lamps really useful. And four handed dentistry, as he said. Working with the nurse. My nurse always has the 3 in 1 tip. Blowing air on the mirror so it never steams up.

And to be perfectly honest, photography is all about experimentation. It’s all about trial and error, seeing what work, what doesn’t. Position of the patient, it starts to become second nature. And the more photos you take, there’ll be an exponential improvement in the photography. And that’s sort of, well that’s my experience of it.

[Jaz]You hit the nail on the head. Photos are something that you just need to keep going even though your first six months of photos will be absolutely garbage. 90% of them will be absolute garbage, but it’s okay because you’re learning. And then eventually it’s muscle memory. It becomes so easy. I can take all my photos with just me.

I don’t even need a nurse anymore. I can do the whole series without a nurse. But that took time for me to do. And one thing that Minesh Patel talks about, which I echo as well, is getting a really light setup that you can hold it in one hand. If you can do that, then it makes things very achievable and you can actually hold the other, the mirror in your own hand, get more control over that.

And just keep taking, even though you’re rubbish, keep taking, keep taking, you’re going to improve over time. And then when you’ll find, when you’ve nailed your settings, then it’s just rinse and repeat. So if you’re someone who has been afraid to venture into photography, please do it. And if you’re struggling with occlusals, I do have a, I made a YouTube video like three years ago, four years ago.

It’s on there about just occlusals because I find that’s a really tricky one. That a lot of people struggle with and of course you mentioned the buccal mirror was like that long, thin one, really good to take quadrant photos. So super important to have all this kit. Tell us James about any resources for photography that you recommend.

[James]Yeah. So I think one resource for photography that I really recommend is the photography for dentist page and also the Two Dentists YouTube channel.

[Jaz]Shout out to those guys.

[James]I think both of those two things that I used and the photography The Dentist Page gave me an idea of the camera setup, the settings to use, and gave me some confidence on taking those first intraoral photos. And the two dentists also provided me with that, and I thought both of those were really useful.

[Jaz]Two dentists, photography of a dentist page. I’m also going to add there’s a course called futurelearn.com which is a good simple course to do as well. That’s how I started. Gosh, that was like 10, 11 years ago.

And also, on Instagram, dentist.camera. My friend Alessandro, he posts really good stuff from basics to more advanced stuff as well with photography. So, I’m glad to have shared those resources. Thank you. Those were the main questions I wanted to ask James in terms of portfolio building.

But I just want to give you the mic, my friend. You’ve had a really, you told me before we started recording, you’ve had a really intense year. And I remember my first year at dental school was constantly learning every single minute something new, right? And every day I’m learning something new.

When you’re a DF1, you’re learning whether it’s patient management skills, people management skills in terms of working as a team. You don’t know what you don’t know. There’s so much in perio, there’s so much in tooth replacement, so much in prosthodontics that we just don’t know because we just haven’t been exposed yet. Right? So what advice would you want to give a to your former self when you started the year? And then, to everyone else who will be joining your footsteps in the coming months.

[James]I think there’s two things. I think in terms of the fear, the doubt, that imposter syndrome. Just understand that that is completely normal. That you are going to feel like you’re not as good as the other dentists in the practice. Because ultimately in terms of skill set, you know, and the faster that you understand that the more content that you’ll be. And one of the things that we were chatting about just before the podcast started was about reframing that into what can I learn from the people I work with.

And my advice would be take photos, even when the work is dreadful, even when the work you’re not proud of, it’s an open contact. But if you don’t photograph that, and take that to your practice principal or your educational supervisor. How are they going to be able to give you advice? And if you can visually show them where you went wrong.

They’ve done so many more courses, have so many more patient experiences with that. That they can completely guide you. So that would be two pieces of advice for those. And use your colleagues around you. Use them for experience because you can use every single situation as a learning experience.

[Jaz]Well said. Every master was once a disaster and no matter what you see, you don’t see the journey. You don’t see everyone’s journey. You just see the beautiful stuff they’re posting out now. But 15 years ago, it wasn’t the way. Dentistry is a tough gig.

But it’s so rewarding, and it is an expression of art. So my big thing now is trying to promote dentistry as art because I’m trying to think, what is it that’s going to make everyone have a fulfilling and happy career? And the more we can be artistic, the more it doesn’t necessarily mean cosmetic dentistry.

You can be artistic with the surgery. You can be artistic in every way. Even the way you communicate with a patient can become an art. Embrace that art and see the beauty in it. And I don’t want anyone to bury their head in the sand and ignore the negativity. Have a awareness of it. But if you focus in on the negativity, it’s a bit like those slalom skiers.

If they’re constantly focusing on avoiding the trees or the obstacles, whatever, they’re going to hit it. But if they’re focusing on the clear path. then they’re more likely to make it. James, thanks so much for giving up your time and enthusiasm to help the next generation of dentists. I think it’s going to help them to get a portfolio.

I think it’ll give them the kick up the butt they need to just do it, right? Just main thing is just do it. And if you’re lucky enough to have listened to this episode as a student or at the beginning of your DF1, then do everything James said. Get that camera and ask your colleagues for advice. And we live in a time now where it’s never been a better time to a dentist who wants to learn.

It’s never been a better time to be a dentist who wants to learn because learning opportunities are everywhere. And the problem we’re having now is that there’s too much, it’s too much noise. There’s too much stuff on YouTube. There’s too many podcast episodes of mine. There’s too many Instagram stuff, right?

There’s too much. And so what you end up doing is you end up drowning your life trying to learn this, learn that, learn that. I’m a big advocate. I don’t know if you heard me say this James before of just in time learning. Yeah. If you know, you know, like, I love what you do on Sundays. That’s amazing, man.

That’s really good. And if on Sunday, you’ve seen that, Hey, on Thursday, I’ve got my first resin bonded bridge. I haven’t done one of those in ages, or it’s been a long while. Since I’ve done it. Then make the flavor of that week. You know what? I’m going to revise the bonding protocol. I’m going to, do we have panavia?

What cement do we have in the practice? I’m going to think about the prep design if required. I’m going to think about my lab. I’m going to think about which photos I’m going to take rather than just revising extraction techniques that week when actually you haven’t singled that out as something you need to focus on.

So a big fan of just in time learning. So I was going to add that in. James, thank you so much, my friend.

[James]Nope. Thank you very much, Jaz. I appreciate it.

Jaz’s Outro:Well, there we have it, guys. Some top tips on how to make the best portfolio, how to put your best foot forward. These are essential nowadays. And if you have a CV, if you have a cover letter and a portfolio, I think you really stand a good chance to get that interview.

And at that interview, you just show them your human side. You show them that you can fit into the team. And with that, I wish you all the best. Thanks for listening all the way to the end. I really hope you get the associate position that you deserve. If you enjoyed this episode, please do consider giving it a rating wherever you listen to it. Otherwise, I’ll catch you same time, same place next week.

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Highlights of the episode:

00:00 Introduction

03:14 Dr. James Murray

04:02 Dental school experience

06:22 Imposter syndrome

08:02 Curriculum vitae

09:09 Covering emails

11:01 Do the research

11:30 Portfolios

14:14 Having the right attitude

19:37 How to make your portfolio

20:45 Photography in dentistry

23:52 Photography tips and tricks

26:30 Resources for photography

27:56 Advice to new graduates

31:22 Just-in-time learning

32:08 Outro

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[Trigger warning: this episode discusses topics related to mental health, depression, self-harm, alcohol abuse, and suicide.]

Humans first, Dentists second. We will all have personal rough patches during our career – but how does this impact our work and our patients?

A Protruserati shares his experiences of a toxic marriage, self harm and alcohol dependence – I am so grateful he anonymously shared his valuable insights and lessons for dentists seeking to prioritise their mental well-being.

https://youtu.be/ZED_yS8v8sc Watch IC040 on Youtube Throughout the episode we touch on coping strategies, emphasising the value of exercise and physical activity for mental well-being. We also explore the guest speaker’s path to recovery from alcohol abuse, including their positive experience with the Allen Carr course, which aimed to change their perception of alcohol. We delve into their experiences with counselling and highlight the importance of being in the right mindset for therapy to be effective. In addition to this we touch on the HeartMath technique, a powerful self-regulation approach that our guest found beneficial in managing emotions and achieving a sense of calm. Below you can find links to these resources, including the ConfiDental helpline – an accessible and confidential listening service designed specifically for dental professionals.

Allen Carr EasyWay – www.allencarr.com/easyway-stop-drinking/
HeartMath – www.heartmath.com
ConfiDental – 0333 987 5158

Access premium clinical videos by Jaz and gain CPD for Podcast episodes via the Protrusive.app

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:00:00 Introduction04:22 Our guest’s story12:32 HeartMath14:59 Poker face18:33 Going to work mentally unwell21:00 Leaving toxic environments27:38 Advice for those struggling31:34 Reaching out33:39 Outro

Click below for full episode transcript: Dr. Anonymous: I didn't enjoy going to work. I think, I always thought, I wasn't very well slept and I didn't have the energy and I had to put it on, and it was a lot of effort. So, yeah, I think it was, it was difficult for me. I didn't want to go to work. Jaz’s Introduction:Do you remember practicing dentistry when you had a cold or you weren’t feeling well? Well, you must remember how difficult that was, right? Because dentistry is such a stressful thing. We’re dealing with people’s emotions all day long. We’re dealing with intricate procedures in small places, so when you’re not feeling your best. Man, that adds even more to an already stressful profession.

There are various times in our careers that we will enter a rough patch. Now, before I give you examples of this, I want to give a warning for this episode that this episode does contain a lot of triggers that might upset some listeners. We tackled some very dark themes in this podcast episode. My guest, who is a dental professional, discusses episodes of self-harm, divorce, excessive alcohol intake.

And these are the kind of themes that we’ll be discussing under the broader umbrella of difficult, rough patches that we may face as professionals. And the reason why you made this episode today is to help anyone who’s listening who may be. Going through a rough patch and of course will.

It’s inevitable. We will all go through rough patches. We’ll all have an argument one day. We won’t be feeling our best every day. I don’t feel my best every day, despite what you guys might think, right? I have bad patches. Everyone has bad patches. This is life and we need the resilience to navigate through those bad patches.

A lot of talk nowadays, more and more, which is brilliant about mental health, looking after your mental health. So I’m hoping this episode will help someone, will inspire someone. If it helps just one person, it is worth it. Because of the nature of this episode, the audio episode will be on Spotify and Apple and Google Podcasts.

The video version will be only available on the premium version of the app, so that’s protrusive.app on the website or on the iOS and Android store, because I didn’t want this stuff to go on YouTube because of how sensitive things are that we discuss. If you’re new to the podcast, wow, you’ve picked a different one to join us, but something that’s so, so important, right?

For our wellbeing and so that we can serve our patients the best. Like when you are not feeling your best, whether that’s emotionally, physically, in any way, you are not serving your patients the best way. So that’s why I think this episode is important. I’m ever grateful to my anonymous guest who joined us today.

He revealed so much about himself and gave so much, or just to help someone else, just to help another dental professional who may be going through a rough patch. So let’s lend him our ears. And be sympathetic not only to this colleague that we had on, but to anyone in our profession going through a rough patch. Hello, Protruserati. I’m Jaz Gulati and I’ll catch you in the outro.

Hello, Protruserati. Today I’m joined by a really good soul, someone who’s volunteered their time to help you guys because this is a very sensitive topic we’re talking about today. This episode is for anyone who has ever faced adversity or will face adversity.

And this could be anything. This could be extreme stress, this could be depression, this could be miscarriage. That’s a very stressful thing. This could be something that, anything that basically means that your frame of mind may be altered, and then maybe when you’re seeing patients and you’ve lost your mojo, and this could happen to all of us in our careers at some points, right?

So it’s about this kind of what lessons we can learn from a colleague who’s joined us today, who went through a difficult patch himself basically and very kindly will share his story. So Anonymous Dentist, thanks for making time for this.

Obviously your voice, this is not your real voice, the voice we’ve edited it, manipulated it in a significant way so you’re not identifiable, but just where do you want to start with the story that you’re going to share today with us?

[Dr. Anonymous]Oh, thanks. Thanks for having me, Jaz. Yeah, I think it’s a difficult one. It’s one of those things that most of us, at some point in our life we experience and the difficult experiences that do make us stronger in a way. So when you look back on, it’s a hard time your life. But when you come out the other end, you come out stronger. So it’s anyone who has, who is going through anything difficult, just know that it’s better when you come out of it.

[Jaz]So what happened to you?

[Dr. Anonymous] For me, I think it was, I was in a pretty bad relationship and I think when you have a long, bad relationship, it takes two people to make it fail. And I was one part of that but for me it was pretty bad. I felt in very, very dark places, on and on.

And I remember at the time I was working long hours, at the hospital, looking after patients in A&E to a pretty bad episode of self-harm, where I ended up in A&E myself in one of the bays, next to the, before I used to look after that kinda thing.

[Jaz]This is while you were in maxillofacial.

[Dr. Anonymous]Yeah.

[Jaz]So basically what you’re trying to say is you had an episode of self harm yourself.

[Dr. Anonymous]Yeah.

[Jaz]Whilst you were also under that role basically?

[Dr. Anonymous]Yeah, so I think basically I did maxfax for about three years and it’s already a stressful job. You’ve got a stressful relationship at home and then sometimes arguments and things can escalate.

So this was at home after a long shift. And I got in warm and I had an argument with my partner and things got out of hand and I basically self-harmed and it was pretty bad. I couldn’t walk for eight weeks. I was in a boot, in a wheelchair, in a cru tch. And eventually I got out.

And the worst part of it is that this happened in the beginning of the second year of that relationship. And I carried on in that relationship or another six years after that. So it was a very dark time in my life.

[Jaz]Does that mean you were off? I mean, I’m so sorry to hear that and what you went through, but wow. I mean, I’m just absorbing all that. That’s a big take. Again, we didn’t talk about the exactly your story. So this is all new to me as well. So firstly, I’m so sorry. But then did you have to like, take some time off work? How are work? Did you tell work what happened and how did they support you?

One thing I want to know is when someone, you work for a trust that you work, for example, and you tell your trust this happened, and I’ll assume that you did tell them what happened or maybe not. You can tell me. Were they supportive? That’s what I want to know the most.

[Dr. Anonymous]Yeah, I think it varies on the trust and on your consultant.And I had a really, really good relationship with the oral surgeon and even the maxfax consultant in that trust. So I think initially I was worried about what to tell them because my main worry is this a significant mental health issue where they’re obliged to report in GDC or not. And so I wasn’t sure what to tell them, but I had a really, really good relationship with the oral surgeon, and I just told him what happened.

Actually first I did lie to him and then he’s like, ‘why don’t you hop off and let’s get some fresh air?’ And I was like, ‘I can’t, I’m in a boot.’ And he’s like, ‘no, don’t worry. I’ll, I’ll bring a wheelchair’. So he called wheelchair. And he took me out of the hospital to get some fresh air. It was really good.

And we were talking and yeah, I kinda broke down with him and I was honest and he was very, very supportive. And one of the nicest people I’ve ever met.

[Jaz]Yeah, it sounds like it already, it sounds like this oral surgeon. He suspected something and he wanted to take you in a safe place to discuss that and that is something to be said about the character of this person, right.

[Dr. Anonymous]It is, it is. Honestly, it is amazing. I think he’s one of those people that I know when we run on clinic and we get a referral for TMJ issues, he’ll run an hour late with a patient. Cause he wants to know like their whole background history about any stress. And he’s such a natural at getting stories outta people or people who they not to be stressed for things like that. And they’ll tell you, they’re telling their life history and everything. He’s a very good soul.

[Jaz]Mm-hmm.

[Dr. Anonymous]And, he still works in that place. So-

[Jaz]So thanks to him, thanks to this individual. You managed to get some support, like you had a couple months off and there was like no, like blame culture or No like you didn’t, obviously it’s tragic what you’re going through at the time, but I’m hoping they were supporting you get through that rough patch.

[Dr. Anonymous]They did, absolutely. And I didn’t take the full two months off. So I think I took, I was in hospital for four days under the plastic surgeons, and then I got home and I took another week off after that and they told me to take the four, eight weeks off, but I was like, I can’t.I need to come back to work. So I went back to work in a wheelchair. The best part about it is I got one of the disabled parking spots right outside the hospital.

[Jaz]Silver linings always silver linings.

[Dr. Anonymous]Yeah. And so I did clinics, cause I could do that on a wheelchair and sitting down and stuff. And, I did a lot of admin stuff. I held a bleep. And then after the wheelchair I think I was in the wheelchair for another two weeks. And then I managed to get on crutches. And then with crutches, I went about doing everything I could. I went to A&E and all the rest of it. So it was yeah.

[Jaz]Was that the first, like, time in your relationship? Was that the first time? If you don’t want me asking, was that first time you relationship that things had escalated this bad or other moments? Not necessarily in terms of outcome, in terms of self harm, but in terms of how you felt and whatnot, and how it might have might affect your mood and your ability to be your best when you go into work, you know? Was that the first time?

[Dr. Anonymous]No. No. I mean, I think with things like this it’s usually towards the end of a really long string of smaller episodes, and then this is like a major event. So, yeah, it does start with small issues and it does get bigger and bigger. Yeah. It’s lots of arguments, lots of, we never quite obviously physical into physical type, but it was emotionally very, very draining. And it does take a toll on your mental health.

[Jaz]Did you get any help as a couple? Well, I mean, I’m hoping you’re going to tell me that this is the direction you went in terms of therapy, counseling, that kind of stuff. Is that something that you explored?

[Dr. Anonymous]So after this event, after the self-harm, we did and I don’t think it helped. I think most people need to be on board for it to work. That’s the first thing. The second thing is when you go to a counselor and you talk about the issues in relationship, there is a fine line where you talking about the problems. And not being looked at as tried to bring the counselor over, the therapist over to your point of view.

So, say things for them to agree with you and think that’s, exactly. And I think that’s the problem that we had in counseling where, one of us didn’t think counselors or therapist could help. And then when we did go and we’re talking about the issues that are bringing us there, you get the blame of thinking, you’re just saying the most awful things to try and win over the counselor and make me look like the bad person. So we tried, I think about four or five sessions that, it wasn’t really for us.

[Jaz]But what if someone listening to this right now is going through a similar thing in a relationship? And would you at least suggest that they give it a go cause it didn’t work for you, but maybe-

[Dr. Anonymous]Absolutely.

[Jaz]Do you think it’s worth giving a go, right?

[Dr. Anonymous]Yeah, absolutely. And I think if not, definitely try everything you can. And if the couples doesn’t work for you, then make sure you get some help for yourselves. At the very least, at least you’re looking after yourself, then.

[Jaz]Well, tell us that how far into this journey that you went through, did you eventually get individual help for yourself?

[Dr. Anonymous]So I did at the end, so this was year two. The relationship continued for another six years after that. We were in a relationship for seven years in total, and then once it all officially ended, then I got some help and yeah. I went to Malta, they had this juice, juice fast retreat thing going on over there.

So I just went to that. And over there, there was a yoga instructor and he is just amazing. Like I didn’t realize I was having help, but me and him would go for walks and yoga and stuff. And then at the end of it, he told me that he’s an instructor in something called HeartMath-ing. I can go through that later on if you want.

[Jaz]Yeah, just tell us what it is. You sparked our interest now.

[Dr. Anonymous]Yeah. So HeartMath, it just blew my mind, basically. It’s a very, so we did yoga. That’s one thing that helps. And then HeartMath is a breathing exercise. Now I know everybody goes on about breathing exercises and how they work and how it affects your mental health.

You don’t really know because you hear about them, you read about them. But I think it’s until you see the effects and the benefits that you realize how important it is. So the way he did it with me is, he goes onto his login for HeartMath and then he has an ear probe that connects to your phone or your laptop or something, monitor your heartbeat.

So he just connected it to me and we started talking about just random things. For five minutes we’re just having a chat and we were moving from topic to topic, talking about films or books or sports activities, just random things. And then after the five minutes, he said, why don’t we just do some breathing exercise for five minutes?

And he said, breathing through your heart, imagine there’s a hole in your heart and you’re breathing in through that, breathe in for five seconds, and then breathe out through the same hole in your heart, just send love to everybody out there in the world to people that you like, to people that you don’t like and breathe out for seven seconds and we’ll do that continuously.

And yeah, just think about the breathing in and the breathing out. And that’s it. We did that for another five seconds and then we looked at the heart rate on the monitor and the results were amazing. The first five minutes were just so chaotic. Your heart rate is just fluctuating up and down and there’s no rhythm. And you look at the last five minutes there’s just this constant level, no heart rate.

And yeah, there’s a whole spectrum and it’s a beautiful, beautiful thing. And for anybody out there who’s interested, just go Instagram and type meyouyoga, and you’ll find him. He’s an Italian guy called Sal Puma, and he’s one of the mentors on HeartMath. He’s just, it’s amazing.

[Jaz]I mean, the advice there basically is that, whatever difficult time you may going through, and sometimes it is self-help and looking after yourself. So important. Now, that can come in many forms and you are a case study. You’re like at n=1 like this, work for you.

And so, and then we like recommendations, right? We go by people, you know, trust and stuff. And so after hearing what you went through and how you try to overcome it, and then listening to that, that might inspire someone to be like, you know what, I’m going to look after myself a little bit more and try a therapy, that sounds amazing to me.

Now to get back to more about how we can help people who may be in a rough patch. If you look back at your time now and the journey and the ups and downs and stuff, do you wish that you would’ve seeked help sooner? Because it looks like you waited till the end to seek help. Imagine someone has had an argument with their spouse this morning and they’re going to work now, they’re listening to this podcast episode.

They’ve had a argument with their spouse. They’re not in a good place. And I mean, you’ve been there, we’ve all been there to some degree, right? And you’re not in a good place and you can’t be your best. And sometimes you need to give everything to your patient.

When you are doing in even a Class II, Class II’s are not easy. They’re tricky, right? They’re fiddly. They need a lot of tension, dedication to get a lovely contact point. So how can you give your best to that individual who’s put their trust in you when you are not in the right frame of mind?

So, what kind of, how would you feel and how did it affect your work in that regard in terms of your enjoyment and fulfillment from work? And then do you wish you would’ve got help sooner? So it’s a two part question.

[Dr. Anonymous]Yeah. So I think with this sort of situation, there’s two aspects to it so one is I think I was also having quite a bit of alcohol at the time and I think that has its own problems and you’ve also got the mental issues.

And I think it’s a bit like the way I felt was what, I don’t know how to describe it. Maybe, I don’t know, in university or you go shopping and you have like, seven Tesco bags in each hand, and they’re really, really heavy. And you walk back to your apartment, 10 minutes and your fingers are really sore and you put bags down and you feel that sense of relief that you’re just like, oh.

And I see, like, it becomes like a chronic situation where you feel like you’re carrying something on your shoulder and it becomes normal for you, and you don’t realize it’s there anymore, but it’s always there. Or like a really tight pair of shoes that you’re wearing. They’re really uncomfortable, but eventually you get used to it, but you don’t realize it until you take the pair of shoes out.

Then you realize that you’ve been carrying this for a while. And I think that’s the first stress. And the second stress is the lack of sleep. I think when you’re having drinks or you’re in a bad relationship, you’re not sleeping well, it is difficult and you just bring your A game whenever you get, and you know, you just try your best. You’re not a hundred percent. You don’t realize it at the time. But when you go to work, nobody can tell. These are people who, people like this are very outgoing and social, and everybody around you thinks that, oh, he’s such a fun-loving guy. He’s such a great guy.

[Jaz]So, you’re saying basically that you had a really good poker face. You’re at work, you’re receptionist. They couldn’t tell these internal struggles that you’re going through.

[Dr. Anonymous]Yeah, absolutely. Absolutely.

[Jaz]And that itself is a burden that is difficult, you know?

[Dr. Anonymous]Yeah.

[Jaz]It’s like you’re living, I guess false life is a term we could use. You’re living you’re living a lie in the way that you can’t express yourself at work. And you are at work so many hours a day, but you’re trying to distract yourself. You’re trying to be your normal self, you’re trying to be you’re happy-go-lucky person that you are rather than it’s stuck in this difficult time you’re trying to get out of that, but that itself plays a burden on you. But I guess you have to put that face on to give your best to your profession. Is that how you felt? Maybe?

[Dr. Anonymous]Yeah. Absolutely. Absolutely. And I mean, who knows about, you’re right about patient care and stuff. I think it’s difficult to look at it retrospectively and see that if you could have done a better job, but when you’re out at the other end and you feel the way you do and you go to work and you know that you’ve got real energy and passion, then you realize that there is something more than you can give.

[Jaz]Was dentistry for you like you know what? I need to get out of home. I need to get out of this, and I’d rather go to work and I love dentistry. Or were you like, you know what? I feel crap. Like you know when you got a cold and you have to like a really nasty cold and you have to go into work with a nasty cold, and it’s just not pleasant.

You’re trying to get through the day and it’s just it is what it is. Where did you lie in that mindset of going to work?

[Dr. Anonymous]I was in the second group. I was definitely in the second. I didn’t enjoy going to work. I think, I thought I wasn’t very well slept and I didn’t have the energy and I had to put it on, and it was a lot of effort. So, yeah, I think it was difficult for me. I didn’t want to go to work.

[Jaz]I mean, dentistry’s so, so stressful already, right? Where that is and the most stressful. The best bits about a job is a people person. It’s a people job basically. You’re seeing people all the time, you’re building connections, trust, that kind of stuff.

That’s the best part, but it’s also the most taxing part that you have to deal with emotions. You have to consent people, you have to make decisions, decision making, both in your treatment plan and what the patient will accept and actually decision making in a micro level, like which wedge to select, to which matrix band, to which type of prep, constant decision making.

So it’s a very taxing profession that itself was adding stress and burden to you and I know obviously those of you listening, watching, you don’t know who I’m speaking to, but this individual, is kind of like me. We’re course junkies. We like to learn and stuff. And so how did you cope with juggling, trying to be the best that you can at your work and learning more and managing this issue that you had internal at home and stuff? Did you take more holidays? Did you try and take more breaks? I mean, how did you cope?

[Dr. Anonymous]I think the courses were amazing. I think that definitely helps. You’re right, I did go lot different courses. I did a lot of learning, I did lot of shadowing, and those were the best days of the whole year. I think, so that definitely helps. Sport is definitely something that does help as well.

So any form of exercise and movement brings you in a good place. And I think whenever you go for a run or something, you hate the idea of it before, but when you finish it, you do realize that you’re full of energy stuff. So, that is good. But otherwise it is difficult. It’s there.

There’s no easy way out of it. I think the only thing to learn is that it’s better to not be in a relationship than to be in a bad one. It was one of those things that was difficult. Those seven years were the most difficult years of my life. It was difficult to juggle.

[Jaz]I spoke to Sandy who came on. He talked about a toxic workplace and how eventually he said he had to draw the line. He had to leave that work and find a new associate position. And he’s thriving now. He’s loving it. Without giving much away about you. I see you now and we had a conversation on the phone and you are really, you’re back to yourself now.

You’re back to your happy go lucky, smiling self. And you’re in a good place now. But getting there can be tricky. And so what was the final trigger, if you like, or final thing that made you make a very bold and brave mutual decision? I hope in terms of, okay, we need to end it now so that we can heal because you decided, it sounds like what you’re saying is that, from what I’m reading between the lines, you’re kind of saying that. You left it too late. You wish you’d left much earlier. But it’s a bit like when you’ve been at practice for 10 years and now it’s becoming toxic.

But because your patients will know, your receptionist know, to have to leave a job and find a new associate position, for example, I’m just drawing comparison. It’s a tough decision to make. Like, you know what I’m handing my notice in? It’s a big deal for a lot of people, your kids might be at local school. It’s the fear of the unknown. What were you thinking when you finally sort of decided that this was it?

[Dr. Anonymous]So, yeah, I’ll tell you exactly what it was. Because I remember that very, very clearly. I think, so I’ll tell you a little bit about my relationship with alcohol and then it’ll lead on quite well to this. So I’m somebody who started drinking quite late in life and when I was at university, I probably only have a drink three or four times a year.

And it was the same in vt, practice, nights out or Christmas time or something like that. When I got into a relationship and I think you talked about this before about lifestyle creep and you get a bit more money and you start to afford things a bit better and then you’ve got company to enjoy it with, and you start to drink a bit.

So then you drink maybe twice a month and you start to drink once a week and then you drink twice a week and it goes on, and then you’re having a glass of wine every night and you think it’s normal glass of wine that’s fine every night with your food. And then you have a couple of glasses a night, you know?

Then, so I was at a stage where I’m having about two glasses of wine every night after work. And I listened to a podcast by Brad Thornton. He’s a dentist. I don’t know if you know him.

[Jaz]Yes. Yeah, of course. Yeah. Brad, shout out to Brad.

[Dr. Anonymous]Yeah. And he interviewed somebody who unfortunately has now passed away, but he interviewed somebody who had a pretty difficult relationship with alcohol himself.

And he was one to two bottles of spirit a day, every day. And he eventually tried to commit suicide. And it was a pretty, pretty harrowing podcast, when you listen to it. And the thing that hit me is that he said in his podcast that he didn’t just start drinking one to two spirit, bottles of spirits a day

straight away, five years before that, it was two glasses of wine at night. And I’m like, I’m having two glasses of wine a night. I’m five years away from attempted suicide, you know? And I was like, okay, something has to change over here. And, it also reminds me of another analogy you said in one your podcast about the frog in boiling water, right?

When the water is cold, it gets a bit warmer and warmer and before you realize it, reassuring in boiling water and you saw get out anymore. So I think that was point, which I was like, okay, I think this needs to end. The things that roll you back are you’re in your early thirties, you don’t have a chance of getting another relationship inside your family and it’s all very scary, but then you realize it’s better than the alternative, which is and things will just escalate and get worse.

So that’s the point at which I was like, I think this needs to end. And I joined Quit Drinking Course by Allen Carr. It was called, The Easy Way Course, and I think a lot of some celebrities have been on it for either smoking or for alcohol. And it was amazing. It was really, really good. It was really, really good.

And I think basically, drinking provides you with some benefit. Firstly. Secondly, I think the main thing that’ll make somebody stop or not stop, sorry, is that they think that it’s very, very difficult to stop and do you like it’s impossible. Or I’d have to go through delirium treatments for three weeks and spread it out in a room or something like that.

Whereas I think in this course, it’s just a one day course. You do realize that it’s not that difficult because everything that you know about alcohol is an illusion, and it’s wrong. And I think as soon as you see it, it’s like, have you seen some of those pictures where they tell you to look at something and you can’t see it and you’re staring at the picture and they’re like, you can see the word in that jumbled up spheres of black and white over there, but you can’t see it.

And then they tell you to squint your eyes and move dark and then all of a sudden you can see it. And then once you see it, you can’t unsee it. You can’t look at that picture again and and not see it. And it’s a bit like that.

[Jaz]And I think it’s a bit like finding MB2. When you first find MB2 okay, then you can’t stop finding it. I want to make it dental in some way.

[Dr. Anonymous]Oh, exactly. So, yeah, I think that’s it. So one of the illusions we talk about it taste, and when you think about alcohol, high end people talk about how this nutty ale tastes so good, or cheeky sutan or I don’t know, peat and brine and all these different flavors and coke and things like that. But actually it’s all, it’s all the marketing.

Think about the first time you ever tried alcohol. I know for me it was horrendous. It tasted disgusting. I couldn’t even swallow it. And I think that’s how-

[Jaz]You have to pretend. It’s like beer. You have to pretend to like beer long enough until you actually like it.

[Dr. Anonymous]Exactly. Exactly. Exactly. And the first time you, I know the first time I tried it, it was disgusting, but there’s always somebody there to tell you, don’t worry, it’s an acquired taste.

And over time you’ll learn to like it. And that’s it. But the reality is that, you need a lack of taste to be able to tolerate it. and that’s how it’s o over time your taste buds just forget how bad it is. And the reality is a poison a half, half a of alcohol neat will kill you.

And I think, back in the day when we were hunter gatherers, that’s how we knew our taste buds knew what to take and what not taken, alcohol is one of those things. If we did try it back then, we would’ve probably just started out and not had it again. So they talk about a lot of different illusions on the course, and I think once you start to see it for what it is, the flavors all come from sugar of some sort. And that’s what really keeps it going.

[Jaz]That’s very useful perspective on anyone. Alcoholism is a serious thing that we need to spread a good message about in terms of overcoming it. So if I was to say to you with after everything you’ve been through, and like for those of you who don’t know, the colleague I’m speaking to today, fantastic dentist, really proactive, like, you could tell this dentist proactive because they sought to go on this Allen Carr course, they sought to go on this retreat.

You have to be in, we actually met on a course once, so I won’t say which course it was, whatever. But you’re a very proactive dentist. But even you found it very difficult to end a toxic relationship. Early enough and that’s, it’s a testament to how difficult and how tough these things are.

So whether someone is going through depression or any other bad moment in their life, tough patch. Rough patch. Okay. What are the top 2, 3, 4, 5, and as many bits of advice if you have, if I just give them microphone and say, listen, any of my colleagues who were in a bad place consider doing the following.

What kind of advice can we leave the Protruserati with to, no matter what they’re going through right now, how can we help them get their mojo back so that they can serve their family, serve their patients well, and live life to the fullest?

[Dr. Anonymous]I think the first thing is just realize where you are in life. Cause I think, just look at your relationship with any sort of drug, whether it’s smoking, alcohol, food, and just see if it’s a healthy relationship or not. And I think if you don’t realize that it’s not a healthy relationship. Then you carry on in that situation for quite some time.

Secondly, I think if you do realize that you’re not having a healthy relationship with something like alcohol, don’t think that you’re alone and don’t be embarrassed about it. When I went on this quit drinking course with Allen Car, it was full of high achievers and our brain when we think about an alcoholic, we think about somebody on the road, homeless person, with a can of beer.

But actually I think there’s a lot of high achievers, doctors, lawyers, dentists for sure, who are very, very successful, who have a bad relationship with alcohol. So if you think you have one, don’t be embarrassed about it because there are a lot of other people in the same boat as you.

You just go and get help. And there’s many ways of stopping drinking. This is the one that I use. Thirdly, I didn’t use ConfiDental, but I’ve heard lots of good things about it. So, when the mental dental group started and I saw what they were doing, fantastic stuff.

So at the very least, if you need some help, you can go through that route. And then I would strongly suggest to go on a retreat somewhere. So, sometimes you go on a holiday and you come back and you got to go to work the day exhausted. And you just, you feel like you need a holiday from your holiday. I think maybe once or twice a year if you can just go on a holiday where you’re not having food and drink and all the rest of it.

Just spend maybe four or five days at a retreat where you have some yoga, some very healthy food. Or in this case it was juice. And, honestly, the energy you get out it, you think that, oh, you’re only having full glasses of juice per day. You must be starving, you’re full, full of energy. And you come back and I was ready to start the next chapter of my life.

And, when you have that good energy, you spread that good energy and you get that good energy back. And I went from a position to your thinking that this is it. I’m not going to have a family ever. And within one year I was engaged, within two years, I’m in a very very happy place and we’re hoping to start a family, soon.

Yeah, so I think once you’ve got some good energy to give out there, and the third thing is always help somebody in some way. And that gives you immense mojo but also juju and also you feel so good. It’s just very, very good energy. The alcohol course I went on they said that the 12th step if you were to go to AA I don’t know, but if you were to go AA, apparently the 12th step is to try and help somebody else get out of the crap. And yeah, it’s just very, very helpful to yourself and your soul, when you help somebody else.

[Jaz]Amazing. Now, I mean, thank you so much for sharing not only your story. I know we’re going to keep everything anonymous, but still, like, I really appreciate you sharing some tough times because, I once recorded with, a colleague and she talked about adversity in New Zealand.

You might have listened to that episode. And she was absolutely brilliant. And I had a dentist message me saying that everything that she was saying about how she felt and how distress that she felt work, she was one of the podcast listeners one of the Protruserati, she was driving and she started flooding in tears.

And she had to literally, like, I think she said, she had to like park her car somewhere, or it might have been on the motorway. She had to go in the sideline basically. But like I’m sure that even if this helps one person. And it’ll help more if it just helps one person that we’ve done something today.

And if we’re in a good place now, then remember that nothing ever is promised. We will always face adversity in life. Life will always come with challenges and some of the lessons and themes that you’ve covered today for us in terms of looking after yourself, getting help, going on in some sort of retreat or something. Even the HeartMath you said?

[Dr. Anonymous]Yep. HeartMath.

[Jaz]Something to consider and how can you help yourself? It’s a bit like when you are on an airplane, they always say, do your seatbelt first before you do someone else’s. Do your life mask first, air mask, whatever, before you do someone else’s.

It’s that you have to look, if you look after yourself, then only then can you serve your family, can you serve your children, can you serve your patients. And so that’s really important. So if any lesson is today, if you found these themes hard hitting, do you feel affected by these, then please don’t.

The worst thing you do is just be like, okay, click on the next episode. Reach out to someone or some organization. It could be ConfiDental, it could be a retreat, it could be someone to help you through a tough time that’s relevant to you. I think that’d be the most important action you could take.

[Dr. Anonymous]Absolutely, a hundred percent. How they say in dentistry, always invest in yourself. Clinically, you always talk about how you go on courses, invest in yourself clinically, but mentally as well. Absolutely. 100%. Take the time twice a year and do something that’s going to give, put you in a good mental state.

Jaz’s Outro:Amazing. Well, there we have it guys, because inevitably we’ll all go through a rough patch, and I hope this episode will help you. It might find you at a time where you are not in a rough patch, but hopefully listening to someone else’s story will just make you aware of colleagues around us that may seem that everything’s going okay, but under the surface there are cracks.

And if you notice those cracks, please send them this episode, or send them to ConfiDental or send them to any of the resources that our colleague shared with us today. And so what I’m going to do is I’m putting the show notes that HeartMath, that Allen Car course for helping him overcome the alcohol addiction and any other resources I can find to help anyone going through a rough patch in their lives.

If this episode was meaningful, if it helped you in any way, I would love for you to leave a review on wherever you listen to your podcast. And I appreciate you listening all the way to the end. I know it was a tough conversation at times because the themes covered, but we can’t just shy away from these themes, it can’t just all be composite veneers the whole time, right?

We need to discuss these real-world themes. So, thank you so much once again for listening to Protrusive and I’ll catch you in the next one. Once again, thank you to the guest that came on, who gave up his time and shared his vulnerable story. I respect you so, so much my friend.

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[Trigger warning: this episode discusses topics related to mental health, depression, self-harm, alcohol abuse, and suicide.]

Humans first, Dentists second. We will all have personal rough patches during our career - but how does this impact our work and our patients?

A Protruserati shares his experiences of a toxic marriage, self harm and alcohol dependence - I am so grateful he anonymously shared his valuable insights and lessons for dentists seeking to prioritise their mental well-being.

Throughout the episode we touch on coping strategies, emphasising the value of exercise and physical activity for mental well-being. We also explore the guest speaker's path to recovery from alcohol abuse, including their positive experience with the Allen Carr course, which aimed to change their perception of alcohol. We delve into their experiences with counselling and highlight the importance of being in the right mindset for therapy to be effective. In addition to this we touch on the HeartMath technique, a powerful self-regulation approach that our guest found beneficial in managing emotions and achieving a sense of calm. Below you can find links to these resources, including the ConfiDental helpline - an accessible and confidential listening service designed specifically for dental professionals.

Allen Carr EasyWay – www.allencarr.com/easyway-stop-drinking/
HeartMath – www.heartmath.com
ConfiDental – 0333 987 5158

Access premium clinical videos by Jaz and gain CPD for Podcast episodes via the Protrusive.app

Highlights of the episode:

00:00 Introduction

04:22 Our guest’s story

12:32 HeartMath

14:59 Poker face

18:33 Going to work mentally unwell

21:00 Leaving toxic environments

27:38 Advice for those struggling

31:34 Reaching out

33:39 Outro

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Join the Protrusive App (Web or iOS/Android) – 2 week Free Trial

There are five things I want to share with you that I do differently now compared to what I was taught in dental school. Dental school is great for laying the foundation, but real-world experience and continuous learning have taught me valuable lessons that have transformed my approach.

1 – Sectioning and Elevating – I routinely section and elevate multi-rooted teeth which simplifies complex extractions and preserves buccal bone for better patient outcomes. This is a skill I had to learn and develop post graduation.
2 – Using air abrasion to aid with plaque removal which has benefits for adhesive dentistry and beyond, like cement removal and bonding zirconia. I cannot imagine practicing without air abrasion!
3 – I use a ‘wedge guard’ during proximal drilling to prevent scratching adjacent teeth, ensuring precise breaking of the contact without causing iatrogenic damage. I know that for many new grads, breaking contact can be stressful and the mission to prevent iatrogenic damage means overly tapered and aggressive preps. The simple use of a wedge-guard has really helped me overcome this.
4 – Onlays! I seldom prepare for full crowns anymore, instead opting for onlays where possible which preserve tooth structure and provide a scientific and artistic challenge in contemporary adhesive dentistry.
5 – Vertical Preparations – when I do require a crown and the tooth is not suitable for adhesive dentistry (poor quality and quantity of enamel, deep subgingival margins) then using ‘vertipreps’ as been a game changer.

Overall, these changes have added value to my practice and improved patient outcomes. Remember, clinical Dentistry is a journey of constant growth. Stay curious and keep evolving – whilst still respecting the best available evidence.

Need to Read it? Check out the Full Episode Transcript below!

Hello Protruserati! Welcome back to the fourth episode of #AskJaz where I answered a question that was sent on the Telegram group – “Jaz, what are some things that you do differently now compared to what you are taught at dental school?”

https://youtu.be/-LYjw2xBETE Watch AJ004 on Youtube Highlights of this episode:

0:24 Dental school inexperience1:04 Section and Elevating for Extractions4:02 Air abrasion for Biofilm removal6:27 Wedge Guard – prevent iatrogenic damage!9:39 Onlay preparations11:39 Vertical preparations

If you enjoyed this episode, check out this episode 6 Signs You are a Comprehensive Dentist

Click below for full episode transcript: Jaz: Hello, Protruserati. I'm Jaz Gulati, and in this Ask Jaz series, I'm going to answer a question that was sent on the Telegram group. It was, 'Jaz, what are some things that you do differently now compared to what you are taught at dental school?' And the honest answer is so much, right? At dental school, you lack experience big time, right? [Jaz]Think about how many procedures you actually get to do at Dental School, how many crowns you actually get to fit. So Dental School is just there to make you a safe beginner, and as you navigate through the real world. You combine your previous experiences with some mentors and courses that you go on and your own individual experiences that you get in practice, which are so powerful.

Your failures teach you so much, your network teaches you so much, and eventually you become the average of the five dentists you spend the most time with. But decided to make a list. And the list I made was of five main things that I do differently now compared to at Dental School. And I think these are all things that have a lesson attached to it or some sort of value attached to it.

So let’s start the list. Number one of the five things that I do differently now compared to a dental school is EXTRACTIONS. Now at Dental School where I trained in Sheffield, we were mostly taught forceps because they were worried about us using luxators and causing damage or an injury, right? Like if you slip with a luxator that can cause a lot of harm.

Now towards the end of Dental School with some mentors, they were showing us how to use luxators, which is great. So luxators became a part of my arsenal during dental school. But I’ll tell you what made me significantly improve my extractions and has made me pretty much fearless. I guess maybe fearless might be an irresponsible term, right?

And sometimes the word fearless can mean irresponsible. I don’t mean it at all. I just mean that previously when I see a molar radiograph or an extraction, I used to have palpitations. I used to get nervous. Can I remove it? Can I not? Should I refer this? Should I not? Kind of thing.

But now I don’t get phased by extractions, even wisdom teeth I’m quite competent with. And only those which are close to the ID canal or show signs that they’re close. Would I refer? And the number one thing which allowed me to become confident with extractions and was not taught to me at dental school is SECTIONING and ELEVATING.

Now, there’s a whole episode we have on the podcast with Chris Waith, about exactly this topic, right? How to make extractions easier by sectioning and elevating, and I wish I learned this technique sooner. I remember being one or two years qualified and trying to take out this lower molar, and the crown completely broke off, leaving the roots behind.

And looking back, all I need to do, all I generally just need to do is section the roots in a bucco-lingual direction so that now the mesial and the distal root are separate and literally just luxate out. Because quite often there’s some bulbosities or slight curvatures that prevent the roots from lifting up vertically.

So by sectioning them, you create two passive insertion, and you convert a multi rooted extraction into two times single root extractions if we’re dealing with the lower or three roots when we’re dealing with an upper. So taking this on board. Now I say that I actually section 80% of the molars that I remove even from the start, if it’s not budging, I’m not getting enough movement within the first 15 seconds or so, my threshold for sectioning is very low.

I’ll be very, very quick to section. The added benefits of sectioning is that you don’t need to do those horrible bucco-palatal, bucco-lingual movements because that’s only going to harm your valuable, your precious buccal bone, which is required for a future implant.

So by sectioning, I can actually direct the forces in the right way, prevent any damage to the bone, preserve more bone. Make my extractions much easier, and I do feel that the patients heal better. There’s less trauma. The trauma is directed at the tooth, at the enamel, at the dentine, not at the bone and the surrounding tissues.

So if you’re not already doing this, sectioning and elevating is super important. If you don’t see some examples of me sectioning and elevating teeth, there’s some on YouTube. There’s also some on the Protrusive app as well in the premium clinical section. And I’m also going to be adding one next week for a lower left second molar. Very carious, very broken down for you to check out.

The second thing I do now, which I didn’t have access to at Dental School, which I firmly believe in so much, is AIR ABRASION. Now the clinical evidence in terms of does air abrasion really improve the long-term outcomes for our adhesive restorations. It’s to be debated, right?

We don’t know whether the bond strengths are always increase. Some studies say they do. Some studies say they don’t, and I know some colleagues who have never air abraded, they just don’t have an air abrasion unit, aluminum oxide particles. And just to be clear, for any younger colleagues, air abrasion is not like the air polisher.

It’s a little bit more sophisticated than that. It’s a little bit more power than that usually. And it’s using a different type of sand if you like. It’s usually aluminum oxide particles. Now, if you’re fancy and you’ve got an AquaCare unit, I’m very jealous of you. That’s probably the Rolls-Royce of all a abrasion units, but something like a Ronvig is very good, a Microetcher. These are a couple of examples of a abrasion units and what it does, it blasts these sand particles, and supposedly it may aid in dentine bonding and it may or may not help in enamel bonding. But the number one reason why I’m a big fan of air abrasion, oh, by the way, actually cement removal.

Like if you have a resin bonded bridge or an old crown and you want to re cement it and you want to get rid of that old cement, then air abrasion is amazing, right? You just blast off the cement. And of course, if you’re bonding zirconia, then part of the zirconia bonding protocol is air abrasion. So air abrasion is a no-brainer personally, but the number one reason why I use air abrasion is PLAQUE and BIOFILM REMOVAL.

So even if it doesn’t materialize, that air abrasion actually makes your composites last longer. One thing that cannot be doubted is that it aids in biofilm removal. So this is something that David Clark, one of the inventors of the Bioclear Matrix got me onto. I was watching some of his videos and he showed where you take a scaler to the tooth and you disclose the tooth and they’re still plaque and you scale some more.

You use ultrasound, scaler, use all sorts of tools, and they’re still plaque when you disclose, but only once you use air abrasion is all that plaque gone. Now, why is that important? Do you really want to bond to plaque? Do you want to bond to biofilm? Of course not because obviously that means weaker bond strengths.

But number one thing is staining, right, that I don’t get much staining on my composites, and I do believe is because I’m obsessive about getting a nice, clean area. So air abrasion will help you get that cleanliness that you desire, that clean and rough surface that David Gerdolle talked about in our episode called Extreme Bonding, again, all these episodes I’m referencing, I will put in the show notes.

So number one was sectioning and elevating. Number two is air abrasion number three. Number three is the use of a WEDGE GUARD or a Fender wedge. These are like two different brand names of these wedges. Essentially, it’s a plastic wedge with a thin metal shield. I can imagine where I’m going with this now, I do remember seeing some at Dental School, but they were very much hidden away and most of my tutors that were teaching me and helping lead my preparations weren’t advocating the use of it.

And so I didn’t really get to use it much. I probably was using it wrong anyway, but these are absolutely fantastic. Now, there is some evidence to say that when we are drilling the interproximal surface of a tooth, we end up scratching the adjacent tooth a significant percentage of the time.

No matter how good you think you are, no much how much magnification you use if you’re not using some sort of protection like a wedge guard or a Fender wedge, that metal strip really does help because we end up scratching the adjacent tooth many times over. Now going back many years, the thing that scared me the most about crown preparations was breaking the contact because I was so scared about touching the adjacent tooth.

I was really worried. And we all go through an experience where we take off a little bit too much compared to what we had, like, and then we have to get soflex disc out and the fluoride and tell the patient what happened and stuff. So it’s not nice. So what we end up doing to prevent touching the adjacent tooth is we end up over tapering that distal wall, for example, quite a common way we overcome it, which is not ideal because then you lose some retention of your crown and quite often you also over reduce that distal wall, for example, because you’re really trying to stay away from the adjacent tooth.

And so that’s not good either. That tooth structure could have been maintained, but when I switched to using the wedge guard, pretty much 90 plus percent of the times now when I’m doing a onlay prep, a crown prep, or when I’m even removing an old restoration, I just stick this wedge guard in. Now you can use some tweezers or better yet, some mosquitoes or hemostats.

Give it a good pinch and direct it in. And you want to sort of go like you’re suturing, right? You want to put the tip of the wedge in and then you want to go slightly apical, and then you want to put your buccal pressure and then like you would with a suture needle, you’d go up. So you go sort of down and up.

It’s difficult to explain. For those of you watching the video version, I’ve got something up right now of me recording, inserting a wedge guard, which again, I’m a huge believer in. And it’s definitely something I do now, which I didn’t appreciate before at dental school and even as a newly qualified dentist, which would’ve saved me a lot of tears.

So if you’re not using one already, it is wonderful. I can break the contact with much more precision, much more ease, much quicker and less fear that I’m going to adjust the adjacent tooth. I don’t mind if I batter the metal or if I batter the plastic. I’ve got some protection there. It is just much better to use something like a wedge guard.

Now if like I was, you are also anxious about breaking the contact. I’ve been speaking to some young dentists and students, and this is something that definitely worries them that I’ve got a whole series coming on the Protrusive app soon called ‘Breaking Contact’. Basically all it is, it’s about 15, 20 cases of me doing crown preps, and all I’m showing you is 20 examples of breaking the contact and how I didn’t touch the adjacent tooth use of a wedge guard and use of any other techniques I can show you to safely break the contact without over tapering and without reducing too much tooth structure.

So watch out on protrusive.app soon for that. And if you think that would be helpful, please comment below so I can hurry that process up for you. Number four, the use of ONLAYS. Like onlays were just not taught to me at Dental School at all whatsoever, so I had to go in courses by Jason Smithson and all these amazing dentists.

To learn about the adhesive onlay and it’s one of my favorite procedures to do. I’ve got rubber dam on. I’m working on enamel, beautiful clean dentistry. I love this procedure. The single onlay is just a beautiful procedure to do. It’s a way for me to express my creativity, if you like. Right? When I’m doing an onlay, I’m in the zone because I feel good that I’m preserving the apical third, the gingival third of the tooth because we’re avoiding a shoulder or a chamfer and we’re doing contemporary dentistry. We’re doing adhesive dentistry. Adhesive dentistry is fun. There’s a lot of science. There’s a lot of art form, there’s a lot of protocol checklists involved, so it really satisfies that inner OCD that we all have.

So I’m doing onlays where I just did not do them at dental school at all. And so if you’re newly qualified, I would encourage you to go on a course where you learn about different onlays. Now I do both metal onlays, rarely. Usually when I’ve got limited occlusal space and I want to put in some slots and grooves, but lithium disilicate is a material I’ll commonly use for my onlays.

And if I’ve got a good amount of enamel all the way around and the thickness of the enamel is good as well, then that for me is automatically going to be an onlay where I need some sort of cuspal protection or an indirect restoration. If you want to see a full protocol, 35 or so minute video CPD verifiable of me bonding an onlay and also prepping onlays, then do check out the Protrusive app.

That’s protrusive.app for examples of that. So just to recap, for I say number five. So number one was how I extract is different to how I did it at dental school. I’m Sectioning and Elevating. Number two was Air Abrasion. So important for that plaque removal and stain reduction. Number three is a use of a Wedge Guard.

Very trusty wedge guard. I use it so much. It just gives me so much peace of mind. And number four is Onlays. There’s a beauty in onlay preps and really it’s not difficult at all. If you can do a crown, you can definitely do an onlay. It’s just a big deal because if you haven’t done at dental school, it’s like your first time doing onlay kind of thing.

So it’s good to see all the content out there and courses out there that teach you this kind of stuff. So number five in the final one of something I do now, which I had no idea about at Dental School, is VERTICAL PREPARATIONS. So verti preps, as you may have heard of them, are not a new thing, right? They’ve been around for a long, long time, decades, because previously we didn’t have powerful tools now to drill these chamfers and shoulders.

So what dentists would do were these feather-edge preparations, and they kind of went outta fashion and now they’re back in fashion because the modern materials, you can actually mill them to very, very thin. And we get to preserve so much tooth structure. So I’m a big believer in vertical preparations.

When I don’t have enamel or when I want to preserve as much tooth structure as possible, if I want to go sub gingival, try and gain some ferrule, these are times that I’ll be using a vertical preparation. So I got to talk nothing about this I never knew existed while I was at then school. And it has been absolute game changer for me and a lot of my indirect work for when I have decided that this tooth is not the best candidate for adhesion.

I’ll be going vertical preparation. And I just love how much tooth I’m preserving and how good the soft tissues look. Now, if this is an area that’s confusing for you and you want to learn some more, I’m doing a series of five live webinars starting probably in August. If you want to stay in the loop, join protrusive.app premium membership and will be doing Verti Prep for Plunkers, a five part live series that will go on there as well for you to essentially do your first premolar case.

So the challenge by the end of these five live webinars is for you to be able to do your first Verti prep on a premolar preparation and cementation, i.e plunking it on. That’s why it’s called Verti Prep for Plunkers. I’m not calling you plunker. It’s like the act of cementing is plunking rather than doing something adhesive, which is much more intricate.

Right? So I hope you join me for that and I will put the links in the show notes. So thanks so much for listening to this five things I do differently now compared to before. That’s Extractions, Air Abrasion, Wedge Guard, Onlays and Vertical Preparations. Any other suggestions for episodes, please do hit me up in the comments or on the productive app or on our special Telegram group. I love to hear from you and thanks for watching all the way to the end.

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In the exciting continuation of the previous episode, Dr. Pasquale Venuti joins Jaz to offer his unique perspective on biomimetic and restorative dentistry. Dr. Venuti encourages critical thinking to improve patient outcomes and discusses a range of clinical scenarios of which he has heaps of experience. In this thought-provoking episode, they delve into topics such as outcome-based reasoning, the controversial use of posts, and the role of ribbond under your composite restorations.

Dr. Venuti fearlessly challenges the status quo by questioning self-claimed biomimetic dental practices and urging dentists to embrace critical thinking in pursuit of improved patient outcomes.

https://youtu.be/iGL_KXU_NbY Watch PDP153 on Youtube Protrusive Dental Pearl: Mouth props are super helpful for long appointments! They serve a crucial purpose in allowing the depressor muscles to relax. By preventing muscle fatigue during extended treatments, these props contribute to patient comfort and overall treatment success. Dr. Jaz shares his approach to communicating the use of mouth props to patients, employing relatable examples to ensure their understanding and cooperation.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

2:00: The benefits and communication of mouth props4:18: Controversy surrounding posts in restorations6:32: ‘No post, no crown’19:20: The use of ribbond in modern dentistry.26:20 Process-based reasoning vs Outcome-based reasoning28:41: Jaz’s “hypocrisy” regarding rubber dam usage31:48: Patient population and its impact on treatment approaches

Access premium clinical videos by Jaz and gain CPD for Podcast episodes via the Protrusive.app

If you enjoyed this episode, check the part 1 of this episode: The ‘Anti-Biomimetic Dentist’ – Restorative Lessons from Pasquale Venuti Part 1

Click below for full episode transcript: Jaz's Introduction: No post crowns, no more crowns, because obviously now we're heading in the direction that everything should be an onlay. Obviously, it's a sin to do a full coverage crown. Jaz’s Introduction:And post are out of the equation. And if you have to use a post, you’re going to use a fiber post, not a cast post. Well, this sounds very familiar, right?

This sounds like the way that we’ve been heading, but Pasquale Venuti offers some different and alternative points of view that I think are very much worth listening. So I left you in a cliffhanger last time with that episode, The Anti Biomimetic Dentist Part One with Dr. Pasquale Venuti. Welcome back. This is part two where he will answer that question about the whole no post, no crown philosophy, what he makes of it.

But he also talks about something called PROCESS based reasoning versus OUTCOME based reasoning. So I guess the bone that Pasquale Venuti has to pick with the biomimetic group, the quote unquote “beef” he has with so-called biomimetic group, is that everything they’re saying, all the little micro steps in achieving the highest bond strength, which is very admirable, right?

But everything they’re doing is process based, right? It’s a little process. Tweak this, tweak that, and let’s see if who can improve our immediate results, our immediate bond strengths or aesthetics or whatever it might be. But you see, Pasquale Venuti argues that this process based reasoning is probably not what we need.

We want OUTCOME based reasoning, right? Because what Pasquale Venuti looks for is, okay, by doing these little micro steps, these extra steps, that which might be time consuming and might cost you more money. Are they actually going to yield a long-term result? i.e are they actually going to add years to the restoration and we just don’t have that data. Now, I talk about this a bit more towards the end of the episode, but Pasquale will do this all justice.

Now, the Protrusive Dental Pearl I have for you before we join the main episode is something that I’ve talked about before. It’s about using a mouth prop, like I’m a big fan of using rubber dam. And again, I’ll reference to why this is relevant at the end.

So make sure you stick to the end of the episode to hear why I am a hypocrite and I’m happy to say that, right? So I’m a hypocrite because I use rubber dam, but I’ll come to that to the end. Now because I use rubber dam, I use a mouth prop, right? So if my patient’s going to be having their mouth open for 45 minutes or an hour plus, I’ll use a mouth prop, which is like when there’s little plastic wedges that you put on one side, and it helps to keep their mouth open.

Now, what I say to my patients is the difference between holding your elbow out at 90 degrees, okay? And after a while your arm gets tired, right? And so it’s much better when you get to lean your elbow against a table.

Now your muscles can relax. It’s the same way with the muscles of mastication and the lateral pterygoids in particular. The mouth opening muscle, the depressor, right? These muscles can get tired by stretching open. Like have you observed some patients, they keep closing their mouth, right? They struggle to keep their mouth open, they keep wanting to close, their muscles get tired, they get fatigued.

So by giving a mouth prop, you’re essentially giving that elbow a table to lean against. Now the problem is, because I’ve talked about the use of a mouth prop before, but the angle I’m coming from now is if you ask the patient, hey, would you like to use a mouth prop? It’ll help to keep your mouth open. Then the patient’s going to say, no, no, it’s okay.

No, no, it’s, it’s, okay, fine. Just do what you do. You do what you need to do. I don’t want to be, I don’t want to cause any trouble. Right. You shouldn’t say that because you see patients don’t say yes to it, not because they’re afraid of it, because it’s the default answer, right? It’s a default answer that patients would give.

So instead, here’s what I say to my patients, ‘Mrs. Smith, I’m going to put this mouth prop in so that instead of keeping your mouth open the whole time, your jaw can relax against this little plastic wedge. It’ll stop those poor muscles from getting tired. I’m just going to put this in before I put the rubber sheets on.’

That’s it. No one ever says no. Okay? And whilst my patients might not realize it, they’re definitely better off because a number of patients who have an achy jaw at the end is way less. And this just makes sense, right? It’s a good thing to do for your long procedure. So anytime you’re using rubber dam, my nurse knows that I need to use my mouth prop.

And it’s better you propose to your patient in that way rather than asking your patient, hey, should we use a mouth prop? They’d be, no, no, no, it’s fine. So A, use a mouth prop and B, present it in a clever way. Now I’ve got lots of reflections littered throughout this podcast, and I’ll also catch you in the outro.

So then, and the next thing talk about Pasquale is the whole concept of a no post, no crown. So this concept of we want to avoid placing post as much as possible and we want to avoid doing crowns and instead do onlays to maintain the gingival third of tooth structure which is responsible for the strength of the tooth.

Now, my own personal views on post is that I haven’t placed a post for like maybe two years now because for me, if I have enough ferrule, then I think almost I don’t need a post that I can just rely on my composite and the crown will be engaged in a ferrule. If I don’t have any ferrule, then I’m thinking, why are we even using a post here?

So, just before we continue the interview, guys, I just wanted to talk about the ferrule if you’re a young dentist or a student and you’re listening to this and you don’t know what a ferrule is, it’s super important. Imagine you have a central incisor and it’s fractured at the gingival level. It’s like the worst kind of emergency you can deal with, right?

And there’s very little tooth structure. Now imagine you stick a post inside and you build up a core. Your crown is completely on core material. Think of the bending and the stress at that adhesive interface, right? This is not ideal. Now imagine now just to make it easier, we’re not going to talk about crown lengthening and that kind of stuff.

Just imagine now that when this tooth broke, instead of breaking at flush to the gingival level, it broke two millimeters. Supra gingival above the gum. Two millimeters supra gingival. Now, when you build up your core and now you prepare this tooth for a crown, for example, okay, central incisor, we’re talking here now instead of your crown being entirely on the core material and all the stress going through the core, it’s now gripping that precious two millimeters of tooth structure.

That precious two millimeter rim all the way around the tooth is the ferrule and inside the crown the most gingival few millimeters of it, that’s the ferrule effect being gained by the crown. So this is incredibly important for the longevity and success of your restorations.

If a tooth doesn’t have a ferrule, its predictability decreases massively. So for me that tooth is for the bin or needs. Some crown lengthening or something like that. Or even if I can’t get that ferrule from a vertical preparation for example, we can gives you a little bit more ferrule to play with.

Main Episode:For me that tooth is unrestorable. So I’d love to hear your views on this mantra of no post, no crown, and find out how much you in your daily dentistry are using post, at the moment

[Pasquale]So first, I don’t like slogan, that’s why I don’t like the slogan. No post, no crown. So it’s like a marketer.

We want to sell something with the slogan. So it’s not easy to separate things. It’s not easy to find a solution for everything. I mean, nowadays, of course, also thanks to the additive procedure. We don’t need to use so many post as before. I barely remember a molar in the last six months I used the post, for example.

[Jaz]Mm-hmm.

[Pasquale]So in the post region is very rarely that I use a post. Unless the tooth is completely broken or the patient is a bruxist patient, but in anterior area, the game is different. It’s different for many reasons. When somebody tells me that he doesn’t use post in anterior area, or, he doesn’t use cast post.

Honestly, I have a clear idea of who is talking with me. So he has no idea about dentistry because when you do a lot of anterior teeth, you realize that some teeth are different. I will give you an example, but I will show you later in the presentation. You have a broken teeth at the level of the gum, okay?

So you have to rebuild in composite for doing an abutment five millimeter of incisors, okay? An abutment of five millimeter. So sometimes especially lower incisors or upper lateral incisors are very thin you end up with an abutment of two millimeter in thickness so imagine, a massive composite, five millimeter high and two millimeter thick.

[Jaz]Almost a cantilevering of off the tooth. Almost like you could snap it. Yeah.

[Pasquale]Composite in two millimeter is easily to bend so it can resist. So the only way for some teeth to just use a cast post, because the only post that you can manage a 1.5 millimeter of thickness is just metal. You have no other aoption.

Another problem sometimes, especially in anterior area, the root is in not on the same part of the crown. So if you place a post, a prefabricated post, you will place a along the root. So you will end up with the post, you will destroy with the preparation.

[Jaz]So guys, Pasquale Venuti made a really good point here, right? If you follow the root of the tooth and like when you stick a post into a root and you’ve done enough post, you’ll know what I mean.

You’ve stick a fiber post in, for example, and you observe that the direction of the post is going off to one direction. Let’s say it’s going off more to the labial, right? Because if you imagine putting in the root and it coming straight out of the root, well the crown of a tooth doesn’t come out straight from the root.

It actually angles right? And because that angle, that offset, what you find is that your post is too much to one side. So when you now build up the core and you start preparing the tooth, you’ll notice actually you’re shaving away the post crown. The post crown itself is too far to one side, and we can get around this issue with a cast post .

[Pasquale]So sometimes you have to correct the position, so you have to customize the post. The only object use a cast post. So there are, even nowadays, of course, there are rare cases, here I use no more than 10 cast post. But there are cases that you have no other option. Unless you decide to extract the tooth. Of course this is an option, but remember this when you have no ferrule, okay, post because you will create a resistance form inside the root. Of course, you can risk as last resort, the crack of the root at some point, but it’s better than the extraction of the tooth. In my experience, I did till now almost 250 cast post.

Teeth completely broken at the level of the gum. In these 20 years of practice, I have zero root fracture at just one the bonding that I will show you later in the presentation.

[Jaz]So these are cases Pasquale with no ferrule? Yeah. I mean there’s no external ferrule.

[Pasquale]Zero. Zero.

[Jaz]Okay. So this is where I have personally, I have shown from my worldview and my experiences, I tend to shy away and I tend to maybe send to the implantologist at that point.

But I learned from you and I say, okay, I respect your experience and to try these post, it looks like you’ve had a fairly good success rate with that.

[Pasquale]So if you do a current cast post, okay, forget to extract the tooth in less than 10 years. So it’s very, very longevous even if you are completely down the gum. Of course, with the vertical prep you are able to recover a little bit of ferrule, just a little bit, but not so much. But anyway, the cast post is so stiff that it will avoid any bending of the residual dental structure. It will be quite longevous for some time.

[Jaz]It’s a very controversial issue in dentistry, the use of post and stuff. But, I respect that when you taught me in Sydney was the benefits of a cast post compared to a fiber post which hopefully we can just discuss a little bit now as well, where do you lie on this usage of fiber post and obviously you’ve talked about the benefits of a cast post in terms of customization and stiffness. What is the big downfall of using fiber cast post?

[Pasquale]Cast post has become quite disused in the last, so I know cast post has never been so popular because learning doing cast post is very steep curve. It’s not easy. So you need the skills from the dentist and skill from the technician. It’s not an easy approach.

And then you need to cycle the appointment. The patient has to come back again just for the post. So you mean in a fast workflow, it’s not easy to be inside. That’s why during the years thanks to this prefabricated post, cast post has become less popular. But there are no other option in many, many clinical cases.

So I told you there are 10 cases in my dental practice every year that I need a cast post, there is no other option, the only option to extract the tooth because either I place another cast post or a fiber cast post or a dentatus post. I will collect ferrule in one, two years. So, I mean, many Implantologists prefer to extract the tooth and place an implant.

Let’s say I’m not against implants, but there are some cases, some young patients or some patients that are very debilitated, some eight years old patients with a lot of health problems that maybe they will be better served by cast post okay? For the last five, six years of their life.

[Jaz]What about those cases where you do have two millimeters of ferrule, and in those cases, would you just build up with composite and not use a post? Or would you be open to using a fiber post for convenience in those cases? That have a root canal treatment, obviously.

[Pasquale]It depends on the occlusal and the biomechanical demand of the patients. So if you have an anterior area, for example, you have a lot of tensional stresses.

If you’re in cast post in anterior area, you are in compressive area. So when you go back, the post, honestly, especially because a molar is very big. When you build up a molar, the composite is five, six millimeter in thickness. So it’s quite rigid when you move forward, especially in thin incisors.

Composite is very thin, so it’s mechanical, not insufficient for the work is deputy to do. That’s why more I go forward the more is probable that I use a sample post. I do not use fiber post for one simple reason. I will show you later why I don’t use fiber post from the biomechanical point of view, but I do not use fiber post because I love the principle plan for failure.

When use fiber post, you will not retreat the tooth anymore. In case you need treatments, you are f***ed up 90% of the times. Because I did, cause I placed almost 300 fiber post, so I had to retreat, but I had to extract the tooth most of the time.

[Jaz]It’s interesting because when we are taught post and crowns in dental school, the angle that we are coming from is that if you do a cast post, when a failure happens, a tooth will fail and you have to do extraction.

But, what they say is that when you do a fiber post, then the post will fail, and then maybe you have a second chance of the tooth. But obviously from experience, you’ve shown that you are buggered. What is the main complication you face in retreating a failed fiber post? Because I’ll be honest with you, I am not experienced enough to have dealt with the failures of fiber post in quantity. So I would very much like to learn that from you.

[Pasquale]People concentrate on the fiber post. The problem is not the fiber post because then I’ve heard post detach. The problem is the cement that is beyond the tip of the fiber post. There is cement, so sometimes you have one, two millimeter of recent cement at the bottom, and you cannot retreat the tooth anymore.

That’s why when I use dentatus post, I ensure myself that the tip of the post will reach the gutta-percha I will never left any cement beyond the tip of the post, the tip of the post has to screw just a bit inside gutta-percha because if I have to remove the post just rotating, I will crack all the resin cement and then I will have free way to the gutta-percha-

[Jaz]So you’re coming from the angle of retreating the actual root canal filling as well, basically, right?

[Pasquale]I come from the humble that from the field of humbleness, I learn that we are not God. Sometimes we do wrong things and endodontically speaking. Sometimes the nature is not so friendly. So that’s why I know that sometimes have to retreat the tooth. I have the possibility and fiber post because not giving me any biomechanical advantage, because they make the treatments quite untreatable.

I will not use anymore in my practice. That’s it. With dentatus post I can reach the gutta-percha every time. I am sure to be in gutta-percha. I am sure.

[Jaz]The common objection you’ll get from most dentists who haven’t been to any of your lectures and teachings is that the short metal post are going to put a lot of stress in the dentine and then you will get a crack.

I know, because I’ve been to your lecture about what is the advantage of it. But what would you say to these dentists who are concerned about the root fracturing in the short dentatus post, that finish in the coronal third of the root? Very often when I’ve seen you do them, am I right? Yes?

[Pasquale]So I never placed the dentatus post that is not beyond the point of inflection. You mean the point of inflection? The point of bending is the level of the bone. You have to be sure that the post is beyond is cervical to the level of the bone. Because if you place a post that is below the level of the body is completely useless here.

Because the tooth will bend at that point. So your pulse is to be below. So placing a longer post in my opinion, at zero benefit unless the crown is completely broken at the level of the gum. At that point, the post has to be as long as possible. That’s it.

[Jaz]Okay.

[Pasquale]But if the ground is quite conservative, need to go so much inside.

[Jaz]Okay, that’s good to share because again, like I said, there’s a lot of confusion about post, so it’s good to hear your guidelines. Guys, I’m just going to interject when I saw Pasquale in Sydney lecture, he mentioned one point, which he didn’t really elaborate on this podcast, but one of the functions of the dentatus there’s little gold color, like screw type post, right?

The reason he use it is to actually give his composite some stiffness, right? Especially for an incisor for example, if you are building up the core in composite, it can get very thin. So by adding this type of post in, which is metal, it gives it some stiffness. It’s prefabricated. You don’t have to send an impression and he just screws it.

Just a tiny bit into the gutta-perchar. The point he makes that the length of this post has to be more apical than the bone level has to be more apical than the bone level. Cause it’s at the bone level where the stresses are being concentrated. So if it’s coronal to the bone level, then it’s adding to the problem.

So if you are going to do something like this and make sure your post is long enough that it’s going beyond or more apical to the bone level. Fantastic. So, I think we’ve done a lot of coverage there on post crowns. Should we move on because I think we covered a little bit about fiber versus metal.

[Pasquale]Yeah, sure.

[Jaz]You’ve already talked about C factor already, so we can go to the last question, which is fibers and dentistry. Is that cool with you? Amazing. Okay. So we’ve covered a lot of ground there. That’s why we had to make into a multi-part episode, I think which is amazing. So thanks for covering so many and get sharing your views.

Lastly, can you tell us about this rise in the use of fibers in dentistry? What I mean is not fiber post. I mean, for those listening, these little fibers that you can place inside cavities before then you place composite on top is what I’ve seen a lot of my colleagues practice on social media and some proponents of biomimetic dentistry suggesting that there are many benefits in terms of stress reduction of using fibers. Have you got any experience of using these Pasquale, or any viewpoints on this?

[Pasquale]So during the years, we are going to substitute what has proven to be good, what we think is good. You can think wherever you like if it’s good, but you have to prove it’s good. What I learned on my shoulder that I will not embrace anything that has not a follow up of at least 10 years. So if somebody want to convince me about something, has to show me follow ups at least of 10 years.

So when we talk about fibers for reinforcing composite fillings, I don’t know, for reducing crack propagation. I mean, there are a lot of alleged function of these fibers. So I cannot find any follow up paper in dental literature. Maybe there is some follow up one, two years. Okay. But even digital dentistry feeling done with the finger lasts at least five years.

No, I think it’s not enough from the rational point of view, in my opinion, they are completely useless. And from the outcome point of view, they are not supported by any outcome. It’s just a trend now in dentistry because we love to do new things in every field. So, but the problem that I will not to complicate my procedures, for example, when we do dentistry, some people use chlorhexidine before placing the art, because you can inhibit.

The metalloprotein, as you know. I don’t know if this is true, it doesn’t true. It doesn’t matter. Can you prove me that this will move longer? The longevity of my restoration?

[Jaz]That’s exactly what I think.

[Pasquale]If you cannot me prove something, I will not add to my step. Those many steps make the procedure very tough for me, for my assistance for the patient because there is a tomorrow dentist.

Tomorrow assistance, and tomorrow patients. I want to stress myself and the people surrounding me with the useless procedure. One of the reason that I do not love so much additive procedure that they require multiple steps. And it’s easier to do some mistakes when you do multiple steps. When you have just to mix cement and plunk a ground, it’s idiot proof procedure.

Now when you start to increase the stuff you have to put inside the tooth, you start to mess up or you or your assistant. Anyway, I don’t see any point to use fibers. Because a lesion work very well when you have the right condition and composite work very well if you are in the right condition. So I don’t know how fibers can increase the performance of the filling. I don’t-

[Jaz]Yeah, so I was just going to say, I think you were coming to the same point was that if in 10 years time, or 15 years time, by knowing how things are, the papers come out and say actually those composites that had a fiber as part of their protocol, maybe done in some universities somewhere in hundreds versus those composites that didn’t have any fibers in similar cavity conditions, seemed to have a less rate of cohesive failure or something like this.

Maybe then, because I respect you as a clinician, I think maybe then you would say, yeah. Okay. There are some studies now, 10 years. It is significant in statistics that you might use it, but you know what’s going to happen. The problem with these studies is that, they will not control for their biomechanical status of these patients.

So this is where the flaws of the studies come in, in terms of getting homogenous, sorry population samples. But that’s in a whole another debate about evidence-based dentistry.

[Pasquale]I would not be, they will never produce any paper. How many randomized clinical trials have you seen in dentistry at 10 years?

[Jaz]Very few. Very few. Zero. There we are.

[Pasquale]But the same, for example, during this pandemic, Pfizer presented the randomized clinical trial for the approval of the vaccine just of two months. During these two months, they divide the patient in two group. One group received the vaccine and one group didn’t receive the vaccine.

So in both groups, the death failure was the same. So, I mean, the vaccine didn’t add any benefit. You can read the paper. So we don’t know what would happen in six months, one year. But anyway, the paper is just two months. So the only difference in the two groups where in the group with the placebo, they get more Covid than in the group with vaccine.

But that trade and hospitalization were the same. That is medicine. That is dentistry. So, we have very few serious clinical randomized clinical trials, and most of them are just for a few months. So even about onlay so I will show you during the presentation that we have no dental lesion supporting the so-called biomimetic dentistry, zero.

We have some papers with 10, 20, 30 year follow ups about crowns, but zero paper about flat onlays just some clinical cases, some case records. That’s it. So they’re basing new slogan, a new group just on nothing.

[Jaz]So guys, after this discussion with Pasquale, I started to look for some evidence, right? Because Pasquale says there’s no clinical evidence for any of this stuff working, particularly when it comes to Ribbond in particular as we’re discussing, right? So I reached out some really prominent figures in biomimetic dentistry and didn’t really get answers really, unfortunately. But then the legend, who is Taylor Paton, who’s our guest on our introductory episode to Biomimetic Dentistry, that was PDP135.

God bless your soul, Taylor. He gave me a lovely reply with some resources and references. What I love about Taylor though is that he actually said that, you know what, it’d be nice to have more clinical data, because when I clicked onto those links and the research that was presented that’s available out there, it was all on extracted teeth.

There’s a bench top studies, so what Pasquale says is very much true in a way, right? There’s so much process based reasoning, right? Oh, do this, improve that bond strength. But where is the outcome, compared to a standard Class II composite, for example, how much longer would a ribbond reinforce Class II composite really last we? Really need to know this before we take added time and added expense to do such procedures.

Let’s say tomorrow a study was done and it was like a 15 year follow-up, and what they found was that composites without the fiber lasted 11.5 years. And the composites with the fiber lasted 12 years, so half a month more, and it said that this was not statistically significant. I’m just making up a random scenario.

You probably wouldn’t want to use it with extra time and extra expense that you’re passing on to the patient. Does it really add significant benefit? However, if the outcome studies were very promising and it significantly extends the life expectancy of your restorations. Then of course we should all be using it routinely.

How important are these contemporary things like ribbond and stuff compared to getting the tooth clean and rough? What I mean by that and what I’m referencing to is a fantastic episode we did with Dr. David Gerdolle episode PDP077. This episode was called, I can’t Believe This Sticks Extreme Bonding Right?

Extreme Bonding Exposed and what David Gerdolle said was that as long as you get nice clean tooth structure, and you get a good etch pattern that these two are so, so crucial in bond strengths and longevity. So how much more do these extra steps, like using Chlorhexidine, using ribbond actually add? So this is the kind of data that we really want.

Now what I don’t want to sound like is I’m taking the side of Pasquale, like we’re friends and I respect him so much as a dentist and I’ve learned so much from him, but I don’t want to seem like I’m bashing biomimetic dentistry, and I’m totally bashing ribbond because that would make me a hypocrite. I’ll tell you why, right?

Remember I told you at the beginning about Rubber dam? I love using rubber dam. I’m a huge fan of it. I think it makes a big difference, like when you’re doing adhesive dentistry, right? And you’re not using rubber dam and you have a mirror and you know it’s that the mirror is steaming up. I always think like what’s happening to your bonding surface?

What’s happening to your etched enamel, right? Because I do make the effort, if I’m doing that, doing it that way, that I encourage the patients to breathe through their nose and if they’re an obligate mouth breather, I will definitely be using rubber dam like I used rubber dam for about 80% of my dentistry.

But guess what? There are no clinical trials supporting the use of rubber dam. So there we are. I’m hypocrite, right? I’m saying that I’m debating with you that perhaps ribbond isn’t all that because we don’t have the clinical long-term data. But here I am using rubber dam and I’m so religious about using rubber dam.

Now interestingly, there was recently an in situ study, right? What they did was they made like a splint with a wisdom tooth in it and they attached it onto a real patient, a real person, and they carried out the adhesive dentistry on an extracted tooth, but in the patient’s mouth with and without rubber dam.

And they found that categorically with rubber dam had better bond strength. So they kind of showed in an institute environment that it is beneficial. But why don’t we have a clinical study comparing patients having adhesive procedures with and without dam? Well, there are some ethical concerns and we might never actually get such studies.

Ultimately, I do think that biomimetic dentists, when they are doing what they do, the protocols that they follow, they’re so passionate about it and I really admire that about them. Right? And I think everything that they’re doing is with the best interest of the patient at heart. I really do think these clinicians are trying to get the best bond strengths and whether or not that actually translates to clinical success long term, we don’t know.

But we also don’t know that by rubber dam, right? So I’m saying great points, Pasquale about process-based reasoning and outcome-based reasoning. But I think biomimetic guys, I really admire that you are really trying to do something. You are doing the research behind it to the capacity that you can, and I’ve seen loads of biomimetic dentists, especially on social media, so passionate about what they do.

And that’s beautiful, right? It’s like when dentistry becomes an art, when you can really fall in love with the nuances of what you’re doing. That’s when dentistry I think becomes less like work and more like fun. So I think we can definitely take a leaf from their book. Well, I look forward to hosting the biomimetic group who will give their viewpoint as well.

And let’s listen to them. Let’s share. And I was going to, while you were saying that, I was thinking already, it’s the same with many aspects of dentistry, including occlusion. There is very little evidence in occlusion and stuff, so a lot of it is dogmas and a lot of it is marketing and that kind of stuff.

So we have to respect that. But that’s a whole another debate, and this is why I respect your way that you taught me. Look at the biomechanical demand of a patient and create an environment that is going to reduce the biomechanical failure and keep everything shallow in that patient compared to someone else who you can do anything in that patient and you’ll succeed.

[Pasquale]Yeah, that’s it. So if you choose the right patient, you will succeed. The problem is, when you work in Manhattan, okay, you work in a posh office, okay? You receive some kinds of patients, some women, there are the wives of some oligarchs, you receive patients that do some work, some desk.

When you work in a village, you work with patient. They are mainly truck drivers. There are farmers. Most of those patients has very low income. Some many women live with husbands that are alcoholics. Many women have a lot of children with some down syndrome or some autism. So they have extremely low income for living.

They’re not living in Manhattan with a lot of girls to help them. So the profile of this patient is completely different. They cannot take care too much of their teeth from the oral hygiene point of view. They develop bruxism very easily because they live in very stressful way. So there isn’t even another problem.

It’s a genetic problem. Where are the people that go to Manhattan. That go to Manhattan the people that are the most beautiful and most successful people. So people there an advantage from the genetical point of view, all the people there, the best woman of the village will go to the city.

Over the years it always happened because a rich man will come from the city and will pick up the best women of the village, so who will stay in the village? Who will stay in the periphery? So the poorest people, the people with a genetic array that tend to be poorer. It’s not poorer, it’s just an average poorer.

So in the village there is also mostly inbreeding between people. So over the years there is a lot of inbreeding because we live it isolated for many years, for centuries in the cities, there is a lot of crossing over. Okay. From different races. So that’s why the genetic in some offices is different from the genetic in other offices.

It’s not just a problem of environment. It’s a multi-level problems. And people do not consider all these kind of things.

[Jaz]You’re right, this is the first time it’s ever been discussed in this podcast and I was really waiting for you to discuss these high level philosophy because I remember just how you talk about dogmas and you love reading your books and the philosophies.

And I see your post on tomorrow tooth are very much a rich and historical events and how you analyze different data. So, we love that. I love that. I love to hear these perspectives. And I thank you for sharing that so much.

[Pasquale]Because you think that if you go in New Delhi, in the most posh office of New Delhi, you have the same genetic pattern of patient of the village in Rajasthan somewhere on the mountains.

[Jaz]Very well said, very well said. Very well said, Pasquale. I’m so, so thankful for your time. Thankful for all that you do.

[Pasquale]All my pleasure.

[Jaz]And then posting your cases, because I learned so much from them over the years. You’ve taught me so much, so much of my daily dentistry has been molded by you and your principles, which I have tested and I’m finding success from.

So thank you for improving me as a dentist and thank you for inspiring a community and I look forward to sharing with all the Protruserati this episode. Thank you so much and have a fantastic weekend.

[Pasquale]Thank you.

Jaz’s Outro:Well, there we have it guys. The end of this two part controversial series, like if you enjoyed this and you want to see Pasquale Venuti live, then he will be lecturing in Bucharest.

I’m going to put the details in the show notes so you can check that out. Do me a favor. If you like my podcast and you think that thought provoking and they help your clinical dentistry, or they make you feel more passionate about our profession, then share it with a colleague. I’d really appreciate that.

Oh, and don’t forget, if you’re Protrusive Premium on the app, either on the web app protrusive.app, or on iOS or Android, you can claim CPD for this and get access to loads of clinical videos. I’m constantly updating every month. Thanks again for listening all the way to the end. I’ll catch you in the next episode.

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Dr. Venuti fearlessly challenges the status quo by questioning self-claimed biomimetic dental practices and urging dentists to embrace critical thinking in pursuit of improved patient outcomes.

Protrusive Dental Pearl: Mouth props are super helpful for long appointments! They serve a crucial purpose in allowing the mandible's depressor muscles to relax. By preventing muscle fatigue during extended treatments, these props contribute to patient comfort and overall treatment success. Dr. Jaz shares his approach to communicating the use of mouth props to patients, employing relatable examples to ensure their understanding and cooperation.

Highlights of this episode:

0:00 Introduction

2:00: The benefits and communication of mouth props

4:18: Controversy surrounding posts in restorations

6:32: ‘No post, no crown’

19:20: The use of ribbond in modern dentistry.

26:20 Process-based reasoning vs Outcome-based reasoning

28:41: Jaz's "hypocrisy" regarding rubber dam usage

31:48: Patient population and its impact on treatment approaches

If you enjoyed this episode, check the part 1 of this episode: The 'Anti-Biomimetic Dentist' - Restorative Lessons from Pasquale Venuti Part 1

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Dental Audio Notes (DAN) is a service designed to revolutionise record-keeping in the dental industry. DAN offers secure audio recording and transcription of patient interactions, allowing dentists to master record-keeping effortlessly.

https://youtu.be/dRlvlGUyQQQ Watch IC039 on Youtube Here’s what makes DAN an invaluable tool for dentists:

Accurate documentation – DAN captures the entirety of the conversation. Dentists can later annotate the recordings, providing additional context and making the documentation even more robust
Time efficiency – writing notes can be burdensome, especially when dentists have a high patient volume. With DAN’s transcription feature, dentists can save valuable time by automatically generating accurate and comprehensive clinical notes
Security – DAN takes care of storage, security, and privacy. Dentists simply need to press the record button, and DAN handles the rest, maintaining the recordings in a secure and confidential manner
Easy access and sharing – With DAN, dentists have the option to refer back to recorded consultations whenever needed. This feature enhances communication and aids in treatment planning. Additionally, dentists can choose to share the recordings with patients, fostering transparency and patient engagement

For those interested in DAN, early registration before September 1st 2023 offers the opportunity to take advantage of the SUMMER2023 pricing. This includes a subscription of £30 per month for 30 hours of recording, with additional hours available at an affordable rate of £1 per hour. DAN offers a free trial period, allowing dentists to record up to 6 hours for free, providing ample opportunity to explore the features and evaluate the service’s suitability.

Dental Audio Notes Website

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:

03:37 An Introduction to Ala Rozwadowska and Adam Marsh10:34 The benefits of audio recording consultations15:12 When to use dental audio notes23:12 Elevating your communication skills27:53 Gaining Consent31:47 Dento-legal feedback34:06 What will DAN be able to do in the future?38:30 Free trial and prices42:43 What Ala and Adam hope for users of DAN44:13 Dental coaches and mentors47:22 Microphones

If you enjoyed this, you will also love Consent Is Like An Onion – Are You Consenting Your Patients Correctly?

Click below for full episode transcript: Jaz's Introduction: As dental professionals, I'm talking dentist, therapists, hygienists, everyone. What's important to us when it comes to our dental records? What's important to you? Jaz’s Introduction:Now, some of you might say that it’s important, that’s really contemporaneous and it’s good legal defense in case anything goes wrong, fine, that’s important.

But you know what’s really important to me is HOW MUCH TIME I would spend at the end of a working day and I’m knocked, I’m tired, and I’m having to just go over my notes and make sure that everything is correct and proper, and this can take a real long time that I know associates and colleagues who spend, gosh, about 90 minutes after day of work, just going through their notes, make sure they haven’t missed anything, make sure they wrote about all the risks that they discussed with their patient.

Make sure they wrote out the protocols properly. Now this is extremely draining. This is extremely laborious, and these are times that we should be spending with our loved ones, not on a laptop or a computer, writing up our notes. Okay, so this is the sad reality of modern dentistry, right? Are you affected by this?

Okay. So I wanted a system whereby I have to type as little as possible and do as little as possible. So I can make time for things are important in life. This is of course why lots of features and apps and programs have come into fruition over the last couple of years to help make our dental notes more efficient.

I’m sure you’re familiar with some of these. Now, let me tell you one thing when it comes to procedural notes. Let’s say you’re doing a root canal extraction, right? Most of the stuff that you do follows a protocol like the way I bond composite is pretty much the same every single time. I will always air abrade.

I will always use the same bond. I’ll always rub it in for an X number of seconds. Do you see what I mean? So therefore, this is where templates are really useful, because you’re only doing minor tweaks here and there. It’s very simple to add your template, just tweak it. But what you can’t really template is the all important initial conversation and the discussion at the end and the consent process.

Because consent is individual to each person. So even if you use all these fancy softwares, you still need to put your fingers to a keyboard and start typing. Until now, because for the last few months I’ve been using Dental Audio Notes and I’ve just been so, so happy because the biggest problem we had is the amount of TMD patients I see.

And they have a story and I want to capture that story, but my poor nurse Zoe can’t keep up with the typing, right? So when I learned about Dental Audio Notes and the ability to record and transcribe everything, it just blew my mind. Now I’m talking to the founders, Ala and Adam today. So a dentist and an engineer coming together to create dental audio notes, which makes us so wholesome and so good.

But their vision was to make notes really high quality so you’re not stressing and worrying. The whole time and to save you time. So this is important, but what I wanted was a transcription. And so I’ve been working with Adam to actually get the transcription even better, and he’s been so responsive, so I wanted to just showcase what they’ve made right.

Dental Audio Notes does exactly what it says on the tin. It allows you to record your conversations with your patients that all important initial conversation, the consent process, and the discussions afterwards. Can you imagine the possibilities of this? Can you imagine how much time this could free up for you as a clinician so you could spend more time with your loved ones and not worrying that you didn’t capture something?

Now, there are so many other uses and considerations and maybe concerns about recording audio for your notes, right? There are some concerning bits, and we discussed that in this interference cast. And so with that, hello Protruserati. I’m Jaz Gulati, and welcome to this Interference Cast, this non-clinical interruption.

We’re talking about notes, how to take better notes, and I’m convinced that audio is the future, not video, because that’d be clunky. That would be not good. Audio just makes a lot of sense and you’ll see why from our conversation with Ala and Adam. So over to the main podcast and I’ll catch you in the outro.

Main Episode:Ala and Adam, welcome to the Protrusive Dental Podcast. How are you guys?

[Ala]We’re very well, very happy to be here Jaz. Thank you so much for having us on. It feels like a huge honor to be actually saying those words to you.

[Adam]I’m very excited. Thank you.

[Jaz]Thank you so much, guys. And so, we’ll do a little bit in introduction, right? So, Ala you are the dentist and Adam, you are the tech guy. And then you guys joined for forces in life. And now in this sort of adventure, this amazing thing that you are going to talk with the most episode will be about this. Tell us a little about yourselves, how you met, and a little about just generally what dentists should know about you.

[Ala]Okay, so we met at uni. Adam was very cool. He had long blonde dreads. I thought he was the coolest guy I’d ever seen. And tried to set him up with my friend because I thought he was so cool that he’d never want to go out with a geek like me. But, actually turns out he’s a geek too, just in secret.

And yeah, so that’s how we met. It was a long time ago. It was about 16 years ago now. So we’ve been on a bit of a life adventure. We’ve got two little ones and now a company together as well. And we are really enjoying the ride. It’s a ride and it’s fun. There’s a bit of hope in it. Yeah, a bit of hope for good life.

Working together to create something good together that actually helps people and achieve something, which I think it’s an idea that’s as old as the hills, so there’s nothing new in it.

[Jaz]But someone’s got to do it. Like, it’s a bit like everyone had the idea for Uber, right? Everyone had the idea for Uber.

Everyone did, right? Everyone had the idea for like Uber eat. So it is one thing, imagining things, but someone’s got to execute. So, we’ll talk about dental audio notes DAN and whatnot, but just a little bit more about the origin story, like how did the conversation actually begin? I mean, I think Ala when we spoke before it was an experience that you hadn’t practiced and then you thought, okay, we’ve got to do something. How can we improve the record taking, which is a big pain area for dentists. Can you tell us more about that?

[Ala]Yeah, so there are a couple of things that happened over the years. One of the main challenges was I was coming home late and Adam was like, why are you, what are you doing? Why are you still at work?

I’m like, oh, I’m just writing up my notes from the day. Like I’m just filling them in just making sure they’re all how I want ’em to be, and I want ’em to be good, you know? And the GDC says as much detail as possible, and that’s kind of what I was aiming for. And Adam is a problem solver.

So he kind of said, do you know what? I like, surely this can be fixed. And he’s got a background in software and do you want to talk about that a bit? I’ve dropped you in it. I’ve said I wouldn’t do that. So Adam, yeah, Adam’s got a bit of a background in that and was just like, I’m sure this can be fixed.

And we looked at it a couple of years ago for the first time, didn’t we? Did like a low tech version and then cloud came along and Amazon Web Services came along and everything started getting good enough that we could actually do that together. And I’m like, do you know what? Let’s just fix it. But Adam is a fixer.

There are so many problems in our lives that he has fixed. It’s one of the reasons we have a big rock in our garden. But that’s another story.

[Jaz]Adam, what’s your day job like? What do you actually do day-to-day?

[Adam]Well, day-to-day now I’m doing DAN. We’ve been-

[Jaz]Oh wow. Okay. Brilliant.

[Adam]Building DAN. And now we’re bringing it to market. Yeah. Before DAN, so I trained as an engineer. And before DAN, I was managing industrial software products. So, industrial process control, energy efficiency, sustainability. Working for global clients. And then the opportunity came up in our lives to look at the record keeping or the seed of the idea for DAN properly and dedicate ourselves to it. So when that opportunity came, we just dove in and focused on developing DAN.

[Ala]It’s just like you say Jaz. It was that moment where you were like, this is an idea, but hang on, we’ve got the skills. We’ve got the opportunity, we’ve got the time in our lives to do that. That sounds like a fun project. Gimme the ball. Let’s grab that with both hands and let’s just do it and let’s see what happens. And yeah, it’s been really good so far. We’re excited for the next stage.

[Jaz]Excellent. And we’re going to delve right into this. And what just reminds me what this conversation reminds me of so far is when you look at Steve Jobs and Bill Gates and you think, why did Steve Jobs and Bill Gates do what they did?

And if you look at the commonalities, right, they’re both, I think they were both born in 1955. And then that’s relevant because when the computers were becoming a bit more accessible, they were at that right age, at the right time, that they were able to capitalize on it. And so now, the reason I draw that comparison away is because you are not only just an actual marriage, you’re actually in a marriage, but like the marriage of dentistry and tech and IT is a wonderful thing.

[Ala]Yeah.

[Jaz]We’re seeing digital dentistry. And so what you two represent is that in action. And that led to the creation of DAN, Dental Audio Notes. And so in terms of my experience, but before we delve into who is the ideal person for it? When I came across DAN from our conversations, I was like, okay, this sounds brilliant.

But the reason that I perhaps took you by surprise, Adam, is the reason that excited me the most about this was the transcript, not so much the actual audio. I was excited by the transcript because I thought if I can just record the conversation, I don’t have to actually write any notes because it’s all there what we did.

And just to take a another step back basically, I actually started exploring different ways to make my notes more efficient. And I don’t know if you’ve come across Adam, perhaps, or maybe Ala as well, dragon speak medical, that kind of stuff. So, I got some colleagues and what they do and shout out to Ronnit who does this, he’s got a microphone and he’s basically dictating his notes and as he’s doing a root canal, instead of being a silent treatment, he’s actually saying medial buccal canal found 16 millimeters.

So as he’s saying it, it’s actually coming up on. So it’s like a contemporaneous as he’s doing it now, he has to be new line, new line. So it sounds a bit robotic, a little bit annoying, but that is one way. But there’s some challenges and some clunkiness with that. So when I came across, DAN, I’m using it at the moment for my TMD consultations because my TMD consultations, it’s very difficult for my nurse Zoe to write everything down the patient’s saying.

And these histories are very complex. There’s loads of facets to it, right? And so now that I’ve been using DAN, my nurse is so much more chill, right? She’s still making those sound. Again, I like the fact that you can, she can still jot things down as the audio’s being recorded, generating the transcript, but she’s just much more chilled that if she misses something, it’s okay, it’s being recorded and there’s going to be a transcript so that when I review it and I send my treatment plan report, I don’t miss any vital piece of information.

So that’s what really caught me. Now, back to you guys. So where do you think is when you started to create this and perhaps if it’s evolved now, who do you think is the ideal dentist to be using an audio recording software?

[Ala]So I think any dentist who is interested in mastering their dental records, so in just getting them right. Just getting them right every time. So part of DAN was born out of the frustration of what you wrote down versus what really happened. And anybody who wants to solve that tension and just not have that in their lives anymore, that’s what DAN is for. So it gives you genuinely complete, accurate and contemporaneous records without having to sit there till 11 o’clock at night making sure that they are complete.

[Adam]Yeah, if you look at the patient record holistically, then it’s full of all different technologies as you were saying. You’ve got x-rays, photographs, and of course written notes and models, and when it came to that, complete, accurate, contemporaneous of the conversation between dentist and clinician.

Then patient to clinician. It just made sense. The audio was the right technology for that because if you’re trying to write it up, it seems that dentists were trying to write up their conversation and you can’t, like, you just can’t achieve complete, accurate and contemporaneous like that.

It’s a trilemma, you can choose two. You’re either going to do it late at night and get everything. Or you’re going to miss stuff if you try and do it immediately and so audio just seems to as the technology, as you were saying, just sort of cover that challenge, and then that migration of technology.

I mean, we looked at this years and years ago, and that was just a case of using some software on your computer managing the files. And that was even before cloud was even a thing to really simplify that into a product. And that evolution now is, is there’s great technologies out there for transcribing audio into text.

And then obviously trying to pick out speakers and identification. And then you could start to lay some filters over that, like you were saying, picking out new words, sentences, things like that. And I mean, that technology landscape is really exciting at the moment. It’s really exciting to see where that’s going in the realm of clinical recordkeeping.

It’s probably a realm that the dentistry like dentists and professionals, I think should probably be influencing and driving. Rather than not necessarily coming from an outside space, because there’s a lot of considerations that clinicians have for their patients that a lot of people from a technology background, it’s just quite, it’s separate. You’re in different fields, you know?

[Ala]It’s actually, that’s been super fun because being able to get a product, so it’s actually works in clinic. And it actually works. It helps your flow of your conversation with your patient rather than getting in the way. So we’ve got the little thing where it can, the view can be on top.

It’s literally two clicks to do the consent and then start the process of recording. It’s the conversation that question that you give to your patient at the beginning confirms the consent and you only keep the record if it’s been consented to. All of those come little bits.

We could just get that right. There is a bit of a joy in that. There’s so many similarities, like you were saying, you had digital dentistry, really bringing joy to your workflow generally. Like anyone who has a cerec machine or uses a facial scanner or uses one of the intraoral scanners or I know that the girls in our clinic really enjoying using their 3D printer and all that kind of stuff at the moment, and anyone who’s got the joy of that, it’s the joy of mastery, isn’t it?

It’s like that’s the fun of dentistry. It’s like getting each bit better and better and better. That’s what I felt clinical record keeping was just missing, that there was no joy. Now, every time when I have DAN on, I feel like I’m literally doing the best that is available in record keeping.

And that’s just a pleasure. And it means I know my notes not perfect, but they’re really good each time. And instead, I can concentrate on that conversation with my patient. I can make sure that I am doing the consent. I can make sure that I am telling them all the bits and pieces that I want to tell them.

And we’ve got all the other stuff in the background, just like normals. So my nurse is still writing in the background. I still have a summary because you need the written record for that quick view so you know what’s happening next time you come in. But if ever I need it, DAN is just there for me in the background and there’s no substitute for reliving that conversation. There’s no substitute for that.

[Jaz]I mean, with having to ever go through a conversation, you can just do the whole Control F, Command F and just find the key words as if you ever needed to. Right? You can just search within, imagine you are really running late and you don’t have even time to do a summary.

I’m not saying that’s the best way to go, but you’ve got this huge transcript there. And you can then extrapolate from it and everything is essentially recorded there. Now I’m going to play devil’s advocate with you guys in a moment because a lot of dentists will be thinking this and it’s important to discuss this basically, but before we even get there, I just want to say in terms of where you designed the product and the way I’m using it.

So I don’t think, and please tell me if you agree with me, if I’m doing a difficult extraction, obviously the most important bits of that is the initial conversation and the end conversation. The actual bits of treatment we don’t record because it’ll be pointless. The audios being recorded for no reason.

No one needs to hear the sectioning of a tooth or whatever. Right? So it’s the conversation, it’s the consent and it’s the proper aftercare, the post-operative instructions that are recorded. And I’m just clarifying for dentists that might be thinking, how does this work? Because many, many years ago I saw in a Facebook group, dentist Facebook group, people were talking about video recording consultations because the state of the current law has become so strict and may perhaps we should be video recording, but obviously that’s clunky huge file sizes.

Audio just makes sense because the conversations is what you said or didn’t say that matters. Right. So that makes complete sense to me. And you guys agree that you don’t need to do anything else. Like you didn’t design it so that you couldn’t dictate what you’re doing as you’re doing it so that you don’t have to write any notes. That wasn’t the intention. It was to get the conversations and the consent. Am I right in that?

[Ala]That’s what we designed it for, but we’ve been speaking to quite a few different people over the years and one of the ladies we spoke to Anne Budenberg, she’s worked with MPS and John Tier and Kevin Lewis, who have all been kind of really helpful to us. They’ve been really, really kind with their inputs, but she-

[Jaz]Just for international listeners, MPS like just tell basic indemnity dental legal people.

[Ala]They’re global. Yeah, they’re global, so yeah, so they were giving us different, so it’s just like any- so you can use it in so many different ways. And initially we designed it with my use case, which was recording my consultations.

It’s really great having Adam just here because as those conversations happen with people and they can be like, oh, can you use it like this? You’ll be like, okay, I can put that functionality and we can just do that. And it’s lovely not having a huge international team of people coding that we have to try and get that over and look, we can literally have that conversation having going to be like, look, I would knock this up. What’d you think about this?

And then let’s get that right and let’s get put that on board. So it’s been lovely being able to listen to people who are on board and getting that thing. So for example, when we first spoke to you, you were really frothing about the transcriptions. We were like, oh, cool, let’s solve this. Then let’s do this. Let’s get transcription. And that’s something that’s going to be you’re enjoying working on that at the moment, aren’t you?

[Adam]Yeah. The core technology is audio. And it’s how people are going to use that and like, yeah, you were saying it’s really a great example earlier. Someone’s actually writing their notes as you go. I mean-

[Ala]DAN can do that.

[Adam]DAN can do that. Because you’ve got the audio and it’s transcribing it. You obviously have that situation. Now, if there might be, you’re recording hours, well, not hours, a longer period of time with fewer words, but yes, but the key certainly for all the beginning was that exchange of information between patient and clinician and clinician and patient.

It’s both ways. Obviously, you as the clinician are trying to make sure that you’ve covered all the things and given all the information. But also you are responding to the information that you are receiving, and the patient might well clearly be giving some signals about some preference. And again, that’s really key. I think you’ve got both sides. It’s not just you, it’s the patient sharing their information as well.

[Ala]Yeah, so hopefully DAN continue.

[Jaz]Very very valid.

[Ala]All of those different ways of using it. And as you use it more and more, you’ll find the stories of where it was really helpful that you wouldn’t have thought it was, so you wouldn’t have even considered it at the beginning.

So, for example, if you have a patient where the consent is really challenging and you think, okay, I’m not entire, or the patient’s not really confident that they’re going to remember it. The patient’s not that confident that they’re going to be able to remember enough to tell their partner about when they go home.

Ideally, that partner would be there in that consultation. That’s not always possible. Ideally, the family will be there. Sometimes they live in Australia. There’s all of those different things where you’re like, do you know what? Shall we just record our conversation? I’ll say everything out and then I can just send that to you, and the relief that’s on that patient’s face.

All that stress of trying to remember or worrying that they might be getting a bit forgetful. All of that stress of being like, oh, how am I going to justify that cost to my partner when I go home? Because that conversation when you go home is just going to be, oh, how did your dental, dental appointment go? Going to cost me five grand?

Like it is literally that whereas, if you can show value to that person who’s at home with no extra work. You’re not having to do anything extra. You’re just having that conversation with your person like you normally would do, and then that person can take that home to them.

So often even that offer of sending it is actually enough, and that person just reduces their stress. They’re like, cool, okay. And then they go ahead and make their decisions just like they normally would, you know? So it’s not something that you have to offer to share. It’s a function that’s available and you can offer to share that if it’s helpful to that person.

The other side of it is if you have a difficult interaction, and suddenly you’ve got somebody who’s you’re coming across some barriers or that person isn’t happy. Okay. Do you know what? Instead of my nurse having to type up a million miles an hour and wondering if they’ve got it and wondering if they’ve got the tone that it was said quite right, let’s just record this conversation.

We’re going to, and the language you can use is great cause it’s really positive. So you can say, oh, let’s record this. We are going to have a really good exchange of information. This is a really important conversation. I’d really like to concentrate just on you and not worry about whether my nurse can keep up.

Although I’m very lucky. All my nurse are very fast typers. I have to say that cause they’ll be listening to this later. But, it’s that nice conversation that you can just be like, cool. Let’s give this the attention it deserves. Let’s give you the time and energy that you deserve.

Let’s concentrate just on us. Is it okay if I take an audio recording and it would just be part of your dental clinical record and then the power of that is that you can take that back. If that conversation doesn’t go as well as you hope it work, and you think, that’s okay. It’s not great, but it’s okay.

You can listen back to that. You can listen back to that with your principal or with your other dentist that you really respect and admire and want their feedback. It’s a very humbling experience because you often pick up things that you would’ve loved to have said differently or you’d have loved to have changed.

But man, coming back to that patient being genuinely interested in what they said and how they said it, and picking up all of that, and then using that in your response to them, that’s so powerful. So you can come from a position where a patient’s left like, it’s okay, but it’s not great. And then, the next email back, you get back from that patient is, do you know what?

I feel so heard. I feel so understood. I’m really glad that you’ve taken the time and the energy with me to talk that through. Let’s proceed, you can’t put a price on that. That’s the bit, and those are the stories that as you use it more and what you’re fighting more and more, that’s good.

[Jaz]It’s like fast tracking your communication skills development. Right. And that the last thing you mentioned is definitely, is that the second scenario, the challenging patient you mentioned? Absolutely. So when I start to explore the different uses of DAN, like I said at the moment I’m only using it for my TMD consultations.

And I don’t see many new patients at the moment cause I’m just so in inundated my regular flow of patients but I would like to use it for brand new patients consultations, because that’s a really important conversation. What are their wants? What are their goals? What are their desires? I didn’t appreciate that first scenario actually.

That patient who maybe an elderly patient who just needs to help or reminders when they go home. Or the patients who needs to speak to their communicator, to their spouse. Exactly what is the conversations that were had and to be able to send them with that audio. I didn’t actually appreciate that, so that’s good.

And the final thing I guess is if a dentist wanted to use it in that way, that as they’re placing the implant and they’re saying, I’m placing a Straumann implant, three millimeters, I’m now doing this. I’m grafting it in the patient’s s data or whatever. Right? And I’m now doing this type of flap, I’m using this suture and they don’t have to do any notes because it’s all transcribed.

That could be a future way of doing it. And then, with AI and stuff, it could tag what’s extra or what’s intro come up with heading this stuff. I’m sure we’re going to talk about that, Adam, I’m sure that’s going to get you very excited. But let’s play, let me challenge you guys or something, right?

One of the dentists listen to this and watching this maybe, they’re probably thinking one thing. They’re thinking, well, if it’s recorded and I forget to mention that their tooth could have fractured or it could have worn the sinus and I’m screwed because a lot of people’s templates, okay, they will have that written there.

But, if they didn’t actually say it and I know the answer. We all know the answer. We know what’s right here. Okay, but what would you say to that dentist who says that, well, that’s too much pressure on me. I now have to be the perfect communicator. What would you say to that?

[Ala]So it’s only recording what you choose to record. So just because you haven’t recorded it doesn’t mean it didn’t happen because that kind of conversation can happen with the dental nurse that could be happening at any other time when the appointment isn’t being recorded. So DAN is picking up what you did say and making sure that you get credit for that in your records.

It doesn’t mean that you didn’t say it, but what it does do is if you ever are in that thing where you think, okay, well I actually need to look back at my records and see if I am screwed. Do you know that relief when you know that it is recorded? Because it shows the effort and the energy that you put into that consultation, and that is something that your template will never give you credit for.

It will never give you credit for the fact that you did that in the words that that patient was able to understand that you did it in the amount of information that they were able to take on board on that day. And sometimes those patients are so anxious would saying all of that had been the right thing anyway.

So that’s what DAN does is it makes it really honest. It makes it really clear cut. It takes away all of that. But it’s in my template, but did I actually say it? So can I be confident in the way I came back to that person? Or you can even say, do you know what, I’ve listened back to my recording. I’ve listened back to our appointment.

I’ve relived that conversation. These are all the things that I did say and that we did talk about. I didn’t say that and I’m in hindsight, I wish I’d have said this differently. You are going to get such a different response from that patient if you come back with honesty and integrity to that.

And I think that’s that duty of candor and all that kind of thing. I think that’s what that’s about. I think that’s what that’s trying to generate is that honesty and that good relationship with that patient and that dentist.

[Jaz]I think personally, the way that we should view it is not like, oh, now there’s a pressure on me to be perfect. Because you said yes just because you didn’t say it in the recording doesn’t mean, you can’t put it in the note because it wasn’t a conversation that was had outside the recording, but if you wanted to be someone like me who I would like to just record everything so that I don’t have to type a single word and just transcribe, that was my dream.

Okay. So for me, I’m like, that should be elevating me. That should be the right kind of pressure. Of course, I never want to be in a scenario where I forget to mention a really important risk such as a sinus involvement. I should be consenting our patients every time that a tooth could fracture of it’s very carious and so that’s putting the right pressure on me as a clinician to make sure that I do right by my patient and I communicate the right things.

And so what should this should prompt for all of us is to make checklists. The checklist manifesto, we should have checklists. And what this does then is having that little bit of pressure that, okay, this is being recorded. I better be making sure that I consent properly. That’s not a bad thing, that’s a wonderful thing for oppression.

[Ala]So it’s been really interesting speaking to some really intelligent people about it. And it’s the people who are at the top of their profession and they know what they’re doing and they get to those little nuggets straight away. It’s amazing. It’s really fun. So Cannon Lewis, so I mentioned he is one of those really people who just knows dentistry inside out.

He was director of the largest global indemnity company, medical protection, Dental Protection Society for I think 18 years and was involved in them for even longer, but he’s now with the consulting with the BDA. So he picked out that the DAN has the potential to do wanders for the quality of the communication between the patient and the dentist.

And that is arguably a more important dividend than the records themselves. So when you are aware that you’re being recorded, because you do feel like you’re on stage, definitely that’s feeling relaxes after a little time. But the first time you put that on, you are on stage, you are aware of exactly every single word you’re saying and how you’re saying it.

It means you are communicating better. It means your patient is also communicating better because as soon as you press the record, they feel on stage too, and they’re like, oh, again, that feeling relaxes. It doesn’t get in the way of a good conversation, but it does give it importance and it means that the patients sit up. They listen better. You are more in tune with them. You’re doing all of that body language with them because you are more in flow with them.

[Jaz]Can I picture you a scenario on, right, on this topic? I think it’s perfect time to just interject here with the scenario. Let’s say a common, not a common scenario, hopefully not too common, but a scenario that’s really a heart sync moment for dentist is they’re about to play veneers.

Maybe they’re perhaps place eight veneers, right? And then you try them in and you’re getting approval before you definitively cement these veneers in. Now you can imagine where I’m going here with this. Now the patient says to you, oh my God, I love them. And a week later they’re like, I hate them, but you just glue them in.

Right? So the way I manage that currently before DAN would be some sort of a consent form, some form of sign that okay and literally says, I like my veneers. I’m happy to glue these in. If I change my mind, that’s okay, but it’s going to cost nine or a pound a tooth to change my mind. And that’s fine.

They know what the deal is, okay? They need to be happy. They need to be happy, and they sign that off. But one problem here with paper and consent forms is it’s not worth the paper is it’s printed on right. Consent forms are, I didn’t understand the time, whatever. That’s why I keep my consent form really simple, but just recording that conversation.

And so if that’s recorded and if someone listens to in the future, did the dentist give the patient an adequate time to look and assess? Was the patient, was the dentist encouraging to the patient to really point out any areas they may not like, was the patient happy with the fit?

And so they can say, it’s all being picked up at audio. Oh my god, I love them. These are amazing. I love you, Doc. Thanks so much. Yes, please glue them in. And the future, they start kicking off I want a refund. Then that’s there to show that, hey, by the way, can you just listen to how ecstatic you are?

I’m sorry that you changed your mind. I can help you, but you’re going to be billed for it. What do you think about that?

[Adam]Seems legit.

[Ala]You’ve got it, and it’s that-

[Jaz]This is the beauty of it. This is the beauty of it.

[Ala]Yeah, it’s all of those things. We were just like, do you know what we work really hard. We try really hard. And your written notes are just they’re grateful that summary, but they don’t pick up any of that. And by just clicking a button twice, you can just have all of that. And if you never use it for-

[Jaz]Just my mind, wondering with all the thoughts, like black triangles, orthodontics risks, telling the patient at the beginning that this is a really extreme rotation and it might not rotate all the way.

Just make sure you understand that, and they’re, oh, yeah, I understand. I’m not looking for perfect. But at the end, when they start being a more of a perfectionist, you’ve got to remind them, hang on a minute. Do you remember this conversation that we had? Let me remind you, this is about, okay. This is why I like you.

[Ala]And then they’re reliving that conversation as well. Then, so they feel those feelings again where they were like, oh no, that is how I felt about it. And like, now how I felt has changed and that’s okay. But that is how I felt. And it brings them back into that and it, it just takes away.

So imagine if you didn’t have that record, you’d be looking back at your records and you’d be like, it says that, but is that just in my template or It says that, but I’m sure I didn’t say it quite that way. That might just be how my nurse paraphrased.

[Jaz]It didn’t capture the emotion of the patient.

[Ala]And the emotion of the dentist as well. Like the way in which you’re saying it in a really caring way, or the way in which you’re saying it in the way that’s right for them. Or using analogies that are good for them, whereas all your nurse might write down at the time is, they’re not fast typers. Or you’ve got a trainee nurse, or you’ve got somebody who’s-

[Jaz]Born black triangles. That’s it.

[Ala]And yeah. Exactly. Even if it’s got all the detail in the world. It’s just different from how you said it when you see it written down.

[Adam]Well, one of the analogies I’ve heard a Ala uses, so you had charting and then photography became a thing. And photography doesn’t replace charting, but it provides color and context to the charting. And now you’ve got 3D models essentially doing that even further and audio is simply that context and color around your clinical conversation, which are supporting your written notes so that your written notes can focus on being clinical. Not a record of your conversation.

[Jaz]Amazing. So the dental legal folk, what do they think about DAN? What’s been the verdict so far in terms of feedback from the medical legal?

[Ala]So they’re really happy for us to be around. It’s been great. It’s been really good feedback. I think they would also like to be working from truth rather than from what is maybe written down in the record or a post facto record of what should have happened in an ideal world. I think it’s an adjunct, so it’s more richness. It’s not a replacement. You’d still want to be having a written record. You’d still want to be, just like you have charting as well as you have photography.

It’s an extra, it’s on top of, but it just happens to be an extra, that’s just two clicks of a button and one sentence with your patient. It’s a really easy extra to do. You’re not having to learn photography skills. You’re not having to kind of populate. Something all of your carefully crafted things that you’ve already got in place.

You don’t have to change any of that. You don’t have to do loads of team training. Although we can train a team if that’s helpful to people, we are happy to do that and to make that happen. We can come in and just show people what it’s about or different ways that we can do that, but you’re not having to do any of that, and you’re not having to get the whole practice on board either because it’s cloud-based, because it’s individual, it’s priced to be okay for individuals to have, or hygienists to have, or TCOs have been some of our people who have appreciated it most because who’s sitting there writing their record for them.

There’s nobody there and they’re having the richest conversations. They’re having the most caring conversations, and they’re the ones that they have their checklists of what they’re going to talk about, and they have that really well, and then they’ve just got discussed implants or patient it’s so narrow compared to what they actually do.

And so they’ve been some of our biggest fans, they’ve been the ones that have been like, yes, come on, dentist, get me my microphone. I want it now. And it gives you credit for training your TCOs to do that.

[Jaz]I think any dentist, any TCO, any therapist, hygienist, colleague who really cares about freeing up their time not to have to worry about what’s in their notes and what’s not in their notes, who actually generally wants their notes to be awesome.

This is a no-brainer. I think I’ve come to that conclusion now. And now that we’re have this conversation, I have one more idea that I know you’re going to jump on Adam. Okay. Here’s my idea. Okay. I used to use Google voice of text in the car, and I used to like come up with podcast ideas or I used to come up with like little chapters of things I was writing core scripts.

Whatever I was just dictating it to the phone. It was typing it a bit like otter and stuff as well. I was come back to it later and looking at the notes and actually, It would pick up when it’s the sound of the engine or it would pick up because it knows what that sounds like. If someone’s coughing, it would just come out like, some that it’s a distraction.

It comes up. So here is how DAN would look perfectly for me and how I envisaged to use it so that I can achieve my dream of doing the least amount of fingers to the keyboard as possible. And this is how it would work. So the sound of the suction is pretty universal, so as soon as the suction goes on, the voice recording will automatically just switch off.

Or be recorded, but later, the two hour file would become a 45 minute file because it would detect when conversations were had and therefore saving stories and saving memory. And therefore the AI in the future I know is very exciting for you Adam. The AI will then pick up, okay, this is the beginning.

This is the middle, this is the extra bit. This is the post-operative summary. It will just label them as well. It could do that, I imagine. And even if it just set up prompts inside that, okay, whenever dentist says postoperative summary, those words, then it will just start that. This is what the imagination I’m having. Do you think it’s a pipe dream or do you think this could happen?

[Adam]So fundamentally that technology can be used to achieve what you’re saying? I think and like it can probably be done with technologies that exist right now and those technologies are only going to get better. The challenge that we will always solve first is privacy and security.

Cause we’re dealing with very personal sensitive information. So you could take the transcript and you could use a well known existing tool and say, summarize this, right? But you should not be putting your patient information through a web browser. Do things like that. So the scope around the med, and this is sort of the challenge for the medical world and which is why dentists I think, really need to be board in driving.

Where this goes is ultimately with technology, you can achieve almost anything you want to, given the resources and time and effort to get there. And you’ve just got to make sure that in the medical world and the dental world, it is done securely and responsibly. To get there-

[Ala]Ethically.

[Adam]And ethically as well. Absolutely. Just picking quickly on what you said about the indemnity providers, for example, the key sort of items that they raised for their satisfaction was that the recording isn’t adjunct to the written record and that it forms part of the patient record. So if, for example, you are recording a very long session of time, we should not delete the audio, even if it is just suction.

Because it’s part of the patient record at that point. But it’s quite easy to tag that audio. And so when listening back, you can pop over things, but the record is still there. And so it’s just the nuances of achieving that vision that satisfy gdpr, all the requirements of security in the US obviously, HIPAA and yeah, security and data privacy.

[Jaz]And you guys are HIPAA compliant and stuff, right?

[Adam]So yeah. HIPAA compliance is a process. We are working on that now. The security side is easily covered. And we’re working on that now.

[Jaz]So, I mean, so that’s the next step. And so that leads me to the final question is where does the future hold? Cause I mean, really impressed with DAN so far. I love using my nurse loves it when I use my TMD consults and I’m only going to expand how I use it in the future. And I’m trying to, I’ll be pestering you a bit, Adam, I’m sorry about can you put this picture, can you do this for the transcript?

I think I’d like to help you give you feedback. You’ll probably hate me, but you know, I found something that I really like, I want to just mold it into, that’s going to be very selfishly, helping to achieve my dreams on not having to type as little as possible. But I do appreciate that you still need that human touch. And I understand that, but absolutely fine. It makes complete sense. But where do you think the future of DAN can evolve into?

[Adam]Sorry, Jaz. I was just going to say that they’re getting feedback from users and being able to know that what you’re doing is in line with your customer base. I mean, as an engineer, you are really the person building a product for yourself. You’re always building it for other people. And so having feedback from users is like the most valuable thing that, and engineers crave it.

[Ala]They really enjoy it. That’s just who that person is. You’re playing to his strengths there.

[Jaz]And so before we talk about what the future hold, just tell us if a dentist wants to you do like a trial, right? If dentist wants to just try you guys out and I think encourage it, right? Just get a microphone and I think you guys talk about that in your videos. How to videos and get started. For the first demo couple of hours and see the transcript and see how it works. I think that’s a great place to start. How can they do that?

[Adam]So, sign up at dentalaudionotes.com. Sign up, set your password, and then you can download the application. The software runs on your local practice PC. Plug in a mic. When you’re ready, press record. DAN then makes a secure audio recording of that conversation you have with your patient. And when you’re ready, you press stop. So, yeah. So DAN, obviously you play back, you can transcribe it and you can share with your patients. And we’ll give you 6 hours of recording for free just from the beginning just to get set up.

You are trying to get your setup right in the surgery. And yeah, from that point on, we’ve just started a summer offer for 30 pounds for 30 hours of recording for each month. 30 hours is, if you work five days a week, then that’s an hour and a half a day of recording.

[Jaz]Just to give some context to someone who’s completely new to this. And Ala you can back me up cause you use this more than I have. At the beginning when I installed it, I just let the whole thing run for the last couple hours and you email me saying I’m the first person to just burn through like a couple of hours.

I sort of realize, yeah. Hang on a minute. Why am I recording the examination part? Because Zoe’s got my performer that I use and she’s got everything down anyway. So why am I recording that? So now, I record, like yesterday I used it, I don’t know if you saw this. It was a, because, I get my TMD patients to fill in a really elaborate history form.

Well, just between me and the patient. I’m just getting to know the patient and they’re summarizing the history form. That took eight minutes yesterday. And then the discussion at the end took nine minutes. So I had a 17 minute, audio file with DAN. And that for me covers everything. And I’ve got everything in the examination.

So if you think about three of those times six, 18 patients for that demo. I think dentists can have a real good use of it and develop it and learn about how to use it and how to use it, how to optimize it for themselves in their practice. So that’s a great deal. And how do they take advantage of this summer offer?

[Adam]It’ll be available on our website, so we’re running it for the summer, so June, July, August. So sign up and get started in that time.

[Ala]And I think it’s because we’re pretty confident that once people start understanding its power, then like it’s just going to change their lives. It really, I think you talking about vision for the future. I think vision for the future is that, audio recording becomes like photography, like the dentists who are any good, the dentists who are wanting to be good, the dentists who are caring about their patients and caring about their work and wanting to improve all the time, that they use audio recording, like they use photography.

So that’s our vision. We want it to be good value because that gives us pleasure and joy as well. we want it to be like, oh, this is a no-brainer. I don’t want finances to be a barrier for people. I want hygienists and therapists who are on their own to be able to use it if they want to. I want practices to be able to use it practice wide or just one nurse to use it.

[Jaz]It is very amazing value. I just want to add in there for you it is incredible value, especially because it’s a tax deductible thing as well. It’s incredible value for what the technology that is, is novel. You could easily charge hundreds a month for it, but you come up very low offer cause you want everyone to get using it.

So I appreciate that and I just want to make it clear from in case anyone doesn’t know this, I have zero financial interest in your product. I’m not a stakeholder. I just love the product and I just want to speak to you, especially Ala because you are a Protruserati even connecting and I always like passing the ball to the Protruserati who are very geeky and really mean the best for their patients.

So that’s why we did this together because I want people to also use DAN and get to know it. And the more people that I start using it, the more feedback you get, I know the more it will develop as well. And this is just the beautiful beginning of it, this is the beginning of the story. The possibilities really are endless.

[Ala]Yeah. Yeah.

[Adam]This is the start of an exciting journey.

[Ala]Yeah. I’m delighted that you’ve seen it clearly like that. It’s such a pleasure to speak about it when you know you’ve got it.

[Jaz]Amazing. And I hope the Protruserati check it out and get the most of it. Guys, any final comments or words for those listening about the use of audio notes as the future and hopefully now the present of record keeping.

[Ala]I really hope it’s enjoyable for people. I hope they enjoy stepping up and sitting up. And coming forwards into it, it’s a thing to step into and be like, right, I’m going to solve my record keeping.

I’m going to master it. It’s just like that feeling when you get your bonding sorted or when you get your crown prep sorted or where you get you are suddenly flying through rubber dam and all those kind of little bits of joy that you get. It’s just like that. And that’s what I hope that people will feel.

I really hope that they’ll get the benefit in their patient interactions because of that, and I really hope that means that if there are ever any challenges for anyone, any difficult things that happen, I hope that they can listen back to it with some either by themselves in their own time or with somebody that they can trust to give them good advice as to how best to proceed, whether that be somebody in their practice or whether that be their indemnity people provider.

And I really hope to be that support, that’s what DAN feels like for me. It’s like a support that’s looking after me, that’s got my back. And that’s what I hope to provide for dentists is that support that forward going, that improvement in consultations and yeah, just a bit of a little bit of joy.

[Jaz]Amazing. And we didn’t actually talk about this, we talked about dentist leveling up their communication. But one thing that I think is worth mentioning is we do so many clinical courses. I always think we don’t do enough non-clinical stuff. And I think a really good non-clinical thing you could do with the aid of DAN is actually sitting with a principal or maybe even someone whose main thing is patient communication.

I will train you to be a better communicator with your patient. I’ll treat you to talk more confidently about smile design, wherever, and you sit with them. And then, you look through your what are your communication skills like in the moment. And then you implement new skills and three months later you listen back to your consultation and how much confident you are, how much of a better communicator you are.

And actually it’s a journey that you can go through to improve your communication. Just like when you start taking dental photography, you take photos and you depose a rubbish at the beginning and your dentistry rubbish at the beginning. And as your dentistry evolves and your photography techniques evolve, you improve in all aspects.

And so my only perhaps, your quality of the Dental Audio Notes will improve. But actually your patient communication, your conversion should improve only because you are more confident and you are saying the right level of information that the patient requires. Yeah.

[Ala]So, some of the people who have been the most interested in using DAN have been those people who are dental coaches and mentors. So my mom is a dental coaching mentor. She was a dentist for a award-winning dentist for a long period of time. She’s really keen using it with her dentist because that’s how she can help them. We’ve had Barry Elton, who’s been really keen that we’ve had we’re very lucky. Adam and I are secretaries for Gloucestershire independent dentist.

So we have really the top speakers in the world who are, who come to help them who come and have dinner with us and stuff. It’s a incredibly privileged position that we’re in where we get to talk to people who are helping a lot of other people and they are seeing the value in that saying, I want to give this to my people.

I know that you are having a chat with Barry about how he can get this to his people so that he can help them. And it’d be really good if we can get that from that want from dentist saying, look, I’ve got this. Coach that I’m paying lots of money for, or I’ve got this amazing person in my practice who’s willing to give me a little bit of time and energy.

I want to use that in the best way possible. I want to have this recorded so that I can listen back and see where I can improve. But you know what? Even if you don’t have those people, just listen back to yourself. It’s a humbling experience. But it’s fun, but it’s humbling and it’s really you’ve said before, you hate listening back to yourself. It’s really cringey. I feel exactly the same.

[Jaz]Yes. The first thing when I start a podcast is listening back to your own voice is cringe. But you earn to get through it.

[Ala]You just get over it, don’t you? You’re just like, okay, it’s cringey. Let’s just carry on and get the value. Yeah. Yes, very much so.

[Jaz]But I’ll be clear. Look for me, it was always, the transcript because I just really struggled getting everything down. And so DAN has really given me a new lease of life when it comes to my TMD consults, which is so complex that it really helps. So, thank you for making this brilliant product. I can’t wait to keep using it and helping you guys to develop it because I’ll be pestering you, Adam, with feedback to achieve my selfish goals.

[Ala]We might pester you back for which microphones you were using because that’s our, one of our challenges is getting the audio quality good enough to get the transcript working right. So don’t worry, we’ll be perfect.

[Jaz]So I think I’m using the same one as I’m same one, I’m using the same one as you, but I’m using the Rode go, right? What’s it called? The go mic. Go to.

[Ala]The wireless go.

[Jaz]The wireless go. It’s just nice not having any wires and stuff and it’s really good and looks swish as well. So yes, it’s not the cheapest, a couple hundred pounds, but you don’t have to start with that. I started with a cheap one first, but it just makes sense that if you do end up using DAN a lot, I just think it’s worth, again, it will be a tax deductible expense because it’s for your clinical clinic and I think it just makes sense to have really good crisp quality audio as well. I mean, what do you guys think about that?

[Adam]Yeah, the audio quality is the number one effect on the quality of transcription. Right. That’s an transcription is an entirely automated process and you need to put quite good data in to get good data out. And that’s down to audio quality. It’s really easy with the cheap mic to get good enough audio quality that you can listen back when you need it.

So for that audio record backup, you can achieve that really easy.

[Ala]With 15 pound mic.

[Adam]Yeah. But to then, have the audio high enough for an automated system to pick out the words and transcribe it. Having a bluetooth wireless mic, like you were saying, is great because you can just position it in a really good location between you and the patient, and it’s small and it like, it’s not obvious.

Whereas if you have one that’s plugged in and it’s going to be on the side, it’s going to need to be a bit bigger and clunky and one of you will always have your back to it. So yeah, that’s a good step.

[Ala]I think if anybody was worried about which mic to use, they should just contact us and we’ll just go through their setups. We’ve got a bit of experience in it now, so we can just help them with price point and-

[Jaz]Of course.

[Ala]Yeah, you’ve got any questions, just get in touch. Yeah.

[Jaz]Amazing. And Adam’s been amazing at emailing and feedback and stuff in that regards. So guys, more power to you guys. I think you guys are doing an amazing thing for the profession and maybe in a couple of years time we’ll reconnect and see what’s new in DAN.

And it’s very exciting to be in your world at the moment. So, you have my full support. You have the full support of Protruserati.

[Ala]Well, Jaz, you are coming to Gloucestershire independent dentists in January, right?

[Jaz]It’s January right Ala?

[Ala]Yeah, yeah, yeah. Yes. So we’ll see you then anyway.

[Jaz]We’ll see you then. Amazing. Fantastic. Well I’ll look forward to seeing you guys in the flesh. Until then, thank you so

View Details

In this thought-provoking episode, Dr. Pasquale Venuti represents Tomorrow Tooth aka ‘the other voice of Dentistry’. He is a renowned dentist who is not afraid to express his controversial views. While he may challenge the modern techniques taught in dental schools today, he brings attention to the shortcomings in current practices and encourages critical thinking.

Dr. Jaz and Dr. Pasquale explore various topics that challenge traditional dental practices, including subgingival caries, flat onlays, post crowns, and cement selection. By raising practical and applicable questions, they encourage dentists to question established norms and seek better solutions for their patients.

https://youtu.be/tZp4s0Wj2zY Watch PDP152 on Youtube Protrusive Dental Pearl: New Restoration Needed and the Patient has an existing occlusal appliance. What can you do?

Imagine a Stabilisation Splint – For patients who rely on an occlusal appliance – how do you manage the scenario if they need a restoration? Do you need to make a new occlusal appliance? ? Not really. You just have to gouge out the acrylic where the new restoration was placed (intaglio surface of splint). If the splint fits well, no further adjustments are needed otherwise additional acrylic can be added to provide retention (like a partial reline of the splint over your new restoration. Don’t forget that vaseline!)

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

02:36 The Protrusive Dental Pearl05:25 Pasquales introduction16:53 Subgingival Caries and Gingivectomy22:10 ‘TableTop Onlays’ – Where is the limit?28:30 Pasquale on C-Factor31:12 What are the Limits of Adhesive Dentistry?36:55 Guideline for Adhesive vs Mechanical

If you enjoyed this episode, check this another episode by Dr. Taylor Paton:Biomimetic Dentistry – What Actually Is It?

Click below for full episode transcript: Jaz's Introduction: In this episode, we're gonna talk about the other voice of dentistry. It's a very provocative episode title, right? Jaz’s Introduction:IThe Anti Biomimetic Dentist, well, for those of you who know the Italian Stallion, Dr. Pasquale Venuti, he’s just amazing. And he’s not shy to express his views. He’s very controversial, and he won’t mind me saying this right?

And it’s not like he’s like completely in the fringe. He’s not like, ozone. He’s not removing people’s amalgams to cure them of their erectile dysfunction or whatever. Whatever, he is not fringe. He’s just on the other side of what we get taught at dental school nowadays. The adhesive approach, but what Pasquale is great at is, is pointing out the shortcomings in the modern techniques, right?

What’s wrong with fiber posts? What’s wrong with blindly following adhesive dentistry? So, what tomorrow tooth, the group, that Pasquale is part of is so good at just expressing the other voice of dentistry, take nothing at face value. So I think you’re gonna really enjoy this episode.

I’ve been sitting on this episode for a couple of years now for various reasons, mostly because the amount of interjections and the amount of additional content this episode required me to do is why it took so long. But hope you enjoy this episode and learn a lot with Pasquale Venuti. Some different views of thinking, some slightly controversial areas will be covered in this episode.

So get those onions ready because there’s gonna be lots of onion chopping during this episode. Hello, Protruserati. I’m Jaz Gulati. Welcome back to another episode of Protrusive Dental Podcast. It is your first time listening. Wow. You’ve chosen an interesting one to join us. And if you are a usual listener, like I said, man, this is the one for the onions.

We’re gonna do a two-part episode. In this episode we’re gonna cover sub gingival caries. We’re gonna cover flat onlays. Like when can you get away with it and when is it a bad idea? Is it ever a good idea? How about post crowns? We’re gonna get really deep in part two when it comes to post grounds and find out why Pasquale Venuti absolutely hates fiber posts.

And lastly, some considerations of looting cement. When is it a decent cement? When is it a looting cement? These kind of real world questions, applicable questions that need to be asked, right? So Pasquale does a fantastic job, and I’ll not waffle on any longer. Let’s do the Protrusive Dental Pearl and then hit the main episode.

Protrusive Dental PearlThe Protrusive Dental Pearl today is inspired by a question from our splint course delegate support groups. Those of you who enroll on splint course learn more about different occlusal appliances as a GDP. These are permissive splints that don’t necessarily move the jaw in certain positions.

A bit safer for GDPs getting started into the management of bruxism with appliances, the management of some types of pain with his appliances. A little bit controversial there, but the question was, when we are dealing with a patient who absolutely loves their occlusal appliance and relying on it for many years and is doing this job, is protecting the restorations, protecting the teeth.

But now this patient needs a restoration. So let’s just take a stabilization appliance, right? Acrylic stabilization appliance, AKA, Michigan, AKA, Tanner. And now you replace a crown on a lower molar, for example. And so now your splint’s not gonna fit anymore. So the question is, what should we do?

How do we manage this scenario? Do we have to make a new appliance? Not really. You just have to gauge out the acrylic, intaglio surface best word ever in dentistry. The intaglio surface of the splint where the tooth is and then seat it back on. And so now, there’s no parts of that splint binding on that restoration from that crown anymore.

And then you assess, right? Do you need to realign it or do you not? Like if the appliance is perfect, how it is and it’s no rocking and it fills retentive and it just as it was before then I’m gonna suggest you don’t need to pull the acrylic out and start realigning that one tooth, because as soon as the patient takes off the splint and starts functioning again, the tooth’s not gonna over-erupt.

And we are keeping it simple. But if you find that by losing that one additional tooth of retention of the splint, basically, that now the splint is rocking, or the retention’s been affected, then yes, you gauge out a little bit more, make some space for a decent amount of acrylic. You put some Vaseline on the restoration, the crown, for example.

You air abrade the inside of the splint. You put some liquid monomer, acrylic monomer and then you mix the doughy acrylic. You put it inside the intaglio surface of a splint where you’ve just gauged out the old acrylic, right? So you’re essentially relining the splint. You then put it over the restoration, and then you just wait a little while, but then start inserting, removing, inserting, removing, inserting, removing.

Because if you don’t do this bit, the acrylic will lock in all the undercuts, and then you’ll have a very sad patient. So once you’ve done that, then you can just meet it up. Essentially, you’ve just picked up that tooth in acrylic so that now, It’s gonna be perfectly seated over that crown. Now it might be binding too much, a little bit too tight in the area, so it might just need a bit of relief.

But essentially it’s a good way not to have to make a brand new occlusal appliance for someone just because we’ve changed one restoration. So the ability to realign acrylic splint is a good thing, and I feel like a lot of time, general dentists are afraid to use it because we’re perhaps not so experienced with using acrylic.

Acrylics are a great thing to use, whether you use it for lucia jigs, crowns, temporary crowns, or just like I showed you, relining areas of splints. I even use it for more advanced cases, converting my B splints, for example, to have a degree of protrusion. So I’m bringing the jaw forward, right?

So I’m adding some acrylic there. Getting the patient to bite into it in a protrusive position, and then that’s like an anterior repositioning splint. So you are converting the kind of occlusal appliance you have to a different type using acrylic. So don’t be afraid to get out the acrylic, but just make sure you don’t let it set in the mouth.

You insert, you remove, you insert your remove so it doesn’t lock in. That’s the biggest mistake that you could make. Anyway, we’d like to learn more about appliances for GDPs, head to splintcourse.com. Otherwise, let’s join in the main episode with Dr. Pasquale Venuti.

Main Episode:Pasquale Venuti, the real, the original Italian stallion. Welcome to the Protrusive Dental Podcast, my friend. How are you?

[Pasquale]I’m so fine. Thank you for the invitation. I’m proud to join your podcast.

[Jaz]Dude, I am so, so happy you came and accepted my invitation. You are someone I respect so much and I’ve learned so much from over the years, and I’ll describe to the Protruserati who listened my experiences with you in the past.

And when I told the Protruserati that you were coming on, so many people were really interested to hear your views which I know you’re gonna really help a lot of dentists understand your perspectives which some people with some dentists think are controversial and that’s totally cool. We love controversy on this podcast.

It’s all about learning from each other. My first experience with you was also a controversial one, Pasquale. I saw some images that you posted on social media around about 9, 10 years ago where you were treating these deep carious lesions, and then you would be destroying these papillas. And I say that as a joke, you were destroying these papillas and you were restoring these teeth beautifully, but just the fact that you’d actually blazed through the papilla for me at the time, as a young dentist, I was like, what the hell’s going on?

You are invading the biological width. I even commented, you are invading the biological width. And then you commented back saying, I did not invade the biological width, the caries did. And that was the first of our many interactions going forward. And I learned so much from you. And I saw you in Sydney.

You were with Lincoln Harrison in Sydney, then again in Stockholm when I see Michael Melkers so I’ve learned so much from you now doing your vertical course online, which I’d love to sing and praise about. But Pasquale, just for those people who don’t know who you are, tell us a little about you as a dentist, your philosophy, your views. Where does that come from?

[Pasquale]We have the same path in dentistry. We were trained at more or less the same way, with the same university dogmas. Well, when I jumped to dental arena, I jumped with the typical overconfidence of the new graduate, a classic Dunning- Kruger effect. I felt smarter and more competent than any other dentist competitor.

And of course, more confident than my father. My father was a family doctor and he never had a formal training in dentistry. He was doing some dentistry just for his passion as family doctor.

[Jaz]Wow.

[Pasquale]Yeah, because at that time there were no dentist in the village. I live in a village of 8,000 souls in 80. There was a shortage of dentist in Italy. So many family doctor did some rudimental dentistry, especially caries you mean, endodontic treatments. Some mobile prosthesis ole bridge. So, my father just read three books in his life. One of N2 endodontics, a very controversial way of doing endodontics nowadays.

A book of fixed prosthodontics of the famous Bible from Herbert Shillingburg, and another book of endodontics from Wayne. They’re now are my library. So it’s not surprising. During this podcast, I’m going to show you some slides. One of the most interesting part of dentistry, you don’t need so much formal education to do good dentistry. So imagine that Greene Vardiman Black the famous GV Black, the best dentist ever. So he degree around 19 or 20 years old in Illinois. And then, he decided to do some dentist. So he went to follow a dentist of Mount Sterling in Illinois.

The. So in this office, he spent three months, he read the only book of dentistry the daughter spare owned at the time, a book of 100 pages. So GV Black was able to perform and to write and to teach the best dentistry ever, just with two months of formal education. Just one book or 100 pages.

So, let’s imagine myself, I had read coming from university, hundreds of books, thousand of literature, of dental papers. So I was very overconfident. So, the problem in coming out from university, you have not right skills and not the right mindset for facing the real dentistry.

So anyway, as soon as I jumped in the office of my father, my father left because he went to do family dentistry. So, I had a fortune to never co live with my father, so I never fight with my father. So, but anyway, I put in the basement every stuff for my father. The dentatus post dental pins. Plastic post for cast post prosthetic bars for vertical prep, amalgam.

And then I put in the new office fiber post of course, glass fiber post. At the time, I was using big shoulder bars for doing horizontal prep because I was taught at university that vertical pep was very dangerous.

[Jaz]Hey guys, I’m gonna start interjecting now and again in this podcast to make it more tangible at various points. So for the young dentist, for the student, Pasquale just mentioned horizontal, vertical, like what does that even mean? Right? It’s a confusing term if you’ve never been exposed to it this way. Well, horizontal just means kind of like a normal crown prep that you were taught at dent school, right? You sink your bur into the tooth and now you have a margin.

Okay, you have a normal margin. This could be a chamfer, this could be a shoulder. So that is a horizontal margin. So for those of you who are watching on the app or the video, you’ll see an image of a normal cramp prep that I’ve done. But then what is different about a vertical prep is that it kind of doesn’t have a margin that is completely straight into the gingiva.

And you can kind of think of it like a knife edge. Now this might be offensive to some groups, but if you think of it as a knife edge, it gives you some degree of understanding. And there’s lots of different types of verti prep. There’s BOPT, there’s shoulders, and we’ll come onto that in little bit of a education that’ll be setting up on protrusive premium called Verti Prep for Plunkers. So that’s coming soon.

But essentially, horizontal prep is like a normal cramp prep. Your shoulder and your chamfer and your verti preps are kind of like knife edge, but that’s quite an oversimplification. But at least now you know what he meant by horizontal and vertical.

[Pasquale]So my dentistry started with this kind of dogmas coming from my formal education. Some cognitive dissonance starts to happen in my mind after two, three years of practice because I was following up a lot of patients from my father practice with therapies done by my father with 20, 30 years follow up now.

[Jaz]And these are root canal treatments, right? You’re talking about root canal treatments?

[Pasquale]Yeah. They were root canal treatments. They were fillings with so-called the kite tissue underneath crowns on vertical prep with overhangs everywhere. But anyway, they were clearly successful after 20, 30 years. And my dentistry have just a track of two, three years. And my cognitive dissonance started to reach the peak.

[Jaz]Okay, so I’m just gonna interject again about cognitive dissonance. It’s a big word. And for me it can be confusing sometimes. So I just thought I’d make it a bit more tangible, right?

What this means, like, cognitive dissonance is that uncomfortable feeling you have in yourself when your thoughts and your beliefs don’t align with your actions. So if I was to give you a dental analogy, example is that maybe you believe or maybe you’ve come to believe from the literature that you’re reading, that actually we don’t need to do total caries removal, that it’s okay to make sure we got nice clear peripheral zone.

The ADJ area must be super clean and so that we don’t exposed, we should be happy to leave some caries over the pulpal area so that we don’t expose and we’re not doing root canals where we shouldn’t be doing them right? But then this is what you believe. But when you come to actually removing the caries, you can’t stop yourself.

You can’t hold back and you end up chasing that carries pulpally and you might be exposing more often than you should. So that’s an example of cognitive dissonance made into a real world dental example.

[Pasquale]When in 2000 I perform an endodontic treatment on a central incisors, and then I placed my fiber post, and then I did my horizontal prep, a big generous shoulder, and I did an horizontal crown on it.

After two years, in 2002, the patient came back with the crown with a post in the hand. So I was shocked because I never saw before a dentatus post or a cast post of my father in the hand of the patient. So something was not working and I didn’t know why. Anyway, after 10 minutes of shock, so I decided to go in the basement, use my first plastic post, and duralay for doing a cast post, so I redid the post doing a cast post this time I redid the crown, and yet the crown is in the mouth of the patient after 18 years now.

[Jaz]So Pasquale just referred to using something called Duralay which is like this red colored acrylic. And what we can do with this Duralay along with a plastic post is if you put it inside the canal and then we can literally use some bits of Duralay and start building a post and core.

So you are kind of like directly chairside building a post and core as the acrylic setting. You are inserting, you’re removing, you’re inserting and removing, just like the Protrusive dental pearl I gave you earlier. And it’s a handy way of communicating to the lab exactly the shape of the canal and how you want the core to be.

Cuz then the lab sends you back a metal replica of this acrylic resin, basically this duralay acrylic resin. Now, I did this once and only once have I done this in my career and it was as a dental student, and this was with an old school tutor. But I was grateful to just gain those skills at the time. So if you’re not familiar with duralay or he didn’t really know what he meant by fabricating a metal post core using the duralay that’s what he meant.

You actually adding little bits of acrylic on to build this bigger piece of acrylic, which essentially is like a post and core in your hand. A tiny little version basically. But then that gets sent to the lab to get processed into metal. Now this is relevant because Pasquale in the rest of this episode, he’s remembering this time where he was challenging what he was taught eg the use of fiber posts and the use of heavy preps, right?

Which is completely the opposite what he does now, by the time he had this doubt, he thought that he knew it all after dental school, but he’s finding that his results weren’t as good as his fathers who was using more traditional techniques. What Pasquale now goes on to talk about is sub gingival caries and removing the gingiva to allow you to reach the caries, cuz sometimes the gingiva’s in the way and you can’t actually seat your matrix.

But what he believes in is removing that inflamed gingiva, which is really crazy when you first get exposed to this. It’s like, whoa, how does this even make sense? But I’ve been doing this for years. And you know what? These papillae do grow back and it’s an absolute game changer for me in my restorative dentistry. And some groups, people do get offended by these techniques, but I think they’ve been absolutely brilliant for my restorative dentistry. So he’ll now talk about that.

[Pasquale]So what I was seeing was in strident contrast with what was published at the Dental literature my patients were not a patient of dental literature.

My patients were an average with low income, with very better oral hygiene, and most of the decay were underneath the level of soft tissue. That’s why my first need is to become free of gingiva when doing some fillings. That’s why I start to cut soft tissue. So I know after cutting hundreds of papilla, so I start to see back the papilla in a few weeks.

So I realized that it was not a big problem. The big problem was not cutting the papilla because at the beginning, for example, I did not cut the papilla, papilla was like a religion to me. So what happened then? I placed my matrix because I had the impediment of the papilla. My wooden wedge was too occlusal and crushed the matrix inside the cavity.

So my feeling was very bad with a very strange profile. But if you got the papilla, you are able to do a perfect proximal profile and papilla will grow up again, a guess.

[Jaz]And this is so simple, Pasquale, cuz this is why I learned from you initially, because the traditional ways that I was taught to manage that would be, oh, this patient needs crown lengthening.

That’s what I was taught. And when I saw you doing such a simple thing like that, and then now having done it hundreds of times, myself, seeing the Pilla come back, seeing year on year, how good the tissues look when they have been educated properly how to clean it. And the fact that I was able to now restore these teeth without surgery and everything’s fine is just mind blowing. Why the only other option was suggested to be crown lengthening?

[Pasquale]Yeah, I started with crown lengthening. I mean we started with the same path. So, my patient had very bad oral hygiene. So after crowd lengthening, they ended up with a big black triangle. They didn’t clean. So the situation is even worse for them.

So, and after some years I get also new decay on the root because with crown lengthening you expose the roots, so the situation is worse and worse and worse. So crowning is a viable treatment in a patient with perfect oral hygiene. But honestly, in my humble opinion, there is no need of surgical crown lengthening in restorative dentistry.

For aesthetic reason in anterior area for increasing the hate of the grounds. If you need federal, you can do auto extrusion, but if you don’t need federal effect, it’s not a problem because you cannot impinge in biology width because if caries is down there, it means that the biology width is reshaping underneath the decay.

So you have not a possibility to impinge it. So it’s fake problem in my opinion. I mean, 20 years ago there was a problem, how to get a isolation in very deep caries lesions because rubber dam sometimes is not enough. But with Teflon nowadays, we can easily manage a very deep margin. That’s why you need such a crown lengthening just if you’re not able to isolate the tooth.

But nowadays, thanks to Teflon, we have almost infinite possibilities to reach every margin, even underneath the level of the bone.

[Jaz]And for those listening right now, if you wanna see examples of these teeth being treated, Pasquale is so good at posting so many cases and also so many follow ups, nine years later, 12 years later, three years later, all over.

So join the Tomorrow Tooth group where Pasquale posts a lot of cases, and I encourage everyone to do that. And I love already how we are getting into the clinical details and stuff, but like, there’s so many things I could ask you and share from the lessons that you’ve taught me to the Protruserati, but we’re gonna focus on a few different tangents we’re gonna go on now.

Firstly, I just wanna mention for the purpose of the podcast, that there is some tension, there is some friction. There is, I don’t wanna say war. War is a harsh term. There is some friction, let’s call it, between the biomimetic dental group and tomorrow tooth principles and that kind of stuff. And I just wanna say that, look today it’s about listening to your views and your experiences.

And then I will also have some biomimetic group on and they will share their experiences. And it’s all about learning from each other and sharing our views. We’re not gonna come at it as an attack. Let’s collaborate, let’s listen to each other’s views. That’s very much the angle this podcast is coming from.

So the theme of what we’re gonna cover in this podcast is we’re gonna talk about traditional retention, resistance form versus adhesive versus completely flat adhesive, and where you think on that. Then we’ll talk about the limits of adhesive, and I know you have some really amazing cases of how you manage these very deep caries lesions, yet still doing adhesive dentistry.

We’re gonna talk about the concept of post crowns and where they lie. And then also go deeper into fiber post versus cast metal coast, cast metal post, which is something that a lot of the listeners have requested for almost a year now. Your views on the C- factor when it comes to indirect restorations.

And finally at the end we’ll talk a little bit about the use, this surge in use in fibers. And I don’t mean fiber posts, I actually mean fibers in composite. So, if you wanna listen to that, you have to wait all the way to the end. So, first question, Pasquale is, and just from my experience, there’s traditional dentistry that the horizontal margins, whatnot.

And then of course, nowadays replacing more and more vertical for those who are enlightened and stuff. And most of my crowns where I don’t have enamel all day round, I will be doing vertical crowns. That’s my philosophy. For me to go adhesive, I want at least 90% enamel for me. And I don’t want to overzealously use deep margin elevation, especially in someone who has poor oral hygiene.

That’s my view at the moment. And that’s very much I think, echoes what you’ve taught me as well. And correct me if I’m wrong later, but I see more and more on social media, the use of a very flat platform for a adhesive onlay, i.e. a tabletop onlay. Whereas whenever I prepare for an onlay, I still like to follow the angles of the tooth and get some form of resistance form.

Even a small degree is better than going completely flat, but I see more and more flatter and flatter adhesive indirect restorations. So what do you think? What is the limit in terms of how flat do we go? Because I saw you post a case recently where you were saying, you know what? You’ve lost faith in these flat preparations and you need to still build in some resistance form. Can you enlighten us on that?

[Pasquale]Yeah. I’ve been practicing dentistry since 20 years now and many of the people that collaborate with tomorrow two, like Roberto Magallanes Ramos John Khademi Dev Clark. So they were practiced dentistry then since fourth years. So we tried during our path, both strategies. The so-called classic strategies with retention and resistance form and the new way of doing adhesion on unretentive and unresistive preparation, the prep, there are completely flat.

So, those preps are proposed by people that self proclaim ourself, biomimetic dentist. I don’t know, what does it mean. Anyway, this kind of dentistry, the flat dentistry, they unretentive and unresistive dentistry has two main problems in my opinion. The first problem is operative problem, so trying and only with no form of resistance is an nightmare because it slips everywhere.

For example, how you check the contact areas on a flat onlay. So we have not a possibility. It’s a circus. The other problem you have not a univocal position of the onlay. So what happens that areas can move and slip a bit or shift eventually the onlay from the decided position.

So, but there is another biggest problem there is not operative it’s a rational problem because we have no literature about the longevity of this kind of unretentive and unresistive. Always. We have just some case. Some follow up study at one, two years old. You mean we do dentistry for serving the patient for 10, 20, 30 years.

But with this background of just one, two years follow up, I would not be so confident to serve my patient with this kind of preps. Anyway, I had the possibility to experiment on my patient this kind of dentistry since 2013. And the rate of failure on my experience at seven years is almost 40% of the bonding.

[Jaz]I just wanna say Pasquale, for those listening who don’t know who you are, like I can guarantee you guys it is nothing to do with Pasquale’s hands not being good enough for this type dentistry. Like, if you see his adhesive dentistry, his isolation’s always meticulous. Pasquale can do any procedure he wants in my mouth.

I trust him. So it’s not to say that, Pasquale is not bonding correctly, not isolating correctly, not using air abrasion, et cetera, et cetera. He’s doing the beautiful dentistry. So this, it speaks volumes when Pasquale is saying that something, at seven years, he’s noticed a 40% failure rate.

[Pasquale]I mean, I will show you later in the presentation some cases, okay? Some tough cases, okay? Tougher than every case has been published in the dental literature so I tried this kind of prep in many ways. But the biggest problem, especially for a young dentist is how to locate the onlay because we have no index. When you have a flat policy, you have no index. And restorative dentistry in indirect restorative dentist index is paramount. Because you have to have a unical position of your restoration.

[Jaz]So what does Pasquale mean by indexing? Let’s make it tangible. Sometimes to understand something, you must understand what it isn’t. So if you have a flat onlay prep, right? And you imagine trying to seat an onlay on this flat prep, and it’s kind of like moving around.

Like you can twist it, you can seat it many different ways, and maybe it’s slipping. A bit, right? Maybe you’ve experienced this firsthand with your fingers. Now the opposite of that would be a crown preparation with lots of slots and grooves, and it fits in really snugly in that one position.

That’s a highly indexed restoration. So what Pasquale means that we should move away from completely flat preps and have a degree of anatomy inside the in taglio surface of the onlay, for example, that’s gonna seat in and not be slipping. The contacts won’t be slipping. The onlays not slipping off.

And this is called indexing. Not only is it but good for your technician, it makes it easier for a technician to make you a good restoration. It makes it easier for you at the time of your cementation or your bonding procedure to make sure that you get that one path of insertion. So indexing is a good thing to have.

[Pasquale]And with flat onlays you have it now. So what we did, at some point, we start to do some hole into the center in order to locate, because it’s not all your problem, it’s all the problem of the technician that cannot have a exact location. So sometimes if the hole is not so deep, the former resistance is not enough. But there are a lot of problems, eh?

I will show you better. One of the biggest misunderstanding in the dentistry nowadays is about C- factor, because the people that proclaim that flat onlay has a very low C- factor, okay, are completely wrong because they do not understand the basis of C factor. Because if they studied the work of Carol Davidson, the inventor of C factor, C factor is called in this way because the name of Carol Davidson.

So they will see that in 1985, Carl Davidson studies the flat onlays. Flat onlays have infinite C factor. C factor is extremely high because you have one surface, there is the tooth surface and the onlay. So, and the cement has to compete with two surfaces opposing each other during shrinking. So you will end up with a lot of crack inside the cement.

So if you have no form of resistance, what happens that under the true load, especially the parafunction, the crack will start to move and to continue inside the mass of the cement you have the bonding at some point, so it works very fine if you have a patient with no parafunction. But if you have a patient with parafunction, you will end up with the only hand in a few years.

[Jaz]As you taught me Pasquale it’s a good way to say it is the biomechanical risk of a patient. And there’s a difference as you taught me many years ago about these. A patient who has low biomechanical demands and high biomechanical demands, and it’s important to appreciate who you’re dealing with.

So maybe what you’re suggesting is maybe those 40% of cases where you found that these flat preparations, would you say that a lot of those were in patients with high biomechanical needs?

[Pasquale]Of course. Of course. Most of the patients, this is for every therapy in dentistry so a filling lasts 30 years in a simple patient, in a patient with lower biomechanical demand.

That’s why sometimes you see gold filling, lasting 30 years, but if you check those mouths, you will see that in that mouth there is no wear. It’s not about gold, it’s about the mouth because all also composite filling can last 30, 40 years.

[Jaz]Wow. Even amalgams do 40, 50 years and we see all the time and everyone says amalgams causes cracks and stuff. I’ve got plenty of patients with 30 years amalgams not a single crack.

[Pasquale]How many cracks you see in a patient with virgin teeth? A lot?

[Jaz]Mm-hmm.

[Pasquale]So you mean the crack is about the force, the vectors, the muzzle vectors. It’s not about what you pull inside a cavity. Anyway, I will show you many cases about cracks just for giving you a better idea.

[Jaz]Brilliant. We’ve talked a little bit about the importance of having a degree of resistance, especially in this patients with a higher biomechanical demand. What is the limits of a decent dentistry? Because I’ve seen you do some really tough cases and go on really over and beyond with your skills to try and isolate and try and to achieve all the adhesive principles. But where do we draw the line? Where is it for you personally, Pasquale, that you say, okay, this will be adhesive, this will be non-adhesive. Where is the limit?

[Pasquale]A couple of years ago, I had a discussion with my friend Marlene Payman from Luve University because I challenged her to define what does it mean, adhesion? So, for example, if I ask you is an adhesive or not? In your opinion?

[Jaz]I would say that GIC would come into the category of an adhesive cement.

[Pasquale]So how do you cut the threshold between an adhesive cement and nonadhesive cement?

[Jaz]Well, actually now I’m thinking about it for me. Now you say adhesive should have some sort of degree of resin. So if it’s glass or iron cement, that’s a chemical setting, whereas a resin modified glass man would have at least common. So actually now I’m gonna revise my answer and say if I’m using something like a Fuji plus, which is a GIC ba base cement, that would be for me. I use it for my non-adhesive crowns for like my verti preps for example, vertical crowns I would use Fuji Plus or something. So I would say no, it’s not adhesive.

[Pasquale]I mean, when you talk about adhesion from the chemical point of view, you have adhesion when you have some chemical bonding between two structures, okay? Instead we are using the word adhesion for defining some cement they have no chemical bonding, but micro mechanical interlocking.

[Jaz]Yes. Yes.

[Pasquale]Because the hybrid layer is just a mechanical interlocking. So the only cement that we can use adhesively in then is glass ionomer not the resin cements anyway.

We tend to classify a cement been adhesive. Just if you get 20 giga pascal in adhesion. For example, if you are under 20 giga pascal, you tend to see the, to say that it is not adhesive cement anyway. The problem is that how long is the micro mechanical bonding, how longevous it is, what can damage the micro mechanical interface?

So that’s the question. You can have some giga pascal of adhesion at the beginning. It is longevous or not so, and what we have found over time that this bonding is very longevous on the enamel, but it’s not so longevous onto the dentine. Because, the problem, the biggest problem with dentine that we have no dentine.

We have what I call the 50 shades of yellow just for no, when a dentine is decay is attacked by dec. It change structures, and when you bond that dentine, it’s not easy to have longevity’s bond, in my opinion. This is my experience. After 10 years, if you start to remove a filling done well, you have a very trouble to remove from the enamel.

But then after you have removed the addition onto the enamel, you can remove the filling with an excavator because the adhesion to the end is completely lost. You can do an experiment. Everybody should do this experiment. You have a deep filling, you have a deep decay. You have to do a deep marginal elevation of this dentine. If you just do a bonding of two millimeter of denting of this deep margin, okay? After the light curing, you can remove within excavator that little piece of composite. That’s why when you do a deep marginal elevation, I highly suggest to create some mechanical interlocking with the enamel.

So you have to extend the platform because if the deep marginal elevation is very minimal, it’ll detach easily because that then is not prone to the bonding procedure.

[Jaz]I mean that makes sense, Pasquale in terms of how deep you are and you’re purely on dentine, but to extend it onto enamel, you mean we should also go a bit more buccal and a bit more lingual.

[Pasquale]Buccally-

[Jaz]So that it’s fine. Understood.

[Pasquale]Yeah. You have to extend the platform at least three, four millimeter inside a tooth, because if you limit yourself a deep little margin, the bonding is quite poor. It’s almost zero, so, but why enamel? The enamel is quite stable. It’s a rock, so it doesn’t change. It’s the same from the first day of the patient to the last day of the patient.

Dentine change over time, change color, change structure. So enamel offer another advantage. It make the tooth very stiff. If you have a lot of enamel, so the tooth cannot bend easily, but if you have lost most of enamel, the residual dentine under the chewing stresses can bend if it bends, the mechanical interlocking with composite will us teach very easily.

So that’s why if you have a lot of enamel go with adhesion, even with the flat surface. But if you have not so much enamel, honestly, it’s better to project and design is something that is re resistive and resistant in my opinion.

[Jaz]Brilliant. So, Pasquale, just to wrap that up, and I told you one of my guidelines for adhesive versus non-adhesive is at least 90% enamel.

Would you like to offer some sort of mathematical or rigid guidelines in terms of that, if that helps the young dentists understand about when to go adhesive and when to go non-adhesive, mechanical.

[Pasquale]So many people will, it’s not about how many enamel you have all around, because some teeth have a lot of enamel around about the surface, but the thickness of enamel is very minimal because, for example, is an erosive patient.

So erosive patient is not easy to treat because you have enamel at 360 degree, okay? But you have adjusted 0 3 0 4 millimeter of enamel. And 0 3 0 4 millimeters is not enough for me adhesion, you need enamel, almost a 360 degree. You can accept 250 degrees of enamel around and at least a thickness of enamel of 1.5 millimeters.

If I have less than 1.5 in thickness, I will not do any adhesion. Anyway I will present later in the presentation some cases that are very paradigmatic. What happens when you do a filling in an erosive patients, so you have enamel, but you have a very teen enamel, and you will see what happens to the fillings in a few months.

Jaz’s Outro:Amazing. We’d love to see that. Yeah. Brilliant. So then, and the next thing we wanna talk about Pasquale is the whole concept of no post, no crown. So this concept of we want to avoid placing posts as much as possible, and we want to avoid doing crowns and instead do onlays to maintain the gingival third of tooth structure where which is responsible for the strength of the tooth.

Now, my own personal views on post is that I haven’t placed a post for like, maybe two years now, because for me, if I have enough feal, then I think almost I don’t need a post. I can just rely on my composite and the crown will be engaged in a feal. If I don’t have any feal then I’m thinking, why are we even using a post here?

So for me that tooth is for the bin or needs some crown lengthening or something like that. Or even if I can’t get that fair ferrule from a vertical preparation for example, we can gives you a little bit more ferrule to play with. For me, that tooth is unrestorable. So I’d love to hear your views on this mantra of no post, no crown and find out how much you in your daily dentistry are using posts at the moment. Well, there we have it guys. I’m sorry I left you on a bit of a cliffhanger there, but we’re gonna cover the big bad topic of post next time. We covered a lot of ground, we covered a lot of breadth, but in the next episode we go a little bit deeper into some of these areas, especially when it comes to posts and why in this world where everyone seems to be anti post, he is pro post.

And even then it’s like a class post that he favors. And we’ll find out a bit more about his philosophies in restorative dentistry. If you’d like to gain some CPD, just head over to the app protrusive.app or on your device like Android, iOS, you can actually download the native app. And just by answering a few questions, you get some CPD for this episode.

There’s also monthly premium content that I add all the time. But I do wanna thank you for listening all the way to the end of this episode, and I hope you look forward to part two with Dr. Pasquale Venuti, same time, same place next week. See you there.

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In this thought-provoking episode, Dr. Pasquale Venuti represents Tomorrow Tooth aka 'the other voice of Dentistry'. He is a renowned dentist who is not afraid to express his controversial views. While he may challenge the modern techniques taught in dental schools today, he brings attention to the shortcomings in current practices and encourages critical thinking.

Protrusive Dental Pearl: New Restoration Needed and the Patient has an existing occlusal appliance. What can you do?

Imagine a Stabilisation Splint - For patients who rely on an occlusal appliance - how do you manage the scenario if they need a restoration? Do you need to make a new occlusal appliance? ? Not really. You just have to gouge out the acrylic where the new restoration was placed (intaglio surface of splint). If the splint fits well, no further adjustments are needed otherwise additional acrylic can be added to provide retention (like a partial reline of the splint over your new restoration. Don't forget that vaseline!)

Highlights of this episode:

02:36 The Protrusive Dental Pearl

05:25 Pasquales introduction

16:53 Subgingival Caries and Gingivectomy

22:10 ‘TableTop Onlays’ - Where is the limit?

28:30 Pasquale on C-Factor

31:12 What are the Limits of Adhesive Dentistry?

36:55 Guideline for Adhesive vs Mechanical

If you enjoyed this episode, check this another episode by Dr. Taylor Paton:Biomimetic Dentistry – What Actually Is It?

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Download our Prescribing Antifungals for Dentists Cheat Sheet!

Miconazole? Nystatin? Amphotericin B? What dose?

When should you refer, and to who?

How often do we prescribe antifungals as a GDP? I always need to brush up on the guidelines and best management of oral fungal infections whenever I make a diagnosis – which is why brought on Oral Medicine Specialist Dr. Amanda Phoon Nguyen to make diagnosing and managing oral fungal infections less painful!

Dr. Phoon Nguyen shared her experience and insights into diagnosing and treating oral fungal infections. Here’s a glimpse of what we covered:

Primary Oral Candidosis:
Explore the three types: pseudomembranous candidosis, chronic hyperplastic candidosis, and erythematous candidosis.
Learn how to identify each type and when further investigation may be necessary.
Candida-Associated Lesions:
Understand the different candida-associated lesions, including denture stomatitis, angular cheilitis, median rhomboid glossitis, and linear gingival erythema.
Discover the significance of these lesions in relation to systemic health.
Treatment Approaches:
Gain insights into effective antifungal medications, such as miconazole oral gel (Daktarin), amphotericin B lozenges (Fungilin), and fluconazole mouthwashes.
Consider interactions and precautions when prescribing antifungals for patients on specific medications.
Denture Hygiene:
Explore the role of dentures in oral candidosis and the importance of proper denture hygiene.
Learn practical tips for denture maintenance to prevent candida colonization.

https://youtu.be/-RqoVZVVnsI Watch PDP151 on Youtube The Protrusive Dental Pearl: What are you Waiting for? If there’s something you’ve been putting off (meditation, exercise, diet, work, etc.), the best time to start was years ago. The second-best time is today! Write it down, tell someone, keep yourself accountable and start right now.

Highlights of this episode:

01:31 The Protrusive Dental Pearl02:47 Dr. Amanda Phoon Nguyen06:43 Candida Albicans08:37 Primary Oral Candidosis14:48 Modifiable Factors18:40 GP vs. Oral Medicine – Where to Refer?21:44 To Prescribe or Not to Prescribe?24:10 Antifungal Medication31:44 Interactions35:48 Angular Cheilitis39:06 Median Rhomboid Glossitis and Denture Stomatitis39:57 Denture Hygiene

If you enjoyed this episode, check this another episode by Dr. Ben Pollock and Dr. Samuel Cope, Got Your Back – Physios and Dentists.

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How often do we prescribe antifungals as a GDP? I always need to brush up on the guidelines and best management of oral fungal infections whenever I make a diagnosis - which is why brought on Oral Medicine Specialist Dr. Amanda Phoon Nguyen to make diagnosing and managing oral fungal infections less painful!

Dr. Phoon Nguyen shared her experience and insights into diagnosing and treating oral fungal infections. Here's a glimpse of what we covered:

1.Primary Oral Candidosis:

Explore the three types: pseudomembranous candidosis, chronic hyperplastic candidosis, and erythematous candidosis.
Learn how to identify each type and when further investigation may be necessary.

2.Candida-Associated Lesions:

Understand the different candida-associated lesions, including denture stomatitis, angular cheilitis, median rhomboid glossitis, and linear gingival erythema.
Discover the significance of these lesions in relation to systemic health.

3.Treatment Approaches:

Gain insights into effective antifungal medications, such as miconazole oral gel (Daktarin), amphotericin B lozenges (Fungilin), and fluconazole mouthwashes.
Consider interactions and precautions when prescribing antifungals for patients on specific medications.

4.Denture Hygiene:

Explore the role of dentures in oral candidosis and the importance of proper denture hygiene.
Learn practical tips for denture maintenance to prevent candida colonization.

The Protrusive Dental Pearl: What are you Waiting for? If there’s something you’ve been putting off (meditation, exercise, diet, work, etc.), the best time to start was years ago. The second-best time is today! Write it down, tell someone, keep yourself accountable and start right now.

Highlights of this episode:

01:31 The Protrusive Dental Pearl

02:47 Dr. Amanda Phoon Nguyen

06:43 Candida Albicans

08:37 Primary Oral Candidosis

14:48 Modifiable Factors

18:40 GP vs. Oral Medicine - Where to Refer?

21:44 To Prescribe or Not to Prescribe?

24:10 Antifungal Medication

31:44 Interactions

35:48 Angular Cheilitis

39:06 Median Rhomboid Glossitis and Denture Stomatitis

39:57 Denture Hygiene

If you enjoyed this episode, check this another episode by Dr. Ben Pollock and Dr. Samuel Cope, Got Your Back – Physios and Dentists.

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What should the occlusion look like when you are restoring or replacing a Class IV restoration? This question is so basic yet so complex which is often not talked about enough. We go on all these composite courses and talk about the layering, but we don’t talk enough about how to put the principles of occlusion into action.

In this episode, Dr. Ibrahim will be talking about how Class IV Restorations can be optimised to get a long term predictable result. We also shared the two mechanical failures in dentistry and the step-by-step process of a Class IV restoration with occlusion in mind.

https://youtu.be/JgbO6PDjSOgWatch PDP150 on YoutubeThe Protrusive Dental Pearl: Occlusion Whisperer – Ask your patient to bite together and listen – in a “good” occlusion you should hear lots of tooth-to-tooth contact, whereas a thud indicates an issue. Use this in addition to more traditional methods of assessing the occlusion, and make sure you are satisfied with the occlusion before asking the patient “how does that feel?”

Are you ready to learn Occlusion in a way that makes sense, in your own time, with first class support and career boosting confidence to deliver Restorative Dentistry to the highest standard?

Then join Occlusion Basics and Beyond Online Course with IAS Academy

Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Highlights of this episode:

00:49 The Protrusive Dental Pearl
02:23 Dr. Mahmoud Ibrahim
03:07 Class IV Lesions
07:21 Mechanical Failure
09:28 The “Envelope of Function” and “Chewing Space”
13:50 Dealing with Limited Chewing Space
17:49 Mock-Ups
19:35 Dots and Lines
21:14 The Process

If you enjoyed this episode, check this another episode by Dr. Mahmoud Ibrahim, Next Level Occlusion (Basics Part 2).

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What should the occlusion look like when you are restoring or replacing a Class IV restoration? This question is so basic yet so complex which is often not talked about enough. We go on all these composite courses and talk about the layering, but we don't talk enough about how to put the principles of occlusion into action.

The Protrusive Dental Pearl: Occlusion Whisperer – Ask your patient to bite together and listen – in a “good” occlusion you should hear lots of tooth-to-tooth contact, whereas a thud indicates an issue. Use this in addition to more traditional methods of assessing the occlusion, and make sure you are satisfied with the occlusion before asking the patient “how does that feel?”

Are you ready to learn Occlusion in a way that makes sense, in your own time, with first class support and career boosting confidence to deliver Restorative Dentistry to the highest standard?

Then join Occlusion Basics and Beyond Online Course with IAS Academy

Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Highlights of this episode:

00:49 The Protrusive Dental Pearl

02:23 Dr. Mahmoud Ibrahim

03:07 Class IV Lesions

07:21 Mechanical Failure

09:28 The “Envelope of Function” and “Chewing Space”

13:50 Dealing with Limited Chewing Space

17:49 Mock-Ups

19:35 Dots and Lines

21:14 The Process

If you enjoyed this episode, check this another episode by Dr. Mahmoud Ibrahim, Next Level Occlusion (Basics Part 2).

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Occlusal appliances are commonly prescribed for the management of Bruxism – but they might be doing more harm than good if you have not screened for an airway issue.

Dr. Aditi Desai discussed the link between airway and bruxism- could an airway problem cause bruxism? Why is it advised NOT to have a standard occlusal appliance if there is an airway issue?

Did you know there are three levels of diagnosis for Sleep Bruxism?

The ‘Possible’ Bruxist, the ‘Probable’ Bruxist and the ‘Definite’ Bruxist – in this episode Dr. Aditi Desai who also featured in PDP 139 on sleep disordered breathing and sleep apnea, will explain this and when it may be relevant to sleep apnoea.

https://youtu.be/DozqYGEPNxYWatch PDP149 on YoutubeThe Protrusive Dental Pearl: Parafunctional Screening Sheet – A simple PDF that you can look for in terms of your extra-oral examination, intra-oral examination and the history – to give a clue that a patient might be a bruxist in just 2 minutes – download below:

Parafunctional-ScreenDownloadDownload and Sign in to the Protrusive App on iOS and Android and head over to the freemium version of this episode and on The Protrusive Vault for those Protrusive Premium members (where you can get full CE or CPD Certificate by answering a few questions)

Highlights of this episode

5:21 The Protrusive Dental Pearl
6:28 Dr. Aditi Desai’s Introduction
9:17 Airway in Dentistry
12:49 Lack of studies with regards to diagnosing sleep bruxism
16:32 Signs to look for to a possible bruxist and how to communicate with them
27:01 Nomenclature of sleep bruxism
30:51 Learning points to assess airway
35:43 Cases that caused the patient to become apnoeic

Get in touch for different Board of Sleep Medicine:

UK: British Academy of Dental Sleep Medicine (BADSM)
USA: American Academy of Dental Sleep Medicine (AADSM)
Australia: Australian Academy of Dental Sleep Medicine

If you enjoyed this episode, you may also like Airway – Dentistry’s Elephant in the Room with Prof Ama Johal

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Occlusal appliances are commonly prescribed for the management of Bruxism - but they might be doing more harm than good if you have not screened for an airway issue.

Dr. Aditi Desai discussed the link between airway and bruxism- could an airway problem cause bruxism? Why is it advised NOT to have a standard occlusal appliance if there is an airway issue?

Did you know there are three levels of diagnosis for Sleep Bruxism?

The 'Possible' Bruxist, the 'Probable' Bruxist and the 'Definite' Bruxist - in this episode Dr. Aditi Desai who also featured in PDP 139 on sleep disordered breathing and sleep apnea, will explain this and when it may be relevant to sleep apnoea.

The Protrusive Dental Pearl: Parafunctional Screening Sheet - A simple PDF that you can look for in terms of your extra-oral examination, intra-oral examination and the history - to give a clue that a patient might be a bruxist in just 2 minutes - download below:

Download and Sign in to the Protrusive App on iOS and Android and head over to the freemium version of this episode and on The Protrusive Vault for those Protrusive Premium members (where you can get full CE or CPD Certificate by answering a few questions)

Highlights of this episode

5:21 The Protrusive Dental Pearl

6:28 Dr. Aditi Desai’s Introduction

9:17 Airway in Dentistry

12:49 Lack of studies with regards to diagnosing sleep bruxism

16:32 Signs to look for to a possible bruxist and how to communicate with them

27:01 Nomenclature of sleep bruxism

30:51 Learning points to assess airway

35:43 Cases that caused the patient to become apnoeic

Get in touch for different Board of Sleep Medicine:

UK: British Academy of Dental Sleep Medicine (BADSM)

USA: American Academy of Dental Sleep Medicine (AADSM)Australia: Australian Academy of Dental Sleep Medicine

If you enjoyed this episode, you may also like Airway – Dentistry’s Elephant in the Room with Prof Ama Johal

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You’re faced with a beautiful crown with what seems like a decent root filling – but there’s an apical infection present. Is the answer always endodontic re-treatment? When should we instead consider apical surgery so we can clear the infection WITHOUT drilling through the crown or having to dismantle posts?

In this episode, specialist endodontist Dr. Peter Raftery and his associate Dr. Manpreet Dhesi will be talking about the Apicoectomy procedure that can be used to treat root-filled teeth using a ‘retrograde’ approach. They will discuss about how it fits into general dentistry, its indications and contraindications, its cost analysis vs implants and and the entire protocol for performing Apicoectomy

https://youtu.be/sZOsLuuf-VoWatch PDP148 on YoutubeProtrusive Dental Pearl: The periradicular surgery guidelines issued by BES and the Royal College of Surgeons. Download the guidelines about periradicular surgery or on the app under the Protrusive Vault (where all the different files and infographics and the different things that you get as a Protrusive premium member)

BES-RCS-Peri-Radicular-Surgery-GuidelinesDownloadDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Highlights of this episode:

1:37 The Protrusive Dental Pearl
3:32 Dr. Peter Raftery’s introduction
4:05 Dr. Manpreet Dhesi’s introduction
5:16 What is Apicoectomy?
6:29 Oral Surgeons vs Endodontists?
8:48 Is a Microscope mandatory for Apicoectomy?
10:08 Apicoectomy for posteriors
11:00 Isolation Protocol for Anterior Apicoectomies
11:35 Apicoectomy Protocol
15:03 Disinfection Protocol
18:41 Moisture control from the bleeding
20:43 Risk of surgical emphysema – Is special handpiece needed?
21:52 Indications and Contraindications for Apicoectomy
27:46 Endodontic Re-treatment
29:05 Cost benefit analysis of Apicoectomy
31:20 Success rate for Apicoectomy
34:19 Case Scenario 1: 82-year old patient with a singular crown, root filling and a radicular pathology
42:10 Retrograde fillings of choice
44:09 Grafting after Apicoectomy – is it needed?
45:04 Equipments for Apicoectomy
47:11 Learning more about Apicoectomy

Apical Microsurgery Instrument Kit- the mirror, the pluggers, and the little curettes by Hu-Friedy UK

Apical-Microsurgery-Instrument-KitDownloadIf you enjoyed this episode, check this another episode by Dr. Peter Raftery: How to Save ‘Hopeless’ Teeth with the Surgical Extrusion Technique

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Stop waffling and start communicating effectively. Stop giving 75 different treatment options and RECOMMEND the ideal plan based on their goal (hint: ask more questions!). Become efficient with patient communication by switching to video letters using Loom.

In this episode, Prav Solanki talks about the trust built between the Dentists and their patients, and how that trust is the foundation for providing the best treatment plan for each patient. After this episode you will realise that sales is NOT a dirty word, and you will love his definition of it.

https://youtu.be/cNVMKpzbqXIWatch IC038 on YoutubeCheck out the example Loom videos on Premium Clinical Videos section of the Protrusive App.

Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Highlights of the episode:

6:33 Prav Solanki’s Introduction
8:56 Sales in Dentistry
13:53 Information that patients needs to know before being eligible for a free consultation
18:47 Learning the art of concise communication
25:56 2 Stage processes in Business
27:58 How to build trust with your patients
34:05 Delivery of the Treatment Plan
36:51 Using Loom for Treatment Plan Presentation

Check out courses by Prav Solanki:

https://courses.iasortho.com/courses/gb/business-mindset-mastery

https://courses.iasortho.com/courses/gb/phone-school-with-prav-solanki

https://courses.iasortho.com/courses/gb/sales-and-communication-mastery-for-tcos

If you enjoyed this, you will also love Presenting Treatment Plans the Comprehensive Way

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Following the cliffhanger from Part 1 where the theme was Diagnosis – we now discuss the two main protocols of internal bleaching: the Inside-Outside Bleaching technique and Walking Bleach Technique for non-vital teeth whitening.

In this episode Dr. AJ Ray-Chaudhuri discussed how to prevent peroxide gel from entering the root canal system while performing non-vital bleaching. We cover every detail of the procedure and offer step-by-step guidance on how to make a tray, how much to charge patients, which gels to use and much more.

https://youtu.be/5Pl238679j4Watch PDP147 on YoutubeProtrusive Dental Pearl: The full protocol workflow – summarised PDF of Part 1 and 2 of this Internal Bleaching Series plus the patient advice sheet AND lab instruction sheet by Dr. AJ Ray-Chaudhuri

Click Here to Request the PDFsDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Highlights of this episode:

2:28 Protrusive Dental Pearl
3:40 Tips and Advice for Internal Bleaching in Practice
7:21 The Inside-Outside Whitening Technique
17:45 Internal Bleaching Protocol
23:21 Getting the proper access cavity
27:21 Dealing with patients who do not follow instructions well
31:47 Considerations and Tips to maximize success or to avoid mistakes
33:08 Internal resorption and relapse

If you enjoyed this episode, check out the first part of this episode: Internal Whitening Protocols Pt1 (Non-Vital Bleaching)

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Following the cliffhanger from Part 1 where the theme was Diagnosis - we now discuss the two main protocols of internal bleaching: the inside-outside bleaching technique and Walking Bleach Technique for non-vital teeth whitening.

Protrusive Dental Pearl: The full protocol workflow - summarised PDF of Part 1 and 2 of this Internal Bleaching Series plus the patient advice sheet AND lab instruction sheet by Dr. AJ Ray-Chaudhuri

Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Highlights of this episode:

2:28 Protrusive Dental Pearl

3:40 Tips and Advice for Internal Bleaching in Practice

7:21 The Inside-Outside Whitening Technique

17:45 Internal Bleaching Protocol

23:21 Getting the proper access cavity

27:21 Dealing with patients who do not follow instructions well

31:47 Considerations and Tips to maximize success or to avoid mistakes

33:08 Internal resorption and relapse

If you enjoyed this episode, check out the first part of this episode: Internal Whitening Protocols Pt1 (Non-Vital Bleaching)

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Non-vital bleaching or internal whitening comes in many forms, but it’s often confusing which exact protocol to adopt. When you learn this technique you can make a HUGE difference to a patient’s smile in a minimally invasive manner.

Restorative Specialist Dr. AJ Ray-Chaudhuri covered the all-important diagnoses and indications of internal bleaching as well as how to treat tooth calcific metamorphosis (the obliterated pulp). We answer the key question: do you always need to have a root canal treatment present?

https://youtu.be/mEHIypt-WW4Watch PDP146 on YoutubeThe Protrusive Dental Pearl: When carrying out internal bleaching make sure to clean out the entire pulp chamber especially the necrotic pulp horns – clean the necrotic tissue inside using ultrasonics. Ensure the entire chamber is de-roofed – remember that these are mostly trauma cases and the pulp went necrotic in youth – hence large pulp chambers. No role for Ninja access here!

Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Highlights of this episode:

3:03 The Protrusive Dental Pearl
5:55 Dr. AJ Ray-Chaudhuri’s journey into restorative dentistry
13:02 Internal Bleaching Protocol
15:45 Whitening obliterated pulp (Calcific Metamorphosis)
21:22 No prep veneer/Composite veneer VS Tooth Whitening
22:50 Q: Best time for Internal bleaching after Endodontics?

STAY TUNED for Part 2 Next week when it gets really spicy – we have a PDF infographic to follow!

If you enjoyed this episode, check out Post Operative Pain after Endodontics – Prevention and Management

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Rochette Bridges are a popular option for interim tooth replacement whilst implants in the aesthetic zone are ‘cooking’. In this episode with Dr Pav Khaira we discuss his interim restoration protocols using Rochette Bridges and Dentures, as well as gaining an insight in to custom healing abutments.

Which cement is best for Rochette Bridges? How do you remove them? Ceramic or Composite pontic? When might we consider a Denture instead?

We then expand in to soft tissue augmentation at the time of implant surgery to get the best pink aesthetics. This episode is packed full of gems even if you do not place implants – much of the benefits of soft tissue augmentation can be applied to non-implant fixed prosthodontics.

The Protrusive Dental Pearl: Steal my Resin Bonded Bridges consent form! It is a visual aid for patients and helps with information and consent for RBBs. If you are on Protrusive Premium, head to the ‘Protrusive Vault’ to download it. Otherwise you can request your free download here.

Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

“It’s all about how you communicate the soft tissue grafting surgery to your patient” – listen/watch the episode to hear this absolute peach of a communication pearl!

Learn Implants from Dr Pav Khaira

Highlights of this episode:

3:40 Dr Pav Khaira’s Introduction
7:20 Interim Restoration vs Immediate Loading of Implant
10:12 TWO Golden Rules of Temporary Dentures for Implants
11:15 What is a Customised Healing Abutment?
17:40 Rochette Bridges Protocol
23:54 Temporary Implant Crown Protocol
31:36 Communicating Soft Tissue Grafting

If you enjoyed this episode, check out Success with Resin Bonded Bridges.

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No need for violins – this episode was to share our behind-the-scenes story of creating an online occlusion course.

This year has been the most challenging for me and Mahmoud Ibrahim as we worked hard to make OBAB the most tangible, real-world, and comprehensive occlusion training on the planet. We faced many struggles, hardships, and sacrifices along the way.

I want to thank you all for your support, your help and your feedback. You have been a great help in this journey and I am so grateful that we were able to accomplish it with your blessings.

In this episode, me and Dr. Mahmoud Ibrahim were invited to the Dental Innovator Podcast to talk about the journey, challenges and sacrifices we made while working on OBAB. This episode will also inspire you regardless of your own situation. Whether you are starting a practice, buying a practice or starting a business within or outside of dentistry, this episode will give you inspiration and a perspective.

OBAB One-Time Pre-Launch Deal is now SOLD OUT – thanks for all your support!

Highlight of this episode:

2:27 Dr. Jaz and Dr. Mahmoud’s Introduction
5:52 Driving force in doing OBAB
8:56 Process in making online course
13:04 Online Course vs Live Course
16:48 Work-Life Balance
20:31 OBAB Journey
28:12 OBAB’s post course support
34:54 Responsibilities in Business Partnership
41:00 Qualifications of Dr. Jaz and Dr. Mahmoud to teach people occlusion
47:33 Dr. Mahmoud’s journey inside and outside dentistry
49:12 Marketing aspect of an online course
52:04 Advice for young dentists
55:42 Innovations in Dentistry

If you liked this episode, you will love How to Win at Life and Succeed in Dentistry – Emotional Intelligence

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As you may recall from the first part of this series, Dr. Wayne William is an amazing dentist in our community who has been kind enough to share his insights into local anaesthetics with us. Today we’ll be talking about the second half of this topic:

The most commonly used anesthetic agents used by GDPs (and why we should ditch one)
Is it safe to inject lingually?
Adrenaline for Cardiac Risk Patients – is it really a worry?

https://youtu.be/E9q4t5z7LdICheck out this full episode on YouTubeDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

The Protrusive Dental Pearl: Do NOT use the technique of lingual infiltration that I did! There IS a better way! (Lingual Infiltrations are not bad – just the way I did them was not ideal)

If you’re curious what technique that was, Protrusive Premium will get to see it in the middle of this episode including Dr Williams’ ‘live’ unedited, uncut reaction. This is GOLDEN content!

Highlights of this episode:

4:34 The Protrusive Dental Pearl
5:38 Large red headed people are difficult to numb. Is it a myth or is it real?
8:29 Lingual Infiltrations
17:02 Adrenaline being avoided for certain patients
23:49 Adrenaline for Cardiac Risk Patients

Occlusion: Basics and Beyond is the most tangible, real-world, and comprehensive occlusion training on the planet.

Get the OBAB One-Time Pre-Launch Deal which SOLD OUT – the only way now is the Waiting List as IAS are preparing 20 extra starter kits.

Be sure to watch the first part of this episode: Articaine ID Blocks and the ‘CIA Technique’ for Local Anaesthetic

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There is a massive trend of Dentists ditching ID blocks in favour of articaine buccal infiltrations. For many that are still using ID blocks routinely, they are afraid of using Articaine due to fear of paraesthesia.

Should we be doing less ID blocks? And when we do, is it ACTUALLY harmful to use articaine or is that a myth?

I have to admit, the main reason I heavily switched to buccal articaine was to avoid ID blocks.

Dr. Wayne William, our straight-talking, no-BS Prosthodontist guest will bust some myths and improve your daily delivery of safe and effective local anaesthesia.

In this episode he taught us the Crestal Intraosseous Approach (CIA), a technique developed by Dr. Wayne to improve our buccal infiltrations.

https://youtu.be/LbOxlXIZCkwCheck out this full episode on YouTubeDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

The Protrusive Dental Pearl: Check out the couple of videos I posted recently on YouTube and on the app

https://youtu.be/yFfKVLmSr5QRobin Hood Dentistry – a careful and well-considered enameloplastyhttps://youtu.be/3QLby2U_W3ENo More High Restorations 2023 Update – Stop Grinding Away Your Composites!“There is no such thing as a periodontal ligament injection” Dr. Wayne Williams

Highlights of this episode:

3:02 The Protrusive Dental Pearl
5:49 Dr. Wayne Williams’ Introduction
8:06 Buccal infiltration with articaine for lower molars
13:09 Crestal Intraosseous Approach (CIA)
22:28 ID Blocks – is it safe?
28:13 Hitting Bone while giving injections – safe or not?
31:04 Failure rate for ID Blocks

Occlusion: Basics and Beyond is the most tangible, real-world, and comprehensive occlusion training on the planet.

Get the OBAB One-Time Pre-Launch Deal before 21st March to get access to OBAB for two whole years and get a fully mentored case worth £550. Plus get £1445 of exclusive extras!!!

If you enjoyed this episode, check out Hot Pulps, Painless Palatals and ID Block Failures

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From the studio that brought you ‘The Fresh Prince of Appliances’…

I present:

Dots and Lines Music Video

https://www.youtube.com/watch?v=5vHKt3kUJ84&ab_channel=JazGulati-ProtrusiveDentalPodcastSign up before 21st March for:

2 years of access instead of 1 (worth £399)
£500 off
Starter Kit and OBAB Hardback Book
1 Fully Mentored Case on our Platform (worth £550)

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After the cliffhanger from Part 1, Dr. Sandra Hulac is back to share more information about Frictional and Constricted Chewing Patterns (CCP) with cases shared and explanations given.

Check out the Full Episode with a Free membership on Protrusive.App

Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

The Protrusive Dental Pearl: Overjet is King. We don’t want tight bites. We want a bit of overjet that gives chewing space – this will reduce the chances of a functional attrition and avoid ‘too much anterior guidance’ or locking the patient in.

“It’s important to know why things fail and try and avoid failure the next time”

Highlights of this episode:

0:28 PDP141 – Stop Blaming Bruxism Part 1 Recap
6:34 The Protrusive Dental Pearl: Overjet is King
6:56 The role of pre-restorative orthodontics
9:24 Case #1: Extremely traumatic deep bite
14:10 Case #2: Crowding of the lower anterior segment
19:41 Case #3 Lot of wear on the front teeth
23:54 Case #4: Chipped and worn front teeth
27:06 Case #5: Worn front teeth
32:41 Case #6: Patient had an extraction ortho

Dr. Mahmoud and I are also excited to share the occlusion that we learned over the years – in a way that you have never seen before!

Occlusion: Basics and Beyond is the most tangible, real-world, and comprehensive occlusion training on the planet.

LIMITED DELEGATE SPOTS DUE TO STARTER KIT STOCK – AVOID DISAPPOINTMENT! Occlusion Online Course

Be sure to watch Part 1: Stop Blaming Bruxism! How to Spot Frictional and Constricted Chewing Patterns (CCP)

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Do you blame bruxism for every time you observe attrition? As you know, I’m no stranger to occlusal appliances, but often they may be inappropriate for the patient who is causing their wear during FUNCTION and not so much during parafunction.

Maybe it’s time for us to start looking at different aetiologies of attrition and this is what the wonderful Dr. Sandra Hulac breaks down for us in this banger of an episode.

We also discussed the differences between frictional and constricted chewing patterns, which are often confused with each other. We share some case examples and discuss how to correctly diagnose these types of chewing patterns.

https://youtu.be/ao0sqY6lXZ4Check out this full episode on YouTubeDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

The Protrusive Dental Pearl: Acknowledge, understand, and believe the fact that often our patient’s centric relation (CR) is NOT more distal/posterior to their maximum intercuspation (MIP) – it can actually be anterior to their MIP!

Highlights of this episode:

2:43 The Protrusive Dental Pearl
6:01 Dr. Sandra Hulac’s Career Journey and Inspirations
18:22 What is a Constricted Chewing Patterns (CCP)?
25:43 How to spot for CCP (Constricted Chewing Pattern)?
30:12 Frictional envelope vs constricted envelope
37:31 Case Discussion

Dr. Mahmoud and I are also excited to share the occlusion that we learned over the years – in a way that you have never seen before!

Occlusion: Basics and Beyond is the most tangible, real-world, and comprehensive occlusion training on the planet.

LIMITED DELEGATE SPOTS DUE TO STARTER KIT STOCK – AVOID DISAPPOINTMENT! Occlusion Online Course

If you enjoyed this episode, check out How to use Injectable Composites to Treat Toothwear

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LIMITED DELEGATE SPOTS AVAILABLE NOW! Occlusion Online Course

As we launch OBAB, Occlusion Basics and Beyond in today’s episode, Dr. Mahmoud Ibrahim and I talked about our philosophy of occlusion. For us, the application of occlusion results in longevity, predictability and stopping your $#*7 from breaking.

We are excited to share with you what we have learned over the years – in a way that you have never seen before!

https://youtu.be/5vHKt3kUJ84Click here to watch our Dots and Lines music videoOBAB was developed to break down this seemingly complex topic in an understandable way that you can easily implement in daily practice in the real world.

Occlusion: Basics and Beyond is the most tangible, real-world, and comprehensive occlusion training on the planet.

But don’t take our word for it:

https://youtu.be/cFPTY0hfOtYCheck out what our delegates had to say about OBAB
Visit occlusion.online to learn more about the course and get the One-Time Pre-Launch Deal before 21st March to get £500 off enrolment and early bird access on April 7th. Plus get £1445 of exclusive extras!!!

Highlights of this episode:

4:00 What is Philosophy of Occlusion?
5:12 Dr. Mahmoud on his experience with occlusion
7:02 Different schools of thought regarding Occlusion
13:00 Importance of Occlusion
22:23 Possible failures doing restorative work without conforming to occlusion
25:13 Occlusion: Basics and Beyond

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Dr. Karl Walker-Finch shares his journey of pain to passion as he reveals the secrets to finding YOUR passion in Dentistry.

We started by discussing our crippling imposter syndrome as we left public Dentistry to practice privately. Along that theme we highlight the importance of taking control of your own destiny.

Karl’s new book, ‘In The Loupe‘ raises money for Confidental (emotional first aid for Dentists) and is a powerful book for Dentists that wish to practise without fear and establish the right work-life balance.

https://youtu.be/YPv71yr62tECheck out this full episode on YouTubeDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

“We do not need thousands of specialists in full mouth rehabilitation” – Dr. Karl Walker-Finch

Highlights of this episode:

3:12 Dr.Karl Walker-Finch’s introduction
5:48 Experiencing Imposter Syndrome
11:40 Private Practice vs Public Practice
16:31 Finding Passion – Ideal work for dentists
20:59 Top tips to help dentists find their ‘whys’ – Dr. Karl’s pathway before niching down
29:34 Taking control of our own destiny
39:32 Implementing the power of atomic habits in Dentistry
44:12 Dr. Karl supporting ‘Confidental’ – helping dentists with their mental health

You can now grab a copy of In The Loupe: The Secrets to Finding a Passion in Dentistry by Dr. Karl Walker-Finch!

If you enjoyed this episode, you will love Passion and Values in Dentistry with Dr. Dhru Shah

Click below for full episode transcript:Jaz's Introduction: n this episode, I'm joined by Dr. Karl Walker-Finch, who's the author of the book called In the Loupe, the Secrets to Finding a Passion in Dentistry. Hence why the name of this episode. Now, some of the other titles that are also considered were GDPs, just Want to Have Fun.Jaz’s Introduction:
And the other one that describes this episode really well, which I almost considered was Fall in Love with Dentistry all over again. Hello, Protruserati. I’m Jaz Gulati and I’m the host of Protrusive Dental Podcast. This is a non-clinical interruption. We call this an Interference Cast. If it’s your first time listening, thanks for joining me.

I appreciate it. It’s a whole three or four years worth of content that you need to explore, but if you are a regular listener, thanks for joining us again. This episode is a bigger picture episode. This episode is kind of like a feel good and an emotional exploration of your why and your purpose in your life and in your career.

Some of the themes that we cover are things like imposter syndrome, my goodness. So I do get imposter syndrome less now than I used to, but when I get it, I get it in a big way. So we’ll talk about how Karl experience is and how we both overcome that. We also talk about our journeys in moving to private density and how we actually felt bad about leaving the public health dentistry and what that kind of looked like.

Our little roadmap. The other thing we discuss is how we both want to, we’re both on a mission, Karl and I to infect you guys, you listening right now with enough positivity that you can head into work with excitement. In fact, the thing I love about protrusive and what it’s become and you guys is the messages I get are kind of like in this vein here.

I’m just going to read a message out to you from, oh, hey, it’s Dr. Albert, Albert, thanks so much, for freeing a listener. You sent a really lovely message. He said lots of nice things and I’ll cut to chase. He said, I’ve been practicing for seven years and have been stuck in a lot of routine, mundane mindsets that have been holding me back.

And watching PDP episodes on YouTube has gotten me so excited about all sorts of new things. Thank you again, and please keep up the great work. So, these messages, which I get saying about how you’re feeling more positive towards sensory, this is what it’s all about, man. This is what it’s all about, and this is such a huge part of what me and Karl discussed today.

We talk about finding your why, but also why Karl does not like goal setting. So if you listen towards the middle to end, you’ll find out why goal setting is not recommended by Karl. And a big part of this is mental health and not feeling like you have to be like every other Instagram dentist. Like you don’t have to do that to be happy.

There are other ways of defining your values and living your life and working your career in tune with your values. And what I love about Karl and his book In the Loupe is that all the profits go towards ConfiDental. ConfiDental is a charity which is emotional first aid for dentists. So Karl, I applaud you, my friend.

I think what you’re doing in spreading positivity in our profession, much needed, positivity is absolutely fantastic. And if you guys enjoy today and the conversations and the themes that you should definitely pick up the book, it’s out from the 27th of February. Show Karl and ConfiDental your support.

I hope you enjoy my chat with Karl today. I hope that you’ll feel inspired to take control of your life and take a massive stride towards having a fulfilling career. I’ll catch you in the outro.

Main Episode:Karl Walker-Finch, welcome to the Protrusive Dental Podcast, my friend. How are you?

[Karl]
I’m fantastic, Jaz. Thank you so much for having me on. It’s feels like it’s been a little welcoming, mate.

[Jaz]
It’s been great to see you because you’re such a great member of the Protruserati. You are the one that came up with a term Protruserati. So for those who want in the background, it was on the Facebook group and I was like, ah, our group needs a name.

It’s just called Protrusive Dental Community. I think that we can do better. And there were so many different suggestions. There were some obscene ones. I’ll have to figure out, I’ll to find that little thread on Facebook. But I loved, I love Protruserati, so thank you so much. Which is why you’ve been sent a hoodie. Just show off your hoodie, man.

[Karl]
Yeah, I’ve got Marty, here. It’s not got baby stain all over it of anything. So yeah, it’s, it’s been-

[Jaz]
Mine’s usually got coffee stains on it, so you’ve done well. No, again, thanks so much for contributing to the community in that way. Tell us a little bit about yourself, buddy. Tell us your origin story. I want to talk about something. I want to talk about a large part I talk about today is your book and what you write in your book. Cause I love that so much. And the charity you’re supporting, and the great content is the best dental book I’ve read in my life. I’m just telling you right with that right now.

Okay. So, I’ve read a lot of dental books, is the best dental book I’ve read in my life. So I want to say that right now. Make it public. But tell us about you, Karl. For those who don’t know you, tell us your origin story.

[Karl]
Yeah, you’re very kind. You’re very kind. Thank you. Well, yeah, so I grew up in Wilmington, moved over to Liverpool for my undergraduate, my BDS, and qualified in 2010.

After some ups and downs job in university, got out into the big wild world of dentistry. Started practicing in the NHS, did five years in the NHS to start off with, married a Yorkshire lass and then moved over to Yorkshire.

And when I moved over to Yorkshire, I was looking for these jobs. I was looking for NHS jobs and every NHS job I could find was in a corporate. And I’ve never worked for a corporate, so I can’t really comment on what it’s like to work for a corporate.

[Jaz]
It’s crap. Sorry, sorry. I’ve got a frog in my throat. Really bad frog. My, awful frog.

[Karl]
You’ve got. But I’d never worked for, and I didn’t, I hadn’t heard great stories and I didn’t fancy it. And so, I thought, well, what else is out there? And there was a private job going practice in Woodfield, well, a couple of factors in Woodfield.

And because of my background in dental implants, cause I’ve done a few dental implants by that point, it fit really well with whether principal dentist wanted to take the practice with regards to offering more things in-house. And so, I got the job there and I started working in a mostly. Private practice.

[Jaz]
Can I just ask you; can I just stop you on that Karl? When you were applying for that position, did you get like something that I experienced when I was going fully private is, this imposter syndrome. Like you feel like you’re not ready to go into private. Did you have, did you battle with that?

[Karl]
I get imposter syndrome most days at the moment. Still, it did. Absolutely. Yeah. I had this trepidation about getting into private dentistry.

I mean, I kind of had this loyalty to the NHS. I wanted to repay the NHS for, you know, all the help and support and the funding that got me through university.

And, you know, I’ve done five years, but I felt like I still wanted to give more. But yeah, I thought, right, well, the standards going to go up. I’ve got to do better. I’ve got to do more than, and to some extent that’s true. Yeah. You know, people are paying a lot more money for this service and yeah, you’ve got to offer a le a better level of service.

But it came to a choice of like, well, do I want to sacrifice me and what I’m doing and the work I’m doing to go and work for a corporate NHS style environment still? Or do I want to push myself and raise my level to fit in and go, yeah, you know what, I’m going private and it’s not going to be perfect straight away.

Nothing ever is. But I thought, you know what? I’m going to push myself and if private is all it’s cracked up to be then great. I’m going to push myself to be at that level. I got in there and I was surprised at how quickly you adapt to the working style. More time, more talking with patients. It’s great you get, actually have proper conversations with your patients and connect-

[Jaz]
Proper relationships as well.

[Karl]
Yeah, and you know, there will be those that can argue, you can do that on the NHS to some extent. And, you know, I always tried to connect with my patients when I was working mostly in NHS, but I really get to dedicate pretty much as much time as I want to or need to, to every patient.

You know, if they’re anxious, they’re just getting more time and that’s fine. Yeah. Whatever it just, you can do whatever you need to do for your patients.

[Jaz]
The thing that I found most liberating is not being confined by what the system can dictate you can and cannot do. And just like forgetting about it.

So now when I’m on Facebook and I’m scrolling through the dental groups, Anything that’s about what does the system say can be done, or what the system is allowed or not, I can just, I can smile and just skip right past that. I’m not giving that any of my time attention. So in the same way, it felt liberated, like the shackles have been broken because now I wasn’t thinking, okay, this patient needs, three root canals, four crowns.

I might as well work at Tesco’s versus also trying to then unfortunately, this, I’m just speaking the truth and trying to think, okay, how can I work smarter here so that it puts me in my practice in a better situation in terms of how much time is spent in the chair. Those are kind of real thoughts that happen every single day and let’s face it.

So having to not think about that and having to just to think, how can I help the patient? Now, of course, in the real world, in private, you have budgetary constraints that every patient carries with them, but that is part and parcel of any service that you provide. But that is much nicer challenge to have and a nicer problem to have than working in a confined environment. That’s the biggest benefit I thought.

[Karl]
Yeah. I think the other thing for me was not, I had this real difficulty doing what I felt was sales selling private treatment to patients when I was on the NHS. And I’d be like, well, I can do this crown for you for 200 and was it 246 pounds or something when I was last in the NHS? That’s, I don’t know what the band three is now, but yeah-

[Jaz]
Hashtag inflation.

[Karl]
I go in, well, yeah. But then going, well, I could do it privately for you for 400 pounds. Well, why would I do it privately? I don’t know, it might be a slightly nicer crown. But the reality was I wasn’t nearly likely to be doing an awful lot more than I wouldn’t. And I just, I felt really conflicted by it.

[Jaz]
I hated that so much, Karl. And same with the root canal. Now, I don’t know how our colleagues do this and some are great at doing it about, oh, you can have the NHS root canal now you can have the private root canal in the private, I get to use. This fancy equipment, the electric equipment.

Wow. I mean, that is a shaky territory. And I didn’t want to go in that. I’d never ever have done a private root canal whilst in mixed practice I just couldn’t do it. Because for me it was like, well, you either do the root canal or you don’t. So anyway, that’s why me And you didn’t make great NHS dentists,

[Karl]
Yeah. And I don’t know. And you know what? I enjoyed my time working as an NHS Dentist. And I enjoy my time working as a private dentist and I’ve had highs and lows in both. But now I would really struggle if I had to go back into a fully NHS or a nearly fully NHS environment. I honestly would, I don’t think I could do it. I couldn’t do the job justice, and I have a great deal of admiration for anybody who can’t.

[Jaz]
Hundred percent.

[Karl]
It’s a hard job.

[Jaz]
You guys, the dentist that and you know what I should give myself stuff on the risk because James, I’m not going to say a certain, I’m not embarrass you, but James, had a nice beer with you one day and you told me off in a nice way for calling out NHS dentist and calling him NHS dentist.

And you’re not, you know, just a dentist who chooses to work under a contract. So, give myself something. There’s no such thing as an NHS dentist, such as a dentist who chooses to work under that contract. And you’re right. And for those dentists who choose to work an NHS contract, are doing an amazing service, keep it up in a good way.

But if you feel as though you need to change course, then you should. And maybe this episode will inspire you. Maybe Karl and my experiences is going to hopefully help you along the journey. We’re always easy to reach on the Protrusive Dental community. Check us out on Facebook. But I want to take this direction of the podcast.

I just want to do a little bit of celebration of your book, Karl. So please, tell us about your book and then I’m going to pick apart because a few of my favorite chapters, a few of my favorite sentences. I want to just get you to speak a little bit more about that. So just tell us about, your book because at the time me and you connected, I was also writing a book.

I’m happy to share the name of my unwritten book. It’s called, The Bit Between Your Teeth. I was really proud of it. Tell us about your book, Karl, because you’ve done far more than I ever could. It’s really good.

[Karl]
Yeah, I mean the points of the book, I’ll say, just to segue in from the last point, I’ve not differentiated you between NHS and private within the book, you know, dentist.

And my career, as I said, has been up and down as a dentist. I’ve been qualified like 11 years now, and I’ve had times where I’ve had that feeling, that dread all weekend about knowing that I’ve got to go back into work on Monday morning and get flew another week of work. And you know, I’m not relating that to any NHS or private.

This is just, I had this dread that thought. I’ve not always loved being a dentist. I’ve not always loved being in dentistry. I do now. I love the fact that we get to help people every day. I love the fact that, you know, we’ve got to have this knowledge, this skill, this passion, this intense attention to detail, the perfectionism, the challenge that every different case brings, and the fact that we can make a big difference to people’s lives.

I love it. I really do. But it’s not always been that way. A few years ago I started listening to these personal development books on audible reading and a lot of stuff. All these great people, Stephen Goldin, Daniel Pink, Austin Kleon I’m looking up at my bookshelf now.

[Jaz]
Simon Sinek. There’s a lot of Simon Sinek I can sense in your book. Yeah, absolutely.

[Karl]
It is. And all of these things say, wow, this is amazing stuff. This is really powerful stuff. But so much of it isn’t really relevant to me. I’m doing all this reading and I’ve read the dental books as well and all these, and I said, you know what, wouldn’t it be great if I could take everything I’ve learned my journey from disliking, hating, not wanting to be a dentist, the fear of going to go through another week, the fear of patients complaining about me getting sued, the GDC, all of that fear and anxiety about being a dentist.

What if I can show people how I’ve built myself a career that I love and you know the thought once upon a time think, oh God, I’ve got to do this for another 40 years. To now going, great. I get to do this for like another 30 years or longer if I want to. How have we gone from A to B? And if we can bring in all of this stuff from all these personal development books.

I mean, my audible, I had a look before to just check. I want like two and a half months of listening time on Audible now, and I’m like, well that’s bonkers.

[Jaz]
What speed do you listen at Karl?

[Karl]
One and a half to two times, depending on the speed the innovator talks.

[Jaz]
Yeah. Okay. That has a strong bearing on it. You’re right.

[Karl]
But yeah. What if we could get all of that into like one book that’s relevant to dentistry and that can make a difference to some dentist lives and, you know, help other people love what they do. I mean, there’s that fear of everything that doom scrolling that we do through Facebook, reading everybody else’s horror stories and the, and how unreasonable these patients have been to them and all of how reason reasonable the principles been to them or the nurses.

All of this stuff, all of these problems that we encounter. You know, what if we could find some way of helping people overcome these issues and grow stronger together and really build this career, this passion, for helping people with dentistry, for doing what we love, because I’m not the only person who loves what loves what I do.

I know you do. It’s obvious the moment you speak to you or listen to one of your podcasts. And there are thousands of other dentists who love what they do as well, but there are many, many other dentists, possibly many more dentists that don’t. And you know, this is not like a switch. It’s not like you’ve either born to love dentistry or not.

You know, this is a journey you can go on and you can build this amazing career for yourself. And what I wanted to do was take everything that. I’ve learned in my career so far and used that to maybe help other dentists get to the same place, that same feeling that I’ve got of going, great. I’m back in work tomorrow.

I can, I’m going to do this and this and this, or, you know, I’ve got a new assessment. Awesome. What’s this patient going to be like? You know, it’s a great feeling to have, but it’s not something that a lot of people do have.

[Jaz]
It’s so true. And I think that’s the number one thing going forward for the mental of dentists with something we’re going to touch on as well. and I’ve always said, I’ve always been the vocal about being about okay, not rather being, but sometimes to know which direction to head in. You have to understand which direction not to head in. And the kind of direction we as dentists should not be heading in is the kind of dentist.

Now as you’re like curing, you’re looking at the clock. Not because you’re counting down how many seconds you are waiting for the like you to finish, but you are actually genuinely waiting for the day to end. Everything that we should do should help us to deviate away from that, I think. And definitely your book is, does that, and I’ve just chosen a few things now.

You talk about finding your passion, and that is such a big part of it, and I just wanted to say that, or read out, or just some segments of it. It’s just to put it in your context so you can explain more about what is the ideal work ferry dentist? So, you, you talk about how the work can sometimes be on one end of the spectrum can be done in laborious and on the other end it can be overwhelming and exhausting.

So, I’m just reading for certain parts of your book. And I love this term that you’ve used, which I’ve never seen related to dentistry before, and use this term emotionally expensive. And that is something that I really loved and I reconnected to. So just explain a little bit more a about that in relation to finding your passion in dentistry.

[Karl]
Yeah. I mean, dentistry is exhausting. I remember that feeling that I still get tired at the end of the day today, you know, don’t get me wrong, but that feeling earlier in my career when I wasn’t quite so used to talking people and engaging with people at such an intensity and forming new relationship, it takes a lot of energy in your mind to really focus in on exactly, you know, what each patient needs, what each patient wants, and you have to make all these decisions through the day, these diagnoses and everything about every step of the treatment that you’re providing.

If you are early in your career, you’re not used to doing that. Your brain hasn’t strengthened its muscles. Cause our brain’s a muscle in a lot of ways. Like anything else, you know, if you want to get stronger, physically stronger, you go to the gym and you push yourself to your limits.

You stress your muscles, and you stress your muscles and they recover and they come back a little bit stronger. And our brain’s the same. You know, you go to work every day and you stress your brain. You push your brain, you push yourself just out of your comfort zone, and you engage with a few more patients and you on a deeper level.

And that’s emotionally challenging at the start of your career when you’re not used to doing that. You can’t go from zero to perfect straight away. You have to build it up over time.

The key with finding your way is when you are getting exhausted and when you’ve been, you know, on the NHS I’ve maybe seen 30 patients.

As in getting towards the end of the day, it’s having that resilience to get back up and go again and say, you know what? This next patient is now the most important person. It’s challenging yourself to push yourself up to that next level again, to go again and to connect with that next person.

[Jaz]
How did you find your passion, you think? So just taking bits and book like everyone’s got their own journey. So how did you figure out that the implants, the cosmetic dentistry, the rehabs, that was your calling. And what do you say then? And then we’ll move on to the fact that the happiness doesn’t necessarily come from just doing the kind of work that you do.

Because the next bit I really loved was, I’m just going to read the bit I absolutely love, was that, ‘If you enjoy doing checkups and routine dentistry, the levels of challenge that brings the stability, the income, and the freedom of not needing to constantly attend the next course, then embrace it and run with it.’

Man, I love that so much. I think a lot of people need to hear that. A lot of people who see Instagram dentistry and everyone’s posting all these full mouth rehabs and people are swimming in Invisalign liners and stuff like that and setting up all these boxes of Invisalign. But really you are just happy to provide a good level of care, which in some people’s eyes might be basic, but yeah, you love that and you don’t feel the pressure of having to go on these complex courses all the time, then there is a place for you in this universe. It’s the message I got from that. And I think so many people would love to hear that.

[Karl]
You know what, it’s not just a place, it’s not just a place for you in this, it’s actually, that’s the bulk of what we need in dentistry.

That’s that. You know, we don’t need 40,000 implant specialists. You know, you can’t, we’re not specialists, but you don’t need 40,000 people who can place dental implants. You don’t need 40,000 people who can do Invisalign. What you need is, you know, maybe 30,000 people, 30,000 dentists out of the 40,000 dentists in the UK who are really good at being general dentists, who are really good at looking after their patients and caring for them and keeping them well maintained, preventing general dental disease, and that’s the most important part of dentistry.

[Jaz]
And I think that needs to be said. So I’m so glad we said that. And then on the opposite side, if you don’t enjoy the routine stuff, there are many different pathways. Or if you don’t enjoy dentistry at all, you go into that as well, in your book. Cause there’s only so many other pathways with dentistry you can take from specialism to hospital community, research.

But it’s about realizing that your happiness doesn’t come from whether you are in NHS, or you are in private or how you’re remunerated. There’s far more to it. So what I want to ask you is, Karl, when you were going through this journey in yourself, how did you realize that okay, just doing the general routine dentistry didn’t quite cut the mustard for you and you wanted to put yourself in these extra courses, uncomfortable scenarios, complications, because with doing a high level work comes high level complications, more sleepless nights, that needs to be said.

So how did you decide that, okay, this is the pathway for me and I want to abuse myself in this way before I can become good at something and provide this level of niche service?

[Karl]
Yeah, I mean, just to pick up on something you said there. Every level of dentistry has complications. Okay. And what you’ve got to be able to do as a dentist, is be able to deal with the complications of the things you’re doing.

So the fact that okay, implant, yes, I place dental implants, yes, I do sinus lift, and are all of this stuff that comes with that I, before you are ready to undertake that treatment, you’ve got to be confident that you’ve got a pretty good grasp of how to deal with the complications of doing that treatment.

That’s one of the biggest hurdles to overcome when you’re pushing yourself to develop, do it, put in an implant in screwing an implant in dead easy. No problem at all. It’s chimps work. It’s the old jokes about theological the surgeons in the hospital, they just screw bones back together or whatever.

You know, the chimps, you don’t need any kind of special skills really to screw in it, and put a screw in a jaw but it’s dealing with the complications, interpreting the situation, doing all the planning and all of that stuff that comes with it. And no matter what level of dentistry you are at, if we can categorize it into levels, even for the general dentist, you’re going to have complications.

You’re going to have complications without MOD restoration that you’ve just done is going to break at some point, and you’re going to have to deal with that. Or you’re going to go to do an MOD restoration and you’re going to have to find that you’re going to find that those costs are really, really narrow, really thin, and they’re going to rake off if you leave them.

You know, when you have to out. You have to make that decision direct and indirect. And so dealing with complications is something that you have to do at every point in your journey in dentistry. Coming back to your point about how did my journey lead me to where I am now? I never got to a point where I said, oh, actually, you know, being a general dentist doing the routine dental checks and all of this isn’t enough for me.

What happened was I went to university and like most people, most students, most 18 year olds go into university to get dentistry. The biggest exposure to dentistry they’ve had is orthodontics. So I went to university. Oh great, I’ll be an orthodontist. Then I got into university, right? Let’s go and explore orthodontics, go and invest myself as much as I can in orthodontics.

And I got there. I was going through it, I think. This is really boring. Don’t like this. It’s my opinion. That’s just my perception of it.

[Jaz]
If you don’t like dentistry, be an orthotist. We all know that.

[Karl]
Yeah. No, no, no. Well, I wouldn’t have looked at orthodontics and I didn’t enjoy the orthodontics, so I was like, okay, well what else is there?

And I was going and I was going to be, actually, I’m not bad at taking teeth out, you know, obviously now 21, 22 year old thinks he knows everything because he’s been on to take out an upper six. But you know, I said, right, okay. Surgery’s possibly where it’s at. And then these things called dental implants, 2009, 2010, were really starting to take off.

Think, right. Well, okay, how can I find out more about dental implants? And I was looking around at where I was going to go for my foundation year in dentistry. And there was this practice on the will called Glen Keir, and I was like, actually, they place implants there. They do a lot of implants. So the guys now my mentor, my foundation trainer was David Speechley, a guy called David Speechley

And there were two foundation trainers in the practice who was Simon Wright. Both of these two are now professors and it’s just, you know, so I saw this practice like, oh, you know what they do implants. I had some colleagues in all the years that I knew from dental school had been there and said, oh yeah, it’s a good practice to be out, get good exposures to all this stuff.

It’s like, you know what, that’s where I want to be. So I did everything I could to get myself into that practice. And when I was there, I did everything I could to shadow Simon and David placing dental implants. I thought, you know what, I quite like this idea of dental implants fill in these spaces, not having these fluffy dentures all over the place.

So I immersed myself in the subject as much as I could. And then come the end of my foundation year, I was thinking, yeah, I still really like this idea of dental implants. I’d love to be able to do this. So I got myself on a course and I went and did Professor Buser’s course in dental implants in Manchester, and I did the year course and got myself some patience and Simon and David mentored me and as it went along, I was just really enjoyed doing the implants and I was still doing everything else alongside it.

Still enjoyed doing the other bits, but the implants, I was like, you know what? I really, really like this. And so, I immersed myself in it a bit deeper. I went round and shadowed some more people. I went on more courses than I did a Master’s in it, and it just built quite organically. It wasn’t ever the case of, oh, I hate that.

General dentistry stuff. So, I’m getting out of that. I want to do everything I can to the implants. I still do dental health checks. I still look after a list of implant patients. And I love that. I love seeing the same faces come back every six months.

The relationship I’ve got with them, checking in with the kids as the kids are now getting older and all of the beautiful things of general dentist, all of those long-term patients that you see over and over again.

I still love doing that, but I also really love the implants as well. And just so happens at the moment that more people need implants than, or more people need me to do implants and rehabs and things like this for them, than general dentistry. And so the balance is tilting that way. So it wasn’t ever a point of going, oh no, I’ve got to get out of that situation.

It was just, I really love this situation. Let’s find out more about it. Let’s do as much to do with that as I can. And over time it’s just built and built and built.

[Jaz]
But you also did this thing whereby you thought it was orthodontics, so you are proactive. You did, you expose yourself to orthodontics and you didn’t get the same love back.

You made a decision. Actually, this might not be for me. So it’s not to say that, you know, if you are a young dentist and you’re thinking, oh, let me try implants, and then you go to shadow someone and you might not like, enjoy it at all, and that’s okay. Now shadow someone else who maybe does oral surgery or someone who does endo and you can visualize yourself being in that position.

So it’s about getting that exposure, getting that mentorship, getting some courses under your belt that are low level, and then eventually you build it up to something like a masters that you’ve done. That’s a good way to progress. And I guess it’s not about moving away from general dentistry, it’s more about finding a niche and an enjoyment of a slightly more specialized area where you can excel in. I guess that’s a good way to describe it.

[Karl]
And that’s the biggest thing for anybody coming out of university now if they’re wanting to, I listen to your podcast the other day with Pav about finding your niche in dentistry. I know it’s like an old one now, but it seems it was a while ago, but it’s that finding what you love and what you really enjoy and what you’re good at.

And if it is, say you wanted to be a general dentists, go and shadow some people being general dentists. Go and find some dentists who are working in nice practices who you maybe look up to and you go and see how they work, see how they operate in whatever it is.

You know, go and find out more about it. Read about it, read papers, read books. Go and shadow people. Ask people about it. You know, speak to people about it. Immerse yourself in that subject. And if the passion sticks, if you do it for a while and it’s still going strong, great. Do it some more.

[Jaz]
That is so true, and I think it’s a point well made that we always think about shadowing people with an enhanced skill or shadowing someone who’s an oral surgeon or an orthodontist or let me go shadow this person doing a sinus lift.

But actually, I remember vividly my experience of shadowing Rajiv Ruwala as a GDP when I was in my DF one. And I’m thinking, I was thinking, wow, man, this is a GDP who just did some beautiful crowns on the anterior. Now I’ve just seen someone for cobalt chrome. Now I’ve just seen child. Everyone’s left smiling the variety’s great.

So that was actually a big part of my journey. So I think I just want to emphasize that if you know, give GDP a shot as well, give general dentistry a good shot. Don’t just think that, okay, you want to be different. You want to be in that 7% of special services. 93% of density is general density.

So embrace it. And you could still find your niche within general dentistry like you have Karl. But it’s still beauty of being a general dentist now. Dentistry is part of our lives. And, I like the bit in your book about taking control of your life and taking control of your destiny.

So I want to ask you, I mean, I have some thoughts on this about, in terms of how I’ve done it, but can you give us examples of you, Karl, in terms of how have you thoughtfully and proactively planned your life and force your destiny in a way that has gone?

[Karl]
So, I really don’t like goals. Okay. I hate goals. Goals are for sport, goals are for these finite games. Football, basketball, whatever you want to play. It’s where you’ve got a tangible goal. You’ve got to score a goal. You’ve got to get a certain number of wickets and cricket, whatever it is. You have a set goal, there’s a set finish line.

And that goal gets you over the finish line to get your achievement. And life dentistry is not like that. There is no finish line in this. Okay. Yeah. You might say when you die or you retire, is your finish line, but you’re not going to, there’s no end point. You don’t, nobody writes their net worth on their gravestone, you know, for instance, so you, oh, I want to earn this much money.

I want to do this, or I want to have this sort of practice, you know, having a set goal. I just don’t get it. I’ve tried setting goals and I just don’t get it. And it’s, yeah, great business and all these corporate people who want you to do goes fine. Great. Okay, go for that. But, you know, when I was starting out an implant then, right?

This goal, I’m going to set myself a goal at placing 50 implants a year. Great. Let’s do 50 implants here. Well, what does that mean? It is absolutely nothing because I could go around and place 50 implants into a piece of wood. Does that count? If I could, if I go to the Dominican Republic and place 50 implants into these jaws that are the size of tree trunks, does that count?

If I’m in the UK and I’m placing implants, am I doing things just so I can get my 50 implants? Am I sort of maybe providing treatment unethically just so I can get my implant count up to place 50 implants? What happens if I’m doing really well one year and everybody wants implants and I’ve placed 50 implants?

Wait. Yeah. And so I can slack off for the rest of the year now because I’ve done my 50. Great. Well, I’ll chill out and then in January I’ll start. Okay. And this whole sort of defined goal thing doesn’t make any sense to me. That is not to say you can go through like without direction. If you have to have some sort of vision, some sort of direction that you want, take it.

Otherwise, you are just standing still. You know, the one certainty in life is change. Change is constant. Which means if you are not improving yourself at all time, if you are standing still, you’re not standing still, you are getting worse because everything else is getting better around you. So you have to constantly refresh yourself.

You have to constantly improve your knowledge just to stay afloat in some senses. But, so you have to keep an eye on your direction and where you’re going and for me, let’s go back to the implant example. That was about not necessarily placing 50 implants a year, but to go, okay, well, I’m going to place an implant, I’m going to plan it meticulous.

Write down to what incision I’m going to make. You know what local anesthetic, which sites I’m putting my local anesthetic in where and every tiny little detail. I’m going to take photos throughout that whole case and I’m going to reflect on that case as well. And every reflect on every little detail. And when that case doesn’t turn out 100% perfect because, hey, listen, in 11 years of dentistry, I’ve never done anything perfectly.

There’s always something I could have done a little bit better in every case. When it doesn’t turn out perfect, I’m going to look back through those pictures. I’m going to look back through my notes. So I’m going to say, right, how could I have done that better? And if I’m just driven for going, oh, well, 50 implants, and once I’m placing 50 implants a year, I’ll be a success, then you’re not going to learn anything at all in that process.

It’s the process of how you get there and reflecting on that process and improving that process that will ultimately lead to you becoming a better dentist. You know, the goal doesn’t matter. The outcome doesn’t matter. You know, goals, when covid hit, you know, everybody’s goals went out the window because goals don’t account for global pandemics.

But if you focus on the process and your development and improving yourself day upon day, then the outcome, the goals that you would’ve set anywhere, you’ll smash them out the park because day upon day you are building yourself stronger.

[Jaz]
It’s the journey rather than destination.

[Karl]
Yeah. I mean it’s, there’s 1,000,001 cliches that we can throw around of that sort of nature.

But it is, it’s about taking the steps day in, day out to build yourself stronger rather than just focusing on that destination, that endpoint, because the destinations will sort itself out. If you’ve started taking the steps in the right direction, you know, lean your ladder against the right wall before you start climbing it.

Whatever you want. However you want to phrase it. It’s about giving yourself the direction and implementing the process. So for me, that’s not how many implants do I want to place next year, but it’s if I continue to do what I’m doing now, well, what’s my life going to look like in five years? What’s my life going to look like in 10 years?

Not in five years. I want to own my own practice and in five years I want to be placed in a hundred implants, or I want a do of doing 50 full large cases. No, no, no. It’s if I keep doing what I do in now, what’s my life going to look like? And if I don’t like what I see, and we go, okay, well what can I do to make that life in five years look a little bit better?

What can I do today that’s going to sow the seeds in the future? And the thing to get your head around here is there’s no immediate payoff. You don’t get this immediate gratification. We love within this world of instant gratification. You know, you put a post on social media and you go, oh great, I’ve got 10 likes, 20 likes, 30 likes.

It’s only been an hour. Oh, I’ve put a blog post out. Yeah. Like 200 people have led this blog. That’s amazing. I’ve got this podcast. And you know, we celebrate the fact that, oh, he got thousands of people. Listen, great. But it’s, what do you do each and every time to make it that little bit better, to add that little bit more value to the people who are reading, to the people who are listening to you, to your patients that you are caring for, and you build those foundations and the rest takes care of itself.

[Jaz]
I love everything you said, and I just want to highlight the four questions that you’ve written your book, a line to exactly this theme. And obviously you’ve covered two those already. So, what Karl talks about in the book is how we can take control of our destiny. And four questions to ask yourself is, if I keep doing what I’m doing, what will my life look like in 5, 10, 20 years?

Number two is how do I want my life to look in a year’s time? Number three is what do I currently do that I hate? That’s a really strong one. And lastly, what do I love doing and want to do more of? So, I mean to an example of how I have used those questions. Not recently, because I’ve very recently read the book, but going back, maybe 15, 18 months ago in my life, I’m just thinking.

I’m in a scenario now where I decided that question number three, what do I currently do that I hate? I got to a situation Karl, where I just didn’t enjoy my commutes anymore. Yes, I was listening to audiobooks and podcast stuff, but the commute was long and I didn’t enjoy the lack of time with my son because I’d leave super early to go to Oxford and then come back and by then my son might be asleep.

So I was really struggling with an internal battle about not having a time with my son. So now I have a three minute drive, but now I started walking, so it’s like a 15 minute walk. And I’ve adopted a shift pattern work, so I found somewhere that does shift pattern. So I work from eight till two or two till eight.

The net result of that is I get so much more time with my son, I get to do the podcasting, and I get to still work environment that allows me to grow. So that was one example of me deciding, okay, this is where I’m at, but I want to take, I want to steer my ship in a certain direction. So I would encourage everyone to get Karl’s book, read that bit and really just answer it yourself, reflect on that bit, and come up with how you are going to take charge of your own destiny rather than allowing life just happening to you.

[Karl]
Yeah. I mean, what you’ve also done there, which is that another, in the essence are a lot of what the book’s about is coming back to why are you doing what you do? Why are you driving 45 minutes an hour to work every day and then doing the same coming home? And what would you rather be doing?

You want to be with your son, you want to be with your family. Of course you do that. I mean, I’m a family guy. That’s, you know, you don’t have to need to start singing that. Thank you, but I I’ve always known, even before I had kids, that family was the most important thing to me. And I want to do everything I can so I can be the best dad, the best husband, the best family member that I can be.

And that involves making sure I spend enough time with my family. That means making sure that I do enough work to provide a stable lifestyle for my family as well. And you know, it’s about figuring out why you are doing each thing that you’re doing. And you go, okay, well why do I travel so far to work if I don’t need to do that.

What would I rather be doing? I’d rather be with my son. Right? What steps can I take to get myself in a position where I don’t have to travel? I could move closer to work or they could be work closer to me and you’ve built yourself this career, your skills, your persona. You know, you are well known in dentistry.

Everybody knows Jaz now. But you built yourself, you’ve built your own personal brand opp to such an extent there. You know, right now you could probably walk into a job near enough anywhere in the country if you wanted it.

[Jaz]
I doubt that very much, but I see what you mean. I appreciate that.

[Karl]
But, building your own skillset up and developing yourself personally and professionally gives you that freedom to go, you know what, actually I don’t want to travel so far to work anymore. Maybe a job closer to home. And I’ve laid the foundations to actually give myself the freedom to choose where I want to go. And that does make all the difference.

[Jaz]
I’m going to ask two more main questions before we take any direction we want. And Karl, the next question is, I love that you mentioned the book atomic Habits. It’s also I think you probably told me about it some months ago. Really great book. I’ve been actually thinking about and we should probably do this, Karl, about how we can apply atomic habits in dentistry, and that is with how we motivate our patients to, how we motivate our staff members to how we can grow as clinicians every day. I think we should do it, Karl. Let’s arrange-

[Karl]
Yeah, there’s definitely something there.

[Jaz]
Atomic habits in dentistry. I think we can do such a great job of that. But I want to just ask you as a little flavor for what’s come, can you gimme an example of how you’ve implemented the power of atomic habits, either in your personal life or at work, because I know you’ve discussed it in the book.

[Karl]
Yeah. I mean, atomic habits is one of the best books, the personal development books I’ve read. I mean, I’ve made about it before. The whole ethos, the whole thing around Atomic Habits is, making small incremental changes day on day. And those changes, if you can improve by 1% every day, that 1% compounds. And over the course of the year, you get a 3700% increase in your effectiveness, whatever that might be.

And the point of atomic habits is building those foundations. So one of the example that I use in the book is I was, I’d moved over to private practice and I’d been there for a year or two, and I thought, you know what, what I really need to do to take my dentistry to the next level is start using rubber dam for pretty much everything, everything possible.

And so one day I just decided, right, you know what? I’m going to implement this today, I’m going to start using rubber dam for every composite restoration. I was already doing it for root canal treatment. I was doing every inlay preparation if an inlay fit, you know, whatever was, I was going to use rubber dam for pretty much everything.

I could possibly have an excuse for using rubber dam for and you know, dental health check. Yeah. Should we use rubber dam for this ? But it was a case of, so mate, I could, that’s it. Flip switch. Okay, that’s what I’m going to do. You know, and yeah, it took me a while to get that rubber dam on at first because I wasn’t used to doing it as often.

And it took a while because the nurse had to get it all up. But when you engage your team, you say to your nurse, look, I think we’re going to do a better job for our patients if we use rubber dam because it’s going to stop all that amalgam stain all over their mouth. It’s going to stop all their saliva washing around this filling while we’re trying to seal it up. If we can do this, I think we’re going to do a much, much better job for the patient.

[Jaz]
And that’s also how you sell it to your patient as well.

[Karl]
Yeah, exactly. It is. And you engage your team with why you’re doing it. And you say this is what’s happening for now. We’re going to do this. And so my nurse know now every single time, every single patient, she’s got the rubber dam on ready for me because she knows if that rubber dam’s not on the side, I’m going to ask for it.

And she’s then going to have to go and get it. Okay. Because she’s already got the rubber dam out. It’s dead easy for me to then go, oh great. I’ve got the rubber dam that I’m going to use it. Everybody knows we’re on board. Okay, we’re going to implement this habit, we’re going to use rubber dam for everything.

And in fact, it’s more than just easy for me to use the rubber dam. I feel bad if I don’t use the rubber dam because my nurse has got to the trouble of getting the thing out. So I know if I don’t use that rubber dam now I’m going to get the look. And I’m going to get daggers because I’ve made her get it out for every patient and I’ve not used it, so it’s easier for me to use it and implement that habit.

[Jaz]
It’s a way of doing it accountability. And I’m the same. I use rubber dam for pretty much everything that I can. And the other example I can give to those listening and watching, in terms of an anatomic habit that you can create is those who are on the journey into dental photography and you’ve bought the stuff, but you’re just not in the habit of taking photos.

Well, don’t be that dentist who, when you’re ready to take a photo, you need to be like, okay, let’s get the mirror. Let’s heat the mirror now. Can you get the retractors out? You know, just has to walk out. Now you need to get your lens and attach it to your body, and then put the flash on. And then you’re thinking, oh crap, I forgot the settings.

Don’t be that dentist. Have the settings ready on, in laminated or set on the camera ready. Have everything attached already. Have the mirror on the heater, already. Have the retractors there, and have this pre-chat with your nurse first saying, Hey, you know what? I’m really serious about taking photos, and I want to do this as much as possible.

And then let’s start by doing an incremental change by every new patient will get photos and then build up from there. And then every composite will get photos. And then you’ll build and build and build. So that’s another implementation of atomic habit. So I’m so glad you mentioned that in the book.

And then now I want to move on to, because I want to do a whole episode with you about incremental changes we can make atomic habits apply to dentistry. I’m so excited for that.

[Karl]
We’ll come back to that one.

[Jaz]
I took, yeah, we’ll come back to that one. And I want to talk about a really, I’ve saved the best for us because something that, I’m really, really keen for you to explore further is the support of charity from this book and in particular, a very, very, I mean, they’re all charities are important, but this is such a key charity. I met Jeremy Cooper at the BACD and I said to him, look, I want to do what I can, what Protrusive, to raise a bar and let everyone know that ConfiDental exists. So please tell us about why you chose ConfiDental and then, tell us about, you and your wife and how, you know, you are taking a direction in terms of helping people with helping dentists with their mental health.

[Karl]
Yeah, my mental health generally, okay, so I’ve never been formally diagnosed with anything, okay. But I have these periods of highs and lows, so almost like a very mild form of like manic depression. It sounds really dramatic, which Oh God, manic depression. Oh. But that’s sort of how it goes.

And it ebbs and flows. And sometimes I can take a long time for a while and then I’ll have like a manic phase and then a low phase. A GP friend of mine sort of said it sounds a bit like what we call cyclothymia, which is like a mild manic depression. And I started reading up about it. I was like, eh, it kind of does sound a bit like me, really.

It’s almost like it’s cyclical up and down. Call it my mom, period. Sometimes it’s, you know, sort of hits me like a hormonal imbalance every couple of months. And I just dip and I probably just offended 50% of your listeners. But, yeah, so mental health has always been something that I’ve had on my radar and my Yorkshire last. My wife, she’s a psychotherapist and so she’s a counselor, so she’s dealing with-

[Jaz]
I had this burning raise to know this right now, because I have a patient who’s a psychotherapist and I have a patient who’s a psychiatrist. I know psychiatry needs medicine first. And basically they just give you drugs. What is a psychotherapist like? How does that differ?

[Karl]
Alright. There’s lots of different types of psychotherapists, but yeah. Psychiatry is a doctor, a medical doctor, you know, one of the proper doctors, not as fake doctors. A proper doctor who has then gone and done psychology, additional psychological training to become a psychiatrist.

Okay. A psychotherapist or a counselor is, so in my wife’s case, she did a degree in psychology and then she did a postgraduate master’s level diploma in counseling and psychotherapy. Now there’s a whole scale of different qualifications you can get as a psychotherapist from doing a weekend course or going right the way to doing a master’s degree and beyond.

Yeah. So that was my wife’s path. She did psychology and then she went on and did counseling, psychotherapy. And again, as there are different schools of thought with occlusion, there are different schools of thought within psychotherapy. So you have, Freudian Type psychotherapy.

You have, legend Carl Rogers, which is person-centered psychotherapy, which is sort of what my life’s original training was in the fundamental principle being, you know, nobody’s born evil, everybody’s born equal.

You don’t blame the person, the perpetrator of whatever it is. Or you don’t blame the person for having said feelings or phone things that, you know, it’s a consequence of the things that have happened to them and all of this which is one school of thought appropriate for helping some people.

There’s things like transactional analysis and all these different areas of psychotherapy. But yeah, Melissa’s training sort of originated in person-centered psychotherapy. But this sort of combination of me having these ups and downs and actually being quite open and free to talk about it because it’s something my wife and I talk about all the time we deal with all the time because of her line of work and in the middle of last year when Covid had hit and everybody was going, oh, it’s okay to not be okay.

And all of this was bouncing around the social sphere and everybody said, oh, it’s okay to not be okay. And then you go, well, everybody’s saying this, but no one’s actually saying they’re not okay. I was getting a bit, I was getting a bity. It was like, you know, everybody’s saying it’s okay to not be okay.

And maybe somebody reading that hashtag somewhere goes, okay, well actually I’m going to talk to my friend about this now. And that’s great. You know, you don’t have to do what I did, which is when you enter a particularly low dip, you write about it, you take a stupid photograph of yourself, and then you post a blog about it on Facebook, which is what I did.

And showing everything, look, this is what it looks like when I’m feeling down. Okay. And you cry and you’re upset, and you’re down and you’re hurt, and a lot of the time, for me it’s often a feeling of complete apathy, a complete sort of devoid of any emotions. And, you know, I’m going to put this out there because what people often in that situation do, is go, Hey, I’m great guys.

Come on, let’s go. And you beat yourself up and you get yourself back out there and you put this brave face on, and then you go home and cry yourself to sleep. And you go, right, well, this isn’t good. This isn’t right. This isn’t healthy. And what I realized was actually this cycle that I was in, I’m able to do something about it.

And I’m not saying everybody can, you know, there’s a whole myriad of mental health conditions that, you know, we’ve got to be aware of. But I realized there was this pattern to it. And, it almost for me was a case of a tick along. Okay. And I’d get quite busy and then I’d go, go, go, go, go.

And I’d basically burn myself out and have a mini burnout. Everything had shut down. I’d find it really hard to get outta bed. I’d find it really hard to get myself motivated to do anything. And then after a few days, my body would go right. We’ve hit reset. Now go again, but don’t do that again, Karl.

That was very naughty, and I realized, I sort of through my reflection, my personal reflection log, my journaling and things like this, I did, I sort of started to see this pattern and this, these conversations with my wife that I was having, I was thinking, you know what? I can do something about this.

So now when I’m getting to those points of seeing myself enter this little mania phase, right, stop, slow yourself down. And most of the time I can stop myself getting into that.

[Jaz]
Well done.

[Karl]
Now, well, yeah. But-

[Jaz]
I mean, I just want to just pause and say like, thank you for sharing this and putting yourself in a very vulnerable position.

And I’m sure everyone who’s listening on their commutes have just taken a moment and maybe just gone, whoa. Like to what you said, and I really respect that you’re sharing this with everyone because I think it needs to be heard. And thank you for telling us about your very real experiences and then from there stems this desire to help other dentists, as you’re going to say in terms of through ConfiDental. I mean, is that a service that you used before or is that?

[Karl]
So yeah, so let’s get back to the point, Karl. The point is, yeah. You know, not if I don’t say this, who’s going to? If somebody what I’d consider a relatively mild form of all of this going on, who talks about mental health things all the time at home with his wife and is married to a psychotherapist, somebody who can help people like this and who regularly helps people like this.

If I can’t talk about it, who’s going to, and maybe if I can talk about, then somebody else will have the strength and the confidence to come out and say, you know what, actually I’ve been struggling a bit and you know, you’re not going to shout this from Facebook or whatever the you want to do, you might go and talk to your wife, you might go and talk to your mom, your dad, your cousin, your friend, whoever it might be.

That talking helps. And for some people who don’t feel that they can talk to anyone or they’ve tried talking to people, because you know, I’m so, so lucky that I’m married to Marisa because Marisa knows exactly how to respond when somebody’s struggling. And when I say to Lisa, oh look, I’m really struggling ’em, she goes, okay, tell me more.

No judgment, no advice, no nothing. She just listens. And I mean, that’s invaluable. And what ConfiDental have set up this charity, they’ve set up this helpline. So you just phone it and you can just talk to someone and they listen and they’re there for-

[Jaz]
They don’t take any names, any GC numbers, or this is just there at the end the phone to speak to someone. They don’t even know your want to know your name or unless you want to relieve it, reel it or whatever. They’re just there to help you in a difficult situation.

[Karl]
I mean, exactly it. And they’re just there to support and they’re dentists who are volunteered and they’re just there to support you through whatever it is.

And you know, I was speaking with John Lewis, one of the founders of ConfiDental and you saying, you know, a lot of the time people are calling up about issues with patients, about concerns over the GDC about and those are our people calling about just the overwhelming sensation of an inability to cope with life.

And that gets people as well. Some people suffer with depression. Some people suffer with anxiety. Some people it’s imposter syndrome. There are all of these things. Some people it’s PTSD, you know? Traumatic experiences. And that can be a car crash, that can be witnessing a cardiac arrest in practice.

You know, it can have a profound effect on you. It could be somebody suing you and going through legal proceedings, that

View Details

I will reveal a little ‘trick’ that might ‘recapture the bite’ on a patient who develops an anterior open bite (AOB) after wearing a nightguard/splint/occlusal appliance.

There is a degree of risk and uncertainty when we prescribe occusal appliances as it hinges on patient compliance and factors that are out of our control. There are certain risks that come with treatment that we should consent for, and this includes bite changes.

Occlusal appliances are not an exact science – the evidence base is not high quality. That does not mean they do not work, it just means that we need more data! We don’t even know the mechanism of HOW occlusal splints work as that is yet to be proven.

Hello Protruserati! Welcome back to the third episode of #AskJaz where I answered three main questions from our Protrusive Dental Community – 1) developing anterior open bite after an occlusal appliance, 2) how to scan/bite register at a desired OVD, and 3) what should the occlusion look like on composite veneers or edge bonding?

https://youtu.be/Li2W-ysYRIECheck out this full episode on YouTubeDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Dr. Mahmoud Ibrahim and I are currently working on a huge project called OBAB, Occlusion Basics, and Beyond – it will be the best occlusion resource in the Milky Way…and that’s our mission! We want to finally demystify Occlusion and make it Tangible AF!

Join the waiting list HERE!

Highlights of this episode:

1:51 Risk of having AOB after an Occlusal Appliance
15:48 Trick to recover an AOB that has developed
26:49 Bite Records for Stabilisation Splints
30:25 Checking the Occlusion after Composite Veneers
37:02 Occlusion Basics and Beyond

Do join our Protrusive Dental Community Facebook Group. It has so many great gems and pearls shared in our little community – ONLY FOR LICENSED DENTAL PROFESSIONALS.

If you enjoyed this episode, check out this episode with Dr. Barry Glassman – Do AMPSAs cause AOBs?

Click below for full episode transcript:Jaz's Introduction: Occlusal appliances can be scary things. When we are given to our patients, we're at the mercy of their compliance. We don't really know if they're going to get along with it or not. [Jaz]
We don’t really know if it’ll help their pain. If pain is the reason that we are prescribing in occlusal appliance, and a lot of times we are taking on a bit of risk because there are certain bite changes that can happen after occlusal appliances.

And despite what you think, you know, you might think, oh yes, anterior only appliances, they’re the big culprits here. They’re the ones, those shifty devices, they’re the ones causing all the bite changes. But actually, you can get a bite changer. A patient can get a bite change from any type of occlusal appliance.

So, I see this quite frequently on the Facebook groups from dentists and also lots of dentists message me and share some of the cases where they’ve had some bite change. They’re trying to get their head around what exactly happened. So, in this Ask Jaz episode, I’m going to cover three main themes.

The main, the big one. The first one is, a patient who develops an anterior open bite after an occlusal appliance, and I’m going to teach you a trick that you can use if this happened to your patient to recover their bite. Okay? So that’s number one. Number two and three, a shorter one. The second one is how to scan or record using silicon bite registration paste, the patient’s centric relation record at the desired vertical dimension for something like a Michigan splint, for example, and the third one.

What should the occlusion look like on composite veneers? These are three questions, or the last two are questions that were sent in by you guys. The first one’s something I promised Professor Paul Tipton, that I would do, which is reveal this trick.

If you’re new to the podcast, welcome. This Ask Jaz series are kind of in their infancy, but I’ve got hundreds of questions that have been sent in by the Protruserati and just find time sometimes to just go through some of these things. And if you are a regular listener, thanks so much for always coming back. Let’s hit the main episode.

So my friends theme number one, your patient gets an anterior open bite after a partial coverage appliance. Or actually, you know what, any appliance. You may have had a patient or nova dentist who had a patient who was given a soft bite guard or stabilization spin, or an NTI, SCi or something, and the patient came with some sort of a bite change classically, an anterior open bite, and this can be a little bit scary for dentists.

And what happens that the dentist passes on this fear to the patient. And really, you know, I talk about it in other episodes, but this isn’t a huge deal, but it’s certainly an inconvenience if you didn’t warn the patient that this was going to happen. So that kind of makes sense. So, when this dentist colleague on one of the Facebook groups posted about this, about how she gave an SCi appliance and the bite changed and she was really upset, I wanted to help.

So what I did was I said, listen, you can PM me. And I’ll talk you through a little trick that you can try to recapture the bite, which has worked well for a few colleagues. And so, professor Paul Tipton, THE Paul Tipton messages saying that he would love to know my little trick to solve an anterior open bite that doesn’t position the condyles in any other position than centric relations.

So Prof, this one’s for you. I got you. And some of the other comments from our esteemed colleagues were along the lines of, unfortunately, whilst the incidence remains low, so that’s an incidence of a bite change or an AOB. After a splint is very difficult, if not impossible to resolve. So guys, I’m about to share with you the impossible.

Allan, this is for you. Akhil, this is for you and for all the others that messaged me. Let’s do this. Let me show you the trick. But before I do, let’s just talk about what this dentist shared with us. So just want to thank this dentist for raising this to the group. And she said that a patient developed an AOB after a few months of wearing an SCi.

So, for those of you who are unfamiliar, SCi stands for Sleep Clench Inhibitor, and it is the same thing as an NTI, which is the American version. So the British version is SCi, American version, NTI, right? So it’s those little appliances that cover like lateral incisor. You can get variations.

But essentially a small appliance on the front is classically what we think of. When we think of an SCi or an NTI. You see, I was told at the school, never, ever, ever to prescribe a partial coverage appliance due to the over eruption that’s inevitably be going to happen, et cetera, et cetera. Fast forward many years and hundred appliances later, guess what?

Over eruption hasn’t happened. It doesn’t happen. It can happen if the patient wears it for a prolonged time and all those things. But the AOB risk, the anterior open bite risk is a real one, but NOT FROM OVER ERUPTION. And that’s kind of the theme of the first part of this Ask Jaz. Now, this dentist on the group went on to say something very interesting.

She said, ‘How unlucky, because the studies show a 1.6% occurrence of an anterior open bite.’ So she’s referring to the study. By Dr. Blumenfeld, right? So Dr. Blumenfeld’s survey, was a 512 dentist, right? And these 512 dentists gave 78,711 NTI splints. So those little ones, and of those 1.6% developed an anterior open bite.

Now, what you need to know is that Dr. Blumenfeld isn’t a dentist. He’s actually a neurologist and he works in a headache center. And so he was fascinated when this appliance was being talked about by dentists as being able to help with headaches. It was natural for a neurologist who’s really into headaches to be interested in this field, and I really commend Dr. Blumenfeld for really integrating medicine and dentistry together.

Because what they found is that when he incorporated the NTI protocols using a dentist, so James Boyd, they found that 50% of their migraine sufferers were now significantly better so that they didn’t need to rely on medication anymore.

Let me say that again. Half of the people with migraines responded positively to the extent that they did not need medicines anymore. So I actually read a lot about this and Dr. Blumenfeld said that, now in his protocols in his neurology practice or for his headache center, is that patients will have an NTI and only those that don’t respond will then go on to have these heavy duty medicines.

I think that’s absolutely fascinating. So there’s a lot of benefit for headache sufferers with this kind of appliance. But when we give someone an appliance like this, are we really facing this unlucky dip scenario that like spontaneous combustion, any one of these appliance like Russian roulette, you’ll get an AOB.

Is this really how this works? Well, when I didn’t know much and I was like fresh off the course and stuff, and I didn’t really know and I hadn’t been experienced and I hadn’t really put much thought into it. I said this to my patients, I said, look, the studies say that there’s about 1.6% chance that you are going to get an AOB.

And patients accepted it and I made peace with it. But just like, when we say about wisdom teeth, right? When there’s a surgical wisdom tooth and the tooth is impacted, then we say, okay, there’s an X percentage chance that you are going to get a numb lip. But for some patients, that’s a 0% chance. When their roots are like way away from their inferior alveola nerve canal, you know that this patient is not going to suffer from that fate, therefore they’re ultra, ultra low risk or no risk.

Whereas other people, the nerve is intertwined with their roots and therefore they are pretty much, definitely going to get some sort of numbness or paraesthesia after having their wisdom tooth surgically removed. So we can’t use a blanket percentage figure to all patients.

But you see, when I went on the course and stuff, they said that yes, your patients may get AOB and understood the mechanism i.e deprogramming, which I’m going to touch on shortly, but it never taught me the features to look out for in patients, which I’m going to go through again with you that will help you to recognize who is high risk and who is low risk for developing a bite change. And so if you want to learn more about this, well over a hundred episodes ago I was talking about this episode 41 of the podcasts was on anterior midpoint appliances. And I did another one, I think it was 58, where I did the continuation of that.

And so within those two episodes, I go really deep into anterior midpoint stop appliances. And the cool thing now is that with my patients who are high risk, who I deem as high risk, I’ll actually put my leaf gauge in and I’ll take a portrait photo of them with potential anterior open bite that they could have from wearing an occlusal appliance.

I.E I’ll take a portrait photo of them with the leaf gauge, their back teeth separated to roughly their central relation contact point. And I’ll show them this photo and I’ll say, listen, if you get a bite change, this is what it might look like. You might find that fine chewing at the front, like having a sandwich.

You might miss the lettuce or you might miss the ham, for example. So you gotta talk about, in real terms for patients, you might not be able to bite your nails anymore. You might not be able to bite sellotape anymore. These are the ways that the patient will be affected. Thankfully, only psychopath smile with their teeth together.

So really, aesthetics and stuff isn’t affected. It’s just those little things like that. But like I said, now with my protocols, I’m able to really consent my patients properly to the highest level. So hat tip to Dr. Michael Melkers, who taught me all this. And just as a way of revision, if you already listened to those two episodes before, or if you haven’t before, and this is all very new for you, the three main risk factors of someone getting a bite change or an anterior open bite spontaneously after an anterior appliance or any appliance.

Any single appliance, okay? If the patient has these three features, we should warn them that their bite could change or they could have an anterior open bite. So they are in order, a minimal overbite to begin with. I.E, they kind of already have an anterior open bite. They have an anterior open bite tendency.

They just maybe got half a millimeter of over bite or that’s it. And so all it takes is a little bit of a shift to reveal an anterior open bite. And so if you really do your homework and you go through all the Facebook groups and you find the previous ones, and you try and find some pre-op photos and models, you’ll find that a lot of these patients had minimal over bites to begin with.

And it kind of makes sense, right? Because orthodontists are treating deep bites and you ask them, how easy is it to treat a deep bite? It’s not easy. It takes time, right? Especially if it’s a severe skeletal deep bite. You’re not going to give someone an appliance and turn someone with a true deep bite into an open bite, right?

So, a deep bite is like ultra low risk for an AOB, but there could be a risk for a bite change. But let’s not get into that. So we’re specifically talking about anterior open bites, someone with a deep bite is not going to go from a deep bite to an anterior open bite from wearing any type of splint, right?

Whereas the patient who’s already kind of got an AOB is more likely to develop one. Now, the second feature that informs high risk is having a large slide from the centric relation contact position to the maximum inter cuspal position. So basically your retruded contact position or rcp. So your first point of contact within centric relation.

If these are all new terms to you, then maybe listen to episode 90, Basics of Occlusion. But essentially when your condyle is seated anterior superior in it’s snug position, the first tooth or teeth that touched together in that position, right? So that place and how different that place is to the patient’s comfort bite where all the teeth meet together and you bite together day-to-day bases your comfort bite, your bite of best fit.

Now, if there’s a big difference between those, then it puts you at higher risk. How large is large? Well, people say that a 1.5 millimeters in an anterior posterior direction is considered large and half a millimeter transverse i.e. Left and right is considered like a large slide. So if your patient has got a minimal overbite, And they’ve got a large slide, they’re at higher risk.

Now, why is it that someone with a large slide is at higher risk? Well, think about it. This large slide exists because there’s a difference between where the condyle wants to seat in this stable musculoskeletal position and where the teeth want to meet together and the way they meet together. So if any point the muscles want to relax or the teeth get worn, they kind of want to go back to that position.

If that position is really far back, then that will change the bite. The patient will notice a change in their bite. And the last feature is a lack of posterior stability. Now this is explained really well by, imagine you’ve got two study models and upper and a lower, and naturally we want to put them together.

And for most patients, we can put our models together and they fit together really nicely, right? We don’t need a bite registration because they just click together really well. But have you ever been this scenario where you’ve got these two study models and you just have no idea how they fit together? It’s like five different positions.

This patient bite together in one position. They have an AOB, another position. They have a crossbite, and they’ve got like three other positions, which are class one. And it’s just, you can’t figure out, you need that bite registration. You see when you have someone who’s got very cuspy teeth and the teeth just sit together like a key and a lock, like a jigsaw puzzle, right?

That’s good posterior stability. Whereas when you got really flat teeth, warm teeth and there’s not really good meshing of the teeth together, that’s poor posterior stability. So if the patient’s brain is kind of struggling to remember this bite, any hint of getting deprogramming, so relaxing the muscles, can you see the potential in the patient just going to any other new bite?

Any other position because that previous position was the brain’s best guess. And it wasn’t even that good. It wasn’t even that comfortable. And so now when the bite changes, the patients kind of forgot the old bite because it wasn’t stable to begin with. So if you have someone with a minimal overbite to begin with, a large slide and quite flat teeth or lack of posterior stability, you can’t really tell instinctively how they should be biting together.

Then that is a high risk patient. That is an ultra high risk patient. I think if you have two of these, you are high risk, but if you have all three, then you’re pretty much going to say to the patient that this will change your bite. And at that stage, you’re probably wanting that bite change so that you can restore them to that position.

Now that dentist on the group again. Okay, now, and I’m coming to the trick. Don’t worry, I’m coming to the trick. Okay? I promise you, with a few minutes, you’ll know my little trick. Okay? So this dentist felt horrible. She felt like a little shock to her system because she felt as though it was her fault that the bite had changed.

And she wishes that she just went for the Michigan splint, which apparently he didn’t get used to wearing. So is it really her fault? I don’t think so. Okay. I don’t think it’s your fault. I really, really don’t. And I was thinking of some analogies, like, how can I explain this right? Now, this analogy isn’t very good, but let’s run with it.

Okay. There’s a film called Room and it’s pretty good film. It’s got like 93% on Rotten Tomatoes, and there’s a spoiler alert coming, so just run with it here. Okay. Room is about a mother and a son and they’re trapped in a room. And so the person who’s like captivated them or kidnapped them, just locked him up in a room and you know, they live his food and medicine.

That’s about it, right? And so this kid was born in this room and raised in his room, and I don’t know, he’s like five or six years old and he’s never left this room before, right? So you can imagine he’s got very pale skin. He’s probably deficient in vitamin D and he’s not a socially normal child because he’s never ever seen another child before.

So then, and here is a spoiler by the way. He makes a break for it with assisted by his mom. And so they make an escape, and they succeed. And so now this kid who sounds like the first five or six years of his life, in this room is finally now let out to the real world. And the real world has different conditions, different environments, better environments.

Right now, he gets some sunshine. He’s going to get a tan. At the very least, he’s going to develop these social skills to see other children, see other people. And you see what happens to this child is that, as a response to this new environment, he changes. And I really think that in a similar way when it comes to our scenario that we’re talking about, the patient’s bite in a way was pathological in a way.

And so when the muscles were able to relax, when they had an opportunity to relax, when you improved the environment, that’s when the bite changed. Because something had to change. Now the patient’s occlusion was out of this room and it got to experience a much more favorable environment. So that’s how I like to think about it anyway.

So as a consequence of changing the environment, the bite changed because the bite i.e. The way the teeth come together is controlled by the muscles and the condyles. I guess the only issue is that we should be able to warn our patients that, yeah, okay, this is going to happen. And so the issue is not that the bite has changed, is that you didn’t anticipate that the bite has changed.

So hopefully now you’ve got a few features to look for, to know when someone’s bite might change. But I’m going to teach you guys a trick. Right, the trick. Okay, prof, you’re listening. This one’s for you and everyone else on Facebook group who want to know my little trick. Okay? So you can use this trick anytime a patient has developed a irrecoverable anterior open bite.

Now what I mean by this term, IRRECOVERABLE. Now, for those of us who wear anterior only appliances or even Michigan splints, for example, when we take it out in the morning, do our teeth go together straight into MIP? Maybe, but you know, sometimes you might hit your centric relation contact point or the bite might feel a bit funny and eventually, oh yep, I’ve got my bite.

And then your teeth mesh together normally. And so that is someone who has a recoverable anterior oven bite. Someone with an irrecoverable anterior oven bite is kind of like the situation we’re talking about now. i.e. the reason the dentist posted that case on that group to get some advice. The patient removed the appliance.

But they weren’t able to remember their old bite. Their existing MIP is now out of the equation and they’re biting in a new position, which is an anterior open bite. Now, by the way, I forgot to mention, I reached out to the dentist and I was helping her. I was coaching her about how to do this trick, and then she showed me the photos kindly of the pre-op situation.

I can tell you now, it definitely wasn’t posterior over eruption the mandible had just shifted to the left, and by shifting to the left, it was now hitting an incline of a molar, and that resulted in anterior open bite and someone who had all those features, including a minimal overbite to begin with. So what’s the trick that I advised her?

Well, those of you who are watching right now, you’ll see this, but I’ll describe it to those who are on their commutes listening on Spotify or on the Protrusive app, right? So let me make it really tangible and show you another case where we actually applied this trick to recover an open bite. One of my colleagues who’s a delegate of the splint course, she gave her patient a Michigan splint.

This is before she became a delegate, and the reason she gave a Michigan splint is to deprogram the patient. I e relax the muscles, relax the lateral pterygoids, and test drive the vertical dimension. And then on the day of the fit of the Michigan splint, all the teeth are hitting. We’ve got the dots and the lines.

The front teeth are hitting, the back teeth are hitting and excursions. We’ve got anterior guidance. Now, four weeks later, the patient comes back and what do you think has happened? Well, it’s worked. Okay. We’ve got some de programmation. So what that would look like is that the mandible slides back a bit.

Distalizes, and now we’ve got a few dots to the back and no dot to the front. So i.e., we went from a complete of a bite on the splint to an incomplete overbite on the splint, and now we have a bit of overjet. So what do you do here? Well, you adjust it all again, you remove all the high spots, and then you achieve the even dots to the back and lines at the front, which is classic for a stabilization splint.

So what this dentist does, rightfully so, is eight months of monitoring for whatever reason, I don’t know why it was eight months, okay? But there were no changes seen on the splint, and the patient was happy to proceed to a full mouth rehabilitation. So had lots of crowns and a treatment for his worn dentition.

But this is where the interesting thing happened. This is where the anterior over bite might happen. So it’s very interesting. I’ll just read it out loud. So I’ve done a full mouth rehab for a tooth wear patient two years ago. In the diagnostic phase of his treatment, I made a Michigan splint for him. He wore it for deprogramming for eight months when his bite on the Michigan splint did not change anymore.

So kind of recapping what I said already. Now, after his treatment was finished, I provided another Michigan splint for protection in his bite. At this point, his MIP was equal to centric relation, so i.e. He’s in his seated condylar position in the musculoskeletal stable condylar position, all the teeth were touching together.

How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs? Is canine guidance always better than group function? Why can’t I just use the DAHL technique on all my wear cases? Can I stop my patients from grinding? What the bloody hell is crossover? What should the occlusion look like after orthodontics?

How and why do you check for fremitus? What on earth is a custom societal guide table? How do you use a leaf gauge? Do you always need to use a facebow? Does everyone really need a perfect occlusion? What is the difference between edge wear and pathway wear? Is it naughty to adjust the opposing tooth? What the is centric relation?

Occlusion is coming. One does not simply just open the bite. May the force mitigation be with you.

To make sure you don’t miss the crucial update about the launch of our occlusion course, OBAB head over to occlusion.wtf. That’s right. It’s actually occlusion.wtf. It’s almost released and you’re going to love it.

Now, she saw him six months later to find that his mandible had distalised and only had contacts to the back with three millimeters of overjet.

And so those of you are watching, I’ve got the photo right here. So we have an incomplete over bite and I would actually probably disagree, I don’t think this is three millimeters of overjet. This is five millimeters overjet. Remember, the overjet is measured from facial of the lower incisor to the facial of the upper incisor.

So the patient actually probably went from a two millimeters overjet to a five millimeters overjet and a loss of anterior guidance. So how did this happen? Well, you know, sometimes patients deprogram more and for whatever reason, the patient wasn’t fully deprogrammed. That’s the most common thing. The other cause for something like this is a change at the condyle level.

Think of the disc going out of place, or think of some resorption, which is rarer. And so anything at the condyle level, any changes, any pathology could change the bite and we can confirm it was muscular because our little trick worked. So what was the trick? Well, if you want to see it in action, you can actually go on the Protrusive Dental Community Facebook group.

It’s kind of the same trick that we do when a patient is high risk. So you’ve identified a high risk patient. I would make one of these devices, which I’m going to share with you now to prevent an open bite so you’ve got a high risk patient and you make them this device alongside their splint to prevent their bite changing.

It’s the same thing that we can give to someone who’s developed an open bite to recover that bit old bite. Now, at this point, you’re probably a little bit confused, but don’t worry, I’ll make it crystal clear, right. Now, this concept of positioning the mandible in a different way is actually borrowed from those who are treating the airway, because what you find with mandibular advancement splints for, let’s say sleep apnea for example, or sleep disorder breathing, is that because you’re holding the mandible forward, you get contracture of the lateral pterygoid muscles, and the risk is a patient will develop a posterior open bite because their jaw has come forward.

They’re now protruding forward, their front teeth are meeting, they become more class three and the back teeth aren’t meeting anymore. So what they started to do is every morning when the patients wake up from wearing their mandibular advancement splint, is that they wear something like on the screen now, where I’ll describe it is an MIP bite, basically, is that it guides their jaw back into their MIP in the morning, so hopefully it prevents this shortening of the muscle, basically.

And so this is AM aligner and it’s got indentations in it to really guide the patient into their MIP. So it’s kind of like an MIP bite registration, but I wouldn’t want to send a patient home with a normal PVS silicone bite because it’s very fragile, right? It’s going to break. So let me explain the trick now, right? So you have a patient and their teeth meet together fairly well, and then after the occlusal appliance, the teeth don’t meet together well anymore, and you have an anterior open bite.

Now, if we accept the fact that it’s not, because of posterior over eruption and it’s just that it’s a change in the muscles. Then what we can do is this, okay, we get the models and we have to do this on models because if you try and get the patient to bite into their normal bite or their MIP, they can’t do it because they’ve kind of forgotten.

That’s the whole thing about deprogramming. They’ve been deprogrammed, right? How can we reprogram them? Well, the way you do it is get the study models. You now squirt some Memosil or Exaclear. Clear silicone materials, right? They’ve got their resilience, they’ve got their bend ability in them, right? Bit of flex in them.

That’s the word I was looking for. You then squirt it all around as if you’re doing a bite registration, a full arch bite registration. You then seat the models together by hand and you are basically creating the patient’s old MIP i.e. I used to bite like this, that bite, okay? You actually do it by hand and ideally you want to rely on some photos or some scans to help you.

Because remember, the whole reason that this mess happened is that the patient probably had poor posterior stability. So you really want to pay attention, look at the photos, and as the material setting, you bring the bite together in the desired bite. The bite you want to go back to, right? And you let the material set.

So now you have a bite registration of the old MIP using the study models, you now transfer that to the patient’s mouth, okay? And you get them to guide their mandible into this bite registration. So let me tell you how this dentist did it after I advised her, okay, so this is what she said. When the patient came, I got his previous models out.

I showed him his previous bite and explained that it was changed because his muscles had relaxed. Before his arrival, I made an AM aligner with Memosil. So just like I described guys after the explanation, I fitted the AM aligner and asked him, and here’s the magic thing, because you know this is something that we make up because there’s no evidence that I’ve seen about how to recover someone’s bite.

So we’re kind of making up. So, this dentist was smart. She advised him to bite into it for 20 minutes. Okay? So, the patient has an AOB but is now got this Memosil bite of his previous MIP and he’s biting into it for 20 minutes. So after 20 minutes, he then removes it and when he closed together, he was able to bite again into his old MIP straight away, and he recognized the difference.

Okay. Without any pain, without any discomfort. Okay. The fascinating thing, which I absolutely find crazy is that the patient was unable to protrude his mandible before, but after this exercise of biting into his bite registration, he could. Isn’t that fascinating? This is the complete opposite of deprogramming.

This is reprogramming, and it just makes sense because if the muscles have forgotten, why don’t we give the muscles some help and remind them? So those of you who are watching, here’s the photo of him biting onto this Memosil, which was made on the study model and moved to his mouth. Why it wasn’t this bite record using Memosil taken in his mouth?

Because he couldn’t bite there. He couldn’t physically get into his old MIP again, he just had this distalize bite with a larger overjet. But this is now guiding him into his old MIP. This dentist went on to change his appliance from Michigan to something else, which isn’t so relevant.

But he preferred this B-splint or this Dual Arch Anterior Scribe Appliance to his Michigan splint. And those who are watching is a para functional pattern that you see. So a big fan. Coloring these splints with a sharpie marker. And the patient gets to see their pattern. It’s like a gothic arch tracing that you get on these splints.

So the patients see that they are still bruxing every night. Because some patients they think that they stop bruxing just because you gave ’em a splint. Whereas I tell our patients, listen, you’re still going to para function, but now you are para functioning on this piece of plastic then on your teeth. And so there it is again.

The trick is reveal. So those of you are listening, it is essentially an MIP bite using the study models in the old MIP, and this can really, really save you. Now, I can’t offer any more guidelines because this hasn’t been studied and we’re kind of making it up, but it helped my colleague and it can help you too, if it ever stuck.

This is worth giving a go because what else have you got to lose? This is a simple and a cheap way to attempt to recover the bite because what’s the alternative, right? Either the patient lives with this AOB, which is totally cool, I think, or B, they consider orthodontics or restorative to try and get their old bite back or something similar to their old bite.

So I think it’s a really handy little trick to have up your sleeve. I hope that made sense. And if it didn’t make sense, and if you’re listening, then maybe you want to just go to the app or YouTube and watch this bit. But in a nutshell, it’s reprogramming the bite using the patient’s own MIP bite record using the study model.

So it’s not deprogramming, it’s reprogramming, it’s trying to make that irrecoverable AOB into a recovered AOB. And if any of you use this, do comment, let us know. Let us know how you get on. And maybe we can do a study one day in terms of recapturing these old bites. So Prof Paul Tipton, I hope you found that useful.

And anyone else who thought it’s impossible, maybe this is a way forward. Okay, so that was a long one. I’m actually exhausted, but we’ve got time for just two more questions. And these are much shorter, right? There’s question number two before we talk about occlusion on composite veneers. The question is, when recording at your desired vertical dimension in centric relation, how do you record it?

Do you gun in some bite reg around the side when they are in their retruded position? Okay, so let’s talk about this and let’s really clarify and make tangible what this dentist means. Let’s say you are making a Michigan splint or a Tanner splint or any type of stabilization appliance. Classically, you would make this splint at centric relation.

So the condyle is in a musculoskeletal snug position, superior anterior against the posterior slope of the articular eminence. Because like I said, it’s a snug position. It is a good position to be in. It’s not essential position to be in, but if the muscles relax, that’s kind of like where the condyles can easily find.

Now classically, when I was trained, I was taught to take a centric relation bite record, so just beyond the first point of contact. And then a face bow and then what the technician would do is a technician would mount everything on a semi adjustable articulator. And then because the bite registration was pretty much at the point of contact, we now need to open because we need a minimum thickness of splint material of 1.5 to two millimeters.

So the technician then opens the bite on the articulator, but remember the articulator, although a very useful tool, does not a hundred percent accurately mimic the patient’s condyles. So by opening the bite, there is a degree of error introduced, so we can be a bit more clever because if at the point of doing the bite record instead of recording it at that very first point of contact, or just beyond it, why don’t we record the bite at the required vertical dimension.

i.e. Record it in a position whereby we’ve already respected that 1.5 to two millimeters of minimum thickness. So what this looks like for me is I’ll have a leaf gauge in, because I like to use a leaf gauge. It’s very, very convenient. It’s not suitable for all patients, but it’s a very, very handy tool.

And so as I have the leaf gauge in, and I’ve set it now so that there’s no back teeth touching, I’ve got the patient in centric elation, grind forward, grind back, squeeze together the muscle seat the condyle so I don’t have to do anything. It’s a hands off approach, the muscles seat the condyle, and because I have that space now, I’m going to scan the left bite and scan the right bite at the centric relation position with my desired thickness.

Already there, or you can actually gun in the bite registration material as this dentist suggested. The beautiful thing about this is that now the technician uses the bite registration at the increased vertical dimension, but still at centric relation. And the scenario they have now is that once they’ve mounted the models, they’ve got the space ready, they can just start waxing up for the splint.

They don’t need to open the bite or close the bite anymore. They pretty much fill in the space with wax. And this is where the magic happens. Now, whether I’m doing, DAHL composites, full mouth rehab, or a Tanner splint, or a Michigan splint using this trick has been really brilliant because when the patient bites together after I put my temporaries, or put my resin or put my splint in, I found much less adjustments to do.

So, I think this is a wonderful thing to do. Anytime you’re aiming for a centric relation record, give the bite not at centric relation, but your desired vertical dimension, which may be at centric relation contact point, but if like for a splint, you want to give them some space, don’t let the technician open up the articulator.

You give them the perfect space, and now their error of opening and closing the articulator, which is not the patient’s mouth is removed. So thanks for sending that question. I would name you, but I didn’t ask your permission to name you, so I don’t want to offend anyone. So, that’s that. Now question three and the final one, I think we’ve gone on for far longer than I anticipated, but checking the occlusion after composite veneers.

So the question from this dentist on Instagram is, ‘Hi Jaz. Would love some advice on an occlusal question. After placing composite veneers on upper anterior teeth, should the incisal edges of upper incisors will be in contact during lateral guidance? What about in protrusive movements? What markings am I looking for on the articulating paper? So all from the articulating paper, right? Thanks in advance.’

Right? Great question. Okay. I love it. Let’s just boil it into his fundamentals. Okay. So first part of the question is, after placing these veneers. Okay. Should the incisal edges be in contact during lateral guidance? I think it totally depends on what the starting situation is, because if you start with our friend, the anterior open bite again, and you put some veneers.

On someone with an anterior open bite, then the edges will never touch, right? Because they have an AOB. And if you’ve maintained that AOB, maybe you’ve lengthened the teeth, but and reduce that AOB, but they still have an AOB. So no matter how much lateral excursion they do, there’s going to be no articulating paper mark on those edges.

Now, on the opposite side, if you’ve got a severe class two patient, right, they might not even go all the way to the edges because the amount of movement they have to do to go on the edge is significant. They might go there, right? But they might not. So for that kind of patient, again, they might not go to their edges of their central in incisors, in lateral excursion.

So really that eliminates a few groups of patients. Would your patients who’ve got a normal amount of overbite, you know, 10% or more, then there is potential for those teeth to touch. So should there be contacts or it depends on the overbite.

If there’s enough overbite for anterior guidance, then eventually the lower incisors may and get onto the centrals. So there isn’t hard and fast rules out there, should they? But it’s rather will they? And if they will, why don’t we optimize that environment? Now, in an ideal world, it should be canine guidance to start with and then swiftly and smoothly, right?

And I don’t mean smooth, like shiny, smooth. I mean like the mandible finds it really easy to move left and right. What we don’t want in a scenario is that the patient’s bruxing, for example, right, and they’re going left and right and they’re bashing against this composite. And this composite, it’s so steep.

It’s not letting the mandible move. And by not letting the mandible move, it’s putting a lot of stress and strain on those restorations. But instead, if you shallowed out the guidance, the mandible can just move freely and not put all that pressure into your restoration. So let’s recap. You go canine guidance, for example, in the classic scenario, because I can’t cover every single scenario because the question you’ve asked really is case by case by case.

So canine guidance, for example, transitioning onto the edges of the centrals, okay? And if they go into crossover, crossover is when they go all the way to one extreme. And I’ll show you an example of this in a moment. For those of you who are watching, the patient who goes into crossover may well come onto their central edges quite regularly.

So in a nutshell, should the patient contact on their edges? Not necessarily. It depends on the existing occlusion, but when and if they do, make sure the transition to them is nice and smooth. So whether that is from the protrusive or left and right, you don’t want ’em to be canine initiated and then suddenly have a jerky movement towards a distal incisal of a central, that’s not going to be good.

Right? You want everything in harmony. And sometimes that means having nice, straight lower teeth, or at least not these sharp jaggedy edges of lower incisors, which are doing no one any favors. So always have a look at the opposing and see sometimes you might optimize the environment. I tell the patients I’m doing a manicure for your lower incisors and they love it.

It feels much better and it reduces the harmful forces and pressure on your upper anterior composite veneers. So before we talk about, the next case, which is protrusive, for those of you watching the video, I’m showing you a patient who’s a severe bruxist. He destroyed one of my small splints in a matter of six weeks.

So I’m showing after his dialed composite restorations what his excursions look like. So they’re nice and smooth as they come onto the edges. They’re really smooth, nice contacts on the edges and as we go to the other excursion. Now we’re going nice and smoothly, transitioning to the centrals and now into crossover.

And there’s no jerky, there’s nothing hitting prematurely. The mandible can move freely left and right, and this is what we’re aiming for in Protrusive. It should be the same thing. It should be no jerky movements as the lower incisors bite onto the upper and it come protrusive. I want to see nice, broad, even Marks ending on those edges or even beyond.

But I want them to be nice and even I don’t want one incisor to be taking more load than the other. And I don’t want like a thin marks. I want nice, thick, broad marks. Okay. Why do we want nice, broad marks onto nice broad edges because it reduces the pressure. Okay? Because ultimately pressure is force over an area.

So if you’ve got a thin little chicken scratch of a line, then there’s going to be a lot of pressure, right? That broad line has more area, so that force is spread over more area. So it’s a bit like, if someone’s going to walk all over you, , do you want them to walk all over you in high heeled stilettos or wearing flats?

Right? So I think we all know the answer to that one, and that kind of is a crude way to explain the kind of marks we’re looking for. So to summarize that, we want nice, even strokes that go from the MIP contact all the way to the edge, and I want nice even contacts on the edges. So the lower incisors, upper incisors come together, the edges are unchipable.

And that’s really important because I’ll show you now for those of you’re watching, but those, you’re listening, there are these group of patients, okay, who just love coming edge to edge then. Even though they’re class two and they’ve got like, you know, five millimeters over jet and you think, how on earth do they go there?

But as soon as they bite together, things fit together perfectly because they like to bring their edges of their teeth together. Couple of reasons I think one could be airway, right? They could be bringing their jaw forward during stressful scenarios to bring more oxygen in to improve their airway. And the other theory, which actually is supported by some weak evidence is that by tapping on your front teeth, you reduce your corsol levels and you reduce your stress.

And so regardless of the reason, it’s important to identify who spends a long time on their edges and who doesn’t, and those who spend a long time on their edges, please, please, please double triple check these excursions and make sure the edges are well accounted for.

You don’t want any sort of uneven edges or sharp bits or fragile bits, okay? You want nice, thick, broad composites. If you’re doing composite veneers on someone who likes to be. Edge to edge. So hope you enjoyed that. It was very much an occlusion theme today sparked by that Facebook group, and we’ve talked about taking bite records at the desired vertical dimension and a little bit about occlusion on composite veneers, if you like this kind of thing, then me and Mahmoud have put together around about 30 hours, can you believe it, of content that’s ready to come out in March, pre-launch deal coming.

So the way you can get involved with that is www.occlusion.wtf. Well, there we have it. Guys, thank you so much for listening to this Ask Jaz. I hope you found that stimulating and interesting about how we can recover someone’s bite.

And for those of you who want to learn more, maybe listen to those episodes that I referenced about those anterior only occlusal appliances, part one and part two that I did way back around about a hundred episodes ago. Can you believe it? If you are looking for an occlusion course, then me and Mahmoud Ibrahim have got some very exciting coming up.

So on 7th of March we’ve got a pre-launch deal coming. So if you want to be in the know when it comes to this pre-launch deal, you want to head to occlusion.wtf. That’s right. occlusion.wtf is an actual website, I promise you. Enter your email address and first name and I’ll email you when we have that deal ready for you.

It’s something that we’re super proud of. Worked really hard over the year. In fact, have a listen to one of our beta testers had to say. Hi, my name’s Marwa. I’m a general dental practitioner. Occlusion Basics and Beyond does exactly what it says it’s going to do. It takes you from the very beginning, the very basic principles of occlusion, and as you go through the modules, your knowledge just gets built upon and built upon.

So much so that by the time I reach the end of the course, I felt like I finally understood topics that I just struggled to wrap my head around for years. And that’s purely down to the way in which the contents delivered. Mahmoud and Jazz, walk you through things in such a clear way that things finally make sense. So I’d really recommend this course to anyone that’s looking to lift that cloud around the dreaded topic of occlusion.

So, once again, that’s occlusion.wtf. If you want to stay in the loop and talking of in the loop, that is exactly what the next episode is about. It’s about Karl Walker-Finch’s book, it’s called In The Loop. I’m very excited to speak with him, to wet your appetite for this fantastic book, which is dedicated to a very important dental charity. So I’ll see you next week for that episode.

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This episode gives it all away – every micro-step on how to successfully treat white patches with Teeth Whitening and ICON Resin Infiltration. If you are an experienced clinician or new to White Spot management with ICON, you will gain something from this blockbuster.

After the success of the ‘Teeth Whitening Under-18s’ episode, Dr. Linda Greenwall is back to make resin infiltration tangible. Dr. Greenwall shares everything from assessment to troubleshooting!

https://youtu.be/CYLXUGTXPRICheck out this full episode hereDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

The Protrusive Dental Pearl: Download the Protrusive Treatment Guide for White Patch management Icon Resin Infiltration inspired by this episode – the Infographic that summarizes this episode with the exact micro-steps and the little nuances with helpful diagrams and tips all in one flowchart.

Please show your support by signing up as a Protrusive Premium member – once you’re in you can download our mighty flowchart and infographic from the Protrusive Vault section (as well as the many benefits of membership!)

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

1:42 ICON Treatment Flowchart
7:39 The science behind Icon Resin Infiltration
16:35 Using Resin Infiltration Posteriorly for Caries
19:33 White Patches Anterior Resin Infiltration Protocol
22:08 Resin Infiltration Treatment – Air bubble Analogy
32:50 Patient Communication – Treatment Planning and Fees
34:50 Resin Infiltration Technique – after the etching process
40:36 Predictors of success and failure
45:02 Expected longevity of Resin Infiltration
47:02 Etiology of white spots
47:57 Dr. Linda’s advice when starting a white spot cases

Learn more about Molar Incisor Hypomineralization with THE D3 GROUP FOR DEVELOPMENTAL DENTAL DEFECTS

Check out the Tooth Whitening Techniques Book, a compilation of before and after photos of patients produced by Dr. Linda Greenwall

If you enjoyed this episode you will also like Teeth Whitening Secrets for Success

Click below for full episode transcript:Jaz's Introduction: Did you know that resin infiltration was initially developed for the management of early carious lesions? But it's actually taken off hugely for the management of white spot lesions anteriorly. I've been using icon resin infiltration for a few years now, and I've had some pretty good results.Jaz’s Introduction:
And so this stuff, this resin that infiltrates into these white patches, like our guest Linda Greenwell, the way she beautifully describes it with her soothing voice is that the white patch is like an air bubble, and she explains that analogy wonderfully throughout this episode.

And it seems to be a really great, minimally invasive way to manage white patches, either after orthotics or MIH or of any origin. Hello, Protruserati. I’m Jaz Gulati and welcome back to another episode of the Protrusive Dental Podcast. That’s right. We got Linda Greenwell back again after that amazing episode about the rules around whitening for under 18.

If you haven’t seen that, do check it out because it does tie in well with this episode because one of the things that Linda will teach us is the importance of tooth whitening before doing resin infiltration. In fact, Linda leaves no stone unturned. Every single micro step and the nuances and considerations, and even the troubleshooting.

What if things don’t go to plan? It’s covered so comprehensively, so beautifully that I think DMG, the company that makes the stuff will probably host this podcast episode on their own website. We also answer burning real world questions such as, do you have to use rubber dam for this technique? And can you use any composite, like sometimes you actually have to have composite at the end of it.

Do you have to use a bond before you use the composite or is the adhesive with the icon enough? And what is the best type of composite to use at the end if required? So if you listen all the way to the end, you’ll find the answer to that one as well.

Protrusive Dental Pearl:The Protrusive Dental Pearl for you is the best infographic or treatment guide you’ve ever seen. As you know, some of the Protrusive guides before have become pretty famous for the amount of detail and concise amount of knowledge on them. And so what we’ve done from this episode, because there is quite a lot to remember, a lot of little nuances.

I imagine if you made a flow diagram of this episode, you’ll see later what I mean. It gets a little bit complicated, but don’t worry, we’ve done all the hard work for you. We’ve mapped out the exact microsteps and the little nuances with helpful diagrams and tips all in one flow chart. That treatment guide is essentially everything you ever want to know about icon resin infiltration with our protrusive masala. Sprinkle all over it.

If you want to access this treatment guide on icon resin infiltration, then check out the Protrusive app. It’s an IOS and Android. You can also access from your browser. If you just head to protrusive.app, that will take you to the app website itself.

It’s under a section called Protrusive Vault, and you’ll find so many of the previous infographics and files, which is only accessible to the premium members. It’s thanks to the premium members that this podcast can stay alive and viable, so I thank you so much for your support. Before we joined the main episode with Dr. Linda Greenwall, I wanted to announce something really special with EVO 4.

EVO 4 is the latest generation of Enlighten Whitening. The changes with EVO 4 really make it superior, so now there’s no more in surgery stages, three weeks, all at home. They’ve also done something very clever with the tray design.

So the whitening tray, sometimes posteriorly, they sort of flap off. There’s a lack of retention sometimes. Quite often molars have small clinical crowns, you see, and that allows saliva to come in. So kind of like with the aligners, they’ve actually built in an attachment, single attachment on each side, which is optional to use, but I’ve used it and super easy.

So if it gets you better results, why not? And they’ve incorporated that as part of the EVO 4 system. The final change, which is pretty important, is that now the gel will ship to you with the tray so you don’t have the gel lying around the practice. It comes with you as a bespoke order with the patient’s whitening trays.

Now, the benefit of that is that the gel doesn’t stay lying around the practice, and the more it lies around the practice over time, the more it breaks down, the more it breaks down, the more acidic it becomes. The more acidic whitening gel becomes, the more sensitivity you have. Can you see where we’re going with this?

It’s less sensitivity. It’s fresher gel for better results to celebrate the launch of EVO 4, my buddy Payman Langroudi and Enlighten Smiles are giving away 20 free kits to the Protruserati. It’s super easy to get a kit. All you have to do is go on the Facebook group, Protrusive Dental Community. On there, I’ve started a thread, and on that thread I’ve asked, who wants a free whitening kit?

Of all the people who comment, we will randomly select using one of those random apps that you see online. 20 winners. So you can start using either on your patients or your staff or your family with the new EVO 4 system. So the Facebook group again is Protrusive Dental Community. Just search it on Facebook.

You’ll find it. Thank you again. Enlighten and Evo 4 for supporting Protrusive Dental Podcast. Now just check out this really geeky, fantastic episode with Dr. Linda Greenwall.

Main Episode:Linda Greenwall, welcome back to the Protrusive Dental Podcast. How are you?

[Linda]
Thank you. I’m good.

[Jaz]
It’s great to have you back. You blew us away when we talked about whitening for under 18. It’s a very controversial topic and it got a slightly controversial response on social media and email, which is fine. We kind of expected that, but in a good way that a lot of dentists were like, wow, someone’s actually standing up i.e you for the profession. So that’s wonderful. And I was actually at dinner, the weekend.

At my friend’s house. And he’s a dentist, and he asked me a question, Linda. He said, which,’ Guest have you had on the podcast whose story really inspires you?’ And it is just, like the almost like the most inspirational guest you’ve had.’ And I said, okay. It has to be Linda. Because of your background, your story, your mission, and the clarity in which you communicate your mission statement is just so you know, you are oozing passion about this in all your educational ventures and what you’re trying to . Achieve.

Through whitening and much further for the restorative dentistry. So I think it was an easy choice for me. So thank you for all that you do for our profession.

[Linda]
So just one more follow up. There’s two more things. Number one, we are really making this year to campaign for the under 18 children because MIH, which is the disease, and a lot of the kids have these white spots that we’re going to talk about.

MIH is a disease and it’s one in six children have this disease. And so whilst they need the mild cases, need icon resin infiltration, they start with whitening. So we are going to focus on the disease aspect, and I’m going to do quite a few series of lectures on the disease aspect of MIH because it’s pretty severe and there’s a whole lot of new information.

That’s the first thing. The second thing is we’ve ramped up our care for the child refugees this year through the Dental Wellness Trust charity that we are working on. And a call to anybody who wants to open their practice on a Sunday, on a weekend to help the child refugees. These children are asylum seeking families, but we only work with the children.

They are not eligible for any NHS treatment or anywhere else. So, we do this treatment for them. We are happy to do it and provide it. This next week we are going to a hotel in Paddington to screen 40 children who need to be desperate for dental care, who can’t get it. So anybody who wants to volunteer, please message me afterwards. Any of that, we’d really love some help. We need to be ready to roll up your sleeve, so thanks so much. Thanks.

[Jaz]
If you weren’t already in love with Linda, there we are guys, you know, what a beautiful, noble thing to do. And just so to make it easy that I’ll put a link in the show notes so they can directly contact you for that.

And you’ll just let me know which is the best contact afterwards so I can take them directly to be able to them to get involved in helping. So that’s amazing. So completely right with today we’re talking about icon resin infiltration, and you already touched on. You know, whitening may be a part of this, but before we get to that, I just wanted to help dentists understand, because dentists, we weren’t taught this at dental school.

Like many things. And when we come across this, you know, “New Technologies”, obviously it’s been around for a little while now. I’m sure you’ll tell us. We get a little bit skeptical about actually using it in the practice. So first thing to cover is what is the science behind icon resin infiltration? How does it actually work?

[Linda]
So the way that it works is literally as it sounds, it’s infiltrates a porous area with resin. It was originally discovered, I think it’s more than 15 years ago now. By a group of researchers in Germany. One of them was called Paris. One was called Lueckel, and one was called Pharck, P-H-A-R-C-K.

And he did a lot of research on this, and I saw this information presented in Chicago when I was lecturing and when I saw the technology, I was like, this can be applied for patients with whitening and for white spots. And this has been nearly 10 years ago. And since then, we’ve been applying the technique.

So when a patient has got white marks or white spots on their teeth, you have to think of them as an air bubble within the tooth porosity. The reason that it occurs, I don’t know, we discussed this Jaz, but we need to talk about it. One in six kids have this. Anytime a tooth is starved of oxygen, so the little embryo is starved of oxygen.

It’s creates an air bubble, there’s a defect, and it becomes porous, and that is prenatally, postnatally or perinatally, anything that occurs around the birth. So when that happens, there’s a defect in the truth. What we know now with the new research is albumin for some reason gets incorporated into the developing tooth structure.

An albumin stops the tooth structure from hardening and calcifying, so it’s soft and it peels off. It just where you get post erupted breakdown and the tooth just starts breaking down and you know, it’s a very severe, there’s about seven different categories. About 20 years ago, a pediatric dentist noticed this disease.

Up until about 20 years ago, we weren’t really seeing it much, and all of a sudden we started seeing this. The history shows that it was around 200 years ago, but it’s much more prevalent now. So it’s now one in six, it’s now globally, all countries have it. Denmark, for example, they’ve eradicated tooth decay completely and they just deal with the severe MIH cases.

So MIH means Molar Incisor Hypomineralisation. There’s a really good website if you put it on the case notes as well, on the podcast notes. It’s called www.thed3group.org. And that is for children, clinicians, parents. Everybody wants to know about MIH and white spots and white mark. So I’ve prepared a whole series of literature. I can give you some of the literature in your case notes. What is MIH? What are the treatment options? What is resin infiltration? In fact, I’ve produced a book of before and after photos for patients.

[Jaz]
Oh, wow.

[Linda]
To see what it does with a little bit, it’s all picture books rather than technical words. So again, that is available, which would soon be available on Amazon. But explaining what it is. So the kids that come to see me, they are been traumatized, they have been bullied because a lot of it is brown, white, and marks. The parents are traumatized. The parents have so much guilt. So one of our options that we want to do, we actually want to do a research study surveying the parents because the parents have lived with this guilt that this cause something that happened during the birth caused the child’s teeth to be this way and the parents feel very strongly.

There’s no access to dental care on the NHS for this treatment. And under 18 whitening as we discussed, but, our next little project is to interview. Often I’ve been videoing the mothers after the treatment for the kid, the mom starts crying, not because of the fees, but because of the impact for that child, and everything is about the impact of the child and the mental wellbeing.

So in my book, which was published in 2007, second Edition, tooth Whitening, I wrote an index of treatment need for children with white spots and white marks. If it’s impacting the child, then treatment. If it’s not impacting in a child, wait till later. So we would start, very rarely we would do eight or nine years old.

We wait until all the teeth are wrapping, so about 12 years old. And normally when they leave year, then year five, year six, and they’re go into high school before that time, that’s when they really want to get the treatment sorted out.

[Jaz]
Now, I just want to say Linda, it is really good you mentioned that because from the previous episode, we did, teeth whitening under their 18s. I don’t think this was the impression that was created at all, by the way, but I don’t want dentists to interpret that as when they see a 14 year old with white spot, they will say, ‘Hey, let’s treat it.’ It should be a case of need. Ie It’s actually bothering the child.

If it’s not bothering them, then that’s the conversation you could potentially ask, oh, is it bothering you? And, later time in their life, basically. But if it’s definitely bothering them and the parent, then that is a worthy conversation to have at that point.

[Linda]
That’s right. But if it’s not, then you just move on and leave it over. But there are a lot of patients and unfortunately because of the, you know, they can’t get treatment anywhere else, they do travel a lot. And that’s fine because if this is all that it needs to help their mental wellbeing, this is fine. So, you know, as dentists, we are not psychologists or psychiatrists, so we cannot diagnose depression and all those things, and that’s not our remit.

But at the same time, we can see when a child is impacted. And if a child is telling you, they don’t often initially tell you that they’re being bullied at school, but when it is, the mother will say, and often, the recent case that I saw with a kid. The child was so, he’d biten the inside of his lip and his cheek.

He was so upset about the bullying, not only so there’s an internal thing where they hold it all together, but the external thing that the teeth are brown and yellow and defects on the teeth. So the beauty about resin infiltration, is that it’s non-invasive. Generally it’s non-invasive, but there are things that can happen, which you need to be aware of, but it’s a simple non-invasive treatment.

And as you know from our previous discussion, whitening is first always whitening because you want to see what whitening can do. Because what happens is that these cases need to be widen for a prolonged period of time. So not 4 weeks, not two weeks. Most dentists think, oh, it’s all over in two weeks. It’s actually longer.

It’s about six to eight weeks, or eight to 10 weeks, because you want to see what can whitening do for this patient first before you do the resin infiltration because-

[Jaz]
Absolutely.

[Linda]
The whitening can shrink the lesion not entirely gone away, although we have seen it go entirely away with patients who’ve got tiny little white spots.

So we’ll talk about predictions later, but if it’s small, it’s easier to get rid of. If it’s pale white rather than very opaque, then it’s much harder. So those are kind of some of the things. So the science behind, basically this technique was done as a method for treating early D1, D2 carious lesions, and that’s when it was just penetrating in the enamel and on the radiographs.

And we have many patients, and I know you do as well, when you see they take their bite wing radiographs, you see these little triangles in their enamel and you go, okay, what’s my treatment decision here? Do I leave it and tell the patient to floss more and use interproximal little brushes, or do I intervene if it’s only in the enamel?

If they change the habits, we can keep this lesion just as it is for seven years. Maybe nothing will get worse, but if it’s just like sort of tiny, but in the dentin, what we do with our digital x-rays is you can sharpen the image and when you sharpen it up, there’s a little thing on software of excellence.

Some of the software, you sharpen it, you can actually see there’s a little bit more decay than on the first digital image. But anyway, when we see that those are your decisions you need to make, do I treat it? Do I intervene, do I prevent it? Do I go through the fluoride and flossing, et cetera. My opinion on those cases especially when they’re multiple lesions, is we all know that the patients don’t really change their brushing habits all.

They don’t really. As much as dentists, we work so hard at trying to get them to change a behavior. We are not always as successful as we want. And so for those patients, I do the resin filtration posterior.

[Jaz]
Which was actually going to be one of the questions I want to ask later on whereby from my understanding, the technique was initially for molars and using it for E2, D1 caries. And so it’s great to hear you are using it, but why do you, I mean, it sounds like such a great, minimally invasive way to treat these early lesions.

Why do you think the uptake amongst, cause I don’t know. I know loads of clinicians and very few that I know are actually using this for molars. I particularly, I myself have the kit, but I use it for interiors and I haven’t had the training to use at molars and I’m a little bit apprehensive and I feel like maybe I should be doing it for molars. Because it’s such a great thing to offer your patients. Why do you think uptake has been slow?

[Linda]
So just a couple of things. By the way, Jaz, with your group of listeners, we can do hands on with you and your team, whoever wants to do it as part of the podcast because we can do it online. And so then-

[Jaz]
Amazing.

[Linda]
You don’t have to go somewhere so we can do it. So there’s two different kits. So you can do, and there’s an anterior kit, which is a round sponge, and there’s a posterior kit which has a different applicator. It’s got like a matrix, it’s a green handle with a matrix which you swap around and I can send you photos of it. And it’s got little pores on the green side.

It’s got little pores. So let’s say your lesion is on the lower right six mesially. You twist the applicator and you put it just mesially. You pre wedge or you put an orthodontic wedge, an orthodontic separator through. You wedge it, you place your matrix and you do the etch, and you would etch it again for two minutes.

And then you would go straight on to the resin and the resin is on for three minutes and then a further minute. So there’s a set protocol which we can go through, but that is for posterior. My point is on these patients, nothing is going to change. And then we are eventually going to have to drill them, those lesions.

So why don’t we just try this? Only problem is that the resin is not radiopaque. So you need a good preoperative radiograph to say, this is how it is. Now you can undertake the technique. And I explain to patient, it’s like a clear fissure seal.

[Jaz]
Got it.

[Linda]
Because we do a lot of fissure sealing in the practice, so it’s like a clear fissure seal. This is prevention. We rather intervene and prevent rather than wait for the lesion to get larger. And most parents are quite acceptable on that. And so it’s a simple technique to do, but you can’t see it working. You can do the technique, you can’t see it with an anterior, it’s all in front of your face, so you can see it working and you can see what’s going on, but it’s a good thing to know about.

And as you know, Jaz, I mean the reason for the success of your podcast. And just by the way, after we did the other one, I was stopped all over when I went to lectures and they’re all like, ‘Hey, I’ve just listened to it. I loved it.’ But so you’ve got a very impactful, very wide range of people. This is wonderful and congratulations.

[Jaz]
Well, thank you so much. Let’s make it happen because it’s a technique I want to learn. And this podcast was made for greedy reasons, in sense that I wanted to share a very specific bit about how to move to Singapore as a dentist so that I can help those people.

So I’d free up more of my time and eventually it led to me talking about things I love. And this is such a great thing, minimally invasive dentistry. And there’s loads of people who actually. Use icon resin infiltration anteriorly for those white spots. But we just lack that direction. And I think what you can give us is that direction.

So I will put a little ad in here for like, ‘Hey guys, if you want to come and join us for the HandsOn Online kind of thing.’ Is it like a HandsOn, like virtual hands online?

[Linda]
Hands on. We send you the hamper. And then we all do it together.

[Jaz]
I love how you call it a hamper. That’s so good. So great. So we can do that. So essentially the resin infiltration works by, well first whitening. Then the resin-

[Linda]
Then you wait two weeks.

[Jaz]Infiltrates into the tooth.

[Linda]
But you must wait two weeks because you want the resin, the enamel bond strength to reestablish after whitening, it’s 20% reduction. So you complete your whitening treatment and get the patient to come back two weeks later. So you’re ready for resin infiltration. Cause you want the bond to be working really, really well.

[Jaz]
Great. And then on the day it’s rubber dam isolation.

[Linda]
Rubber dam isolation. If you can’t, we use Optragate. Some kids don’t like the intrusiveness of rubber dam. We tend not to use local, so it can be uncomfortable for children.

So if we can, and we also do it for everybody with white spots between adults and kids. It doesn’t have to be just kids, and it works just as well on adults as well. So you would isolate because you are using hydrochloric acid. So you would isolate either with a full rubber dam or you can do the Optragate with a barrier.

And the Optragate works very well and you just bury it up. Some people just barrier where the white mark is on the tip of the tooth. So there’s different types of isolation that you can do, but you must do it because the hydrochloric acid causes staining on the gingiva, does cause burning. You get chemical burns.

There’s no legislation about hydrochloric acid. You can use whatever you want, whichever concentration on whichever age. No legislation on this. Of course, as dentists, we need to do everything that’s safe and there’s product safety legislation and the beauty about icon is so much research on this and there’s ongoing research.

I traveled last month to Paris to work with Professor Jean-Pierre Attal, and they have, which is very in innovative. They’ve got a discoloration clinic at the University in Paris.

[Jaz]
Wow.

[Linda]
And I go there to consult with them, to help them. I’m what you call like the special, I don’t know, like a, the godmother. The godmother for them.

The fairy godmother, the godmother for the clinic to help them. And we look at cases together. But Jean-Pierre Attal has published so much, and if you want to look up more, look up his work. And he has PhD students all the time working on resin infiltration. And so I always go to learn with the best that I can learn.

And so I spent a wonderful day in the clinic working with him and in his research lab looking at resin infiltration under the microscope and all those things. And so we working with them and producing more papers on this as the new information is coming along.

[Jaz]
So, what does it look like? Cause you likened the porosity or the white spots like an air bubble. I love that sort of likening into an air bubble. It’s a great visual image. And essentially once you infiltrate it, can you go over that analogy? What happens to that air bubble?

[Linda]
So then what happens, there’s a few more things about that. It depends. Little about the white mark. It depends where the white mark is located. If the anatomy of the white mark is also really important, so if the white mark is like a thin crescent on the cervical area, because it’s been poor oral hygiene, those are really super easy to do the resin infiltration. Really easy cause they’re tiny demoralization areas where the white markers on the incisal tip or in the body of the tooth and there is a depth and there is, it’s very, very opaque.

And on the severe cases, there’s actually enamel missing on their labial enamel because their enamel’s so weak. There’s a divot, like a, from a, I don’t know if you play golf, but there’s a piece missing out of the enamel. And so you need to do whitening resin infiltration. Plus you need to do a composite bond and you need to be ready to do a composite bond as part of the treatment plan.

And often some people find it difficult to work out. Is it a amelogenesis imperfecta or was it MIH. Or is it, you know, there’s many different type of things that it could be, or fluorosis, for example. But, so you need to look at the location, where is it? And then if it’s severe, it needs to have a composite bond.

So when we go with the analogy of the air bubble, the first step is you would clean the tooth. I use pumice and Hibiscrub with a little tiny micro brush, not a normal prophy brush, but the pumice and Hibiscrub. Then I would use my aqua care and I use it on the sylc mode, so the sylc is like, it’s got Novamin inside with vanilla flavor, we tell the kids it’s going to be like a vanilla ice cream on your tooth and we jetted and clean it. So you’ve got that, which starts the abrasive. Very mild. Abrasive, but it’s jetting in, so the conditioner, because the problem with MIH children is they are super sensitive. So just rewinding a little bit.

And many, many cases need sensitivity management treatment. That’s really important. And but this is the whitening. But that’s part of how we diagnose that it’s this. There’s not only MIH, it’s for all white marks and white spots and white specks and flex and all kinds of things that you would do the resin infiltration.

So you’ve got a nice clean tooth. Now you decide. Is this a basic lesion? Is this an intermediate lesion or is this an advanced lesion? A basic lesion is orthodontic demoralization, poor oral hygiene with those white lesions. One isolated little flick, tiny little, tiny little thing. That’s step one. The intermediate lesion would be, again, one lesion, quite diffused, a jagged edge, quite diffused within the middle. So it’s like a spider shape lesion. It’s not clearly demarcated.

OBAB:Occlusion is just so confusing. Does occlusion even matter? Wait, don’t you just grind away all the blue marks, right? You mean like plant it low, let it grow or leave it high and let them cry. Listen, what are these interferences even interfering with?

Is it safe to lengthened teeth? How much can I raise my patient’s bite? How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs? Is canine guidance always better than. Why can’t I just use the DAHL technique on all my wear cases? Can I stop my patience from grinding?

What the bloody hell is crossover? What should the occlusion look like after orthodontics? How and why do you check for fremitus? What on earth is a custom suicidal guide table? How do you use a leaf gauge? Do you always need to use a facebow? Does everyone really need a perfect occlusion? What is the difference between edge wear and pathway wear?

Is it naughty to adjust the opposing tooth? What the is centric? Occlusion is coming. One does not simply just open the bite. May the force mitigation be with you.

[Jaz]
To make sure you don’t miss the crucial update about the launch of our occlusion course, OBAB head over to occlusion.wtf. That’s right. It’s actually occlusion.wtf. It’s almost released and you’re going to love it.

[Linda]
An advanced lesion is multiple lesions on many, many teeth upper 4 to 4. Large deep lesions plus a central incisor with a whole piece of enamel missing, or it’s brown or yellow because there’s a defect. So those are your lesions. So you would start with the basic-

[Jaz]
One little trick. I learned Linda, and I just want some validation from you. Is that, is this a good thing to do? Is this something that you practice as well? Is that to shine a light cure behind that central incisor with the big white patch and see, can you still see the outline of that white patch.

And that gives me a clue as to, okay, what are we up against here? Because if you can’t, if you see the outline the white patch, that tells me that, okay, it’s potentially going to be quite deep and more of an intermediate to advance. Is that something that you practice as well?

[Linda]
Yes. So that’s called transillumination and the way that we do it, we take a photo with it as well. We use, instead of the curing light, you can use a curing light, but SDI make a really good diagnostic light. So instead of the white, instead of the blue light, it’s a white light. So we take a photo with no flash with the light behind.

And then you’ve got the photo of the transillumination before this. There’s a researcher whose name is Omar Marouane. Not marijuana, but Marouane. From the University of Tunisia and David Manton. They’ve published on this. And he’s done a whole, a series of transillumination as before he starts.

And then as the treatment is completed and with the transillumination, you can see how the lesion shrinks and you can see how the lesion is penetrated with the resin. So going back again, then we need to assess, what am I dealing with, with the transillumination? Then you will etch the tooth. So the etching, it’s called Icon Etch, and that’s for two minutes.

Now, we are not used to etching for two minutes. We are used to our 15 second quick flash, flash. So this, you need a timer, you need to time it out. Exactly. And the way that you do it is you place the etch all the way into the lesion. But what happens, because it’s an air bubble, it’s very porous, so it just sucks in all the etch like that.

And so you need to, during those two minutes, you need to keep replenishing. So you twist, it’s a special syringe, which is a twist sponge, so that you twisting and you keep replenishing as you go along and you massaging in gently not tickling the tooth, but more like massaging the etch into the tooth and you keep going and going and going for two minutes.

If you’re doing a lesion with sixth teeth, what you would do is you place the etch after isolation all the other techniques. We said go with the etch on all sixth teeth, and you start, you set your timer for two minutes, and you start massaging all the way for two minutes on all those teeth.

[Jaz]
On that point, the surface area that you’re etching, Linda, would you just do the, imagine you got quite, well demarcated white patches, 3 to 3, let’s say canines, canines. Would you want to do just the white patch only or do you want to extend it a border beyond the white patch? And if so, what is that border that you’re aiming for?

[Linda]
You don’t want to extend it too far. You don’t want to extend it too far, so you can just go over the little white area. So there’s a margin, but coming back to the air bubble analogy, what you’re doing is you’re opening up the top, the lid of the air bubble with your etching.

So you would then use the alcohol not for drinking. We taught in Croatia when you and the guy just, he lost it at the alcohol and so we couldn’t carry on with, he couldn’t get it out. It’s not for drinking. The alcohol is a test. It’s the test because alcohol replicates the refractory index of enamel.

[Jaz]
Of the result that, you know, if you were to resin infiltrate at that point, it was like a preview, right?

[Linda]
It’s a preview, it’s a test. So you put the alcohol on and you drip feed it for 30 seconds. Very, very, you drip and you watch, so you just drip it and check. If when you drip it on the tooth, the white spot’s completely gone. You know that you can go on just on your basic step etch alcohol resin infiltration. That’s a basic case.

But if when you drip it on the tooth, you think, I’m not really sure on this, it’s not looking fab, because you can still see the whole extent of the white lesion. You go back again, then you start again. So you do more micro abrasion so you can then you’ve got a few more abrasion options. You can sandblast with a MicroEtcher from Danville, you can sandblast it.

[Jaz]
How many microns? Because that’s the next question my Protruserati are thinking right now.

[Linda]
Honestly, you guys 30 or 50. I don’t think it really, maybe we’ll go on and on about.

[Jaz]
That’s what I think too, but that’s the next question that they’re going to be thinking.

[Linda] Our dentists just keep, you know, I know we anal, but this is like, it is what it is. Whatever it is. 30 or 50. It doesn’t matter guys. Don’t lose sleep over it. You know, whatever you’ve got, you will then. So you sandblast. So you go sandblast etch alcohol, and you do that up to seven times. If you have availability, micro abrasion paste, that is-

[Jaz]
Opaustre?

[Linda]
Opalustre™, and you’ve got 6% hydrochloric acid. Then I will micro abrade, so often I know it’s going to be a complex case, it’s a deep lesion. I go straight onto the micro abrasion before I do anything else because again, that roughens up the surface.

So you, if you go onto the advanced lesion, you can do only etch alcohol sandblast, sandblast etch alcohol, sandblast etch alcohol. Now, there is a new step, which I saw at the University of Paris. Professor Jean-Pierre Attal has taught his students to take a scalpel and where it’s really, really chalk. After you’ve etched it, you opening the lid again of the air bubble and you gently shave off the very opaque, like chalk you gently, gently so that you’re not using a handpiece unless you need to.

You gently shaving off some of that chalk dust and then you go back and you go etch alcohol, etch alcohol, and then you test it as you go along, but that way-

[Jaz]
Up to seven times.

[Linda]
Yes, up to seven times. But that way, you committed. If you start with your handpiece or your scalpel, you committed to a composite bond so often.

Actually, I would say like 80% of time, I would always add the composite bond onto the treatment plan anyway. If you don’t need to do it, you don’t, but you don’t want to do it as an excuse afterwards because, you know, so you just added on.

[Jaz]
You’ve answered one of my queries, and actually a question that I discussed with a dentist before is that when they’re communicating and they’re treatment planning for patients, the way I, and I’d love to know, I’m sure you got much better automated version than what I do, but essentially, I charge the patient or the parent or whatever for I will manage this white spot, how, I will manage it.

There’s a range of things that I might do. I will manage it. It may go up to removing some enamel and doing some composite at the end. It may stop short of that, but I will. So, because one lady dentist, she messages me saying is that, I don’t know how to charge this case. I don’t know how to communicate it because, I want to tell them, okay, it might be, it’ll be whitening.

And then it might be icon, but then if it’s a composite, I’m going to charge you this much more. And if it’s this much more I’m not, I’ll be like, don’t do that. Just charge it as a package and just do what you need to do. What are your thoughts on that?

[Linda]
I think that’s good, but often, so as we discussed, sometimes whitening does the trick honestly, in a 5% of the cases.

That’s it. So then you don’t have to have anything else, which, so that’s why I think you need to charge properly for the whitening and then the management of the white spot. And then you can go into the package, the resin infiltration or removing enamel and then with a composite bond. But if you know it’s going to be, then you were, if you know that there’s already a defect, you’re going to do it anyway.

So I like your idea. I think that’s great. That’s a very important to choose which composite you’re going to place over that. But coming back to the actual technique, you need to warn the patients that you may need to remove a little bit of the enamel. So that, yes, it’s minimal invasive. And the other thing, one of my students messaged me afterwards said, the tooth goes very flat.

It does go flat if you’re massaging and etching and all that, and sandblasting. And then again, you need to pre-warn the patient. The tooth number one may become more translucent because you’re taking off a tiny layer. So you see the little mamelons, you know, you see that little blue translucent area.

More often it goes more flat and it’s got a horrible taste during it. So even though it can feel rough at the back, and again with kids, you need to just warn them. So just coming back to the technique, so we’ve done the etching process. Then once you see, okay, the alcohol is really removed, I can see it’s working.

Then you go in with your infiltration. And the infiltration is done twice. So there’s two schools of thought. This is the classic thought is that you go in for three minutes. Again, if you’ve got six lesions, you place it on, it’s still the air bubble, it’s still porous. So to get, it just keeps being absorbed. So you keep replenishing as you massaging in for those three minutes, replenish, replenish, keep replenishing.

So you’re twisting and holding and massaging and checking. All that. Remember, really, really important, to floss through because the resin, it’s a clear resin. It’s called TEGDMA resin. It will adhere between the two teeth, and its difficult after it ends approximately. So you must floss through before you go. Then you will do your light. Your light, it’s 40 seconds, not a quick flash of 20 seconds.

So the way I do it, if I’m doing six lesions, is I will flash it across all of them just to get started for 20 seconds. Then I go back individually. And do 40 seconds each lesion as we are going along each lesion like that. Just checking. Again, some research says, but we don’t recommend it at the moment cause we need more research.

Why don’t you do it for longer? Why don’t you just etch for 11 minutes and place the resin for that amount of time? But there’s not enough research. Again, we go with Professor Jean-Pierre Attal, who’s done the research with these PhD students on it and published a lot. So you will do all your infiltration for three minutes.

It’s a long three minutes, and you keep going and going and going. Massaging, massaging, massage it, then floss through. Then you go back again. At that stage you can transilluminate and look and see what the resin has done the first line of resin. And then you go again with one minute. Et cetera, floss through.

Then you need to look and see how it’s looking and make sure there’s not too much excess. You know how resin is. The TEGDMA resin is quite flowy anyway, so just have a look and if you need to remove any excess, you take your soflex disc, not the black one, but like a medium blue, not the navy, the medium one, smooth over and use a rubber wheel.

And also those lovely composite polishing burs, the EVEs and the Astropols and all that purple and cream, you just polish. You just polish it up nicely. Remind your patients not to go and have anything with food staining. Immediately afterwards, one of my students sent me a photo where her patient made to have ramen 10 days later and the teeth became orange.

I think it’s because, number one, that maybe there’s a couple of things. Maybe the risen wasn’t cured enough, so you need to really do those 40 seconds of cure and then make sure it’s smooth enough so that it’s a nice labial contour is nice and smooth, not a big blob of resin.

[Jaz]
Hence why you use the polishers in a sequence to make sure it’s resin. So you are polishing the resin as you would do for a composite.

[Linda]Like a composite. Yes. And then afterwards, in terms of maintenance, It’s a really good technique. What we also learned from working with it is that the resin keeps going. It keeps infiltrating. So just on the first occasion, you think, I’m not really sure if it’s fab, you go back again.

You know, that’s the end of the appointment. It’s been your hour. You’ve done this. You’ve gotten, you know, because between the photos and the consent and the explanation and the technique, it’s a good hour. A good hour means another 10 minutes as well. Anyway, and so after that you bring the patient back and you would review the patient about three weeks or a month later because one of the very first times I did this technique, I didn’t do any whitening for a patient who was about 64 years old.

I wasn’t even sure if could work. At the end, when I finished, I was like, this is not bad. When she came back, it was even more stunning, but it’ll completely eradicated. So it keeps working, which is why you say to the patient expectations, manage the expectations. The other thing is when you’ve got a rubber dam on, you’re going to get more white spots visible than within the first place.

So often on those kinds of cases, I will actually draw with a pencil the white spot, the extent of that white spot. It’s there. Because I don’t have to do that one, that one and that one because-

[Jaz]
That’s genius. I didn’t consider that before. That’s so clever.

[Linda]
Just, but you just write, you just kind of draw that and you work on that part of the tooth first. Then you rehab the patient, rebates come back and you review the situation. Now the next common question is, what happens if you’ve done the resin infiltration? Will the whitening work? And the answer is yes. So because the way whitening works, it works in multi directions the same way. This is a new hot topic. We can discuss it another time. Whitening and Invisalign, hot topic number three. Very, very hot.

[Jaz]
Mm-hmm.

[Linda]
And the same way when you’ve got the buttons on the teeth for the Invisalign, they think, well, don’t do the whitening now. Wait till the end. Absolutely not. After a few weeks, you get on and do it. And the whitening goes underneath, through the enamel, through that way from the pulp dentin into the enamel, it goes that direction. So it’s absolutely fine to do the whitening at a later stage if you want to rewrite it.

[Jaz]
That’s a real gem. And I didn’t even think of that question to ask you, but you’re, I’m so glad you covered it, that a lot of people are concerned that once they do the icon resin infiltration, that’s it.

They’re done, they can’t whiten. But you just answered that really well. And there’s a few other questions I have, but you know what? I’m going to save those for our hands-on session, so there’ll be lots of goodness there. So I think you’ve described the protocol beautifully, and you’ve also talked about about transillumination stuff.

What are the predictors of success and failure? Are there any cases that you see that you think, oh, this might not work so well. Or equally an opposite to that. Cases that come in and say, yes, this, I’m going to nail this. Because a lot of dentists, when they’re first starting out with this technique, they’re always like, oh, let me ask a mentor. Cause I’m really not sure.

[Linda]
Let’s just say there’s just one more thing. I just wanted to mention this.

[Jaz]
Sure.

[Linda]
In terms of the predictors, if you don’t infiltrate completely and when you finish the infiltration, at the end of the point or the end, the first resin, the first time you kind of do it, you go, ‘Hey, but there’s a white halo around this lesion.’

That means you haven’t completely infiltrated with resin properly. Okay? So at that stage, if there’s a halo effect, it means it’s not infiltrated deeply enough or correctly. So you need to then go back a step or two. You would take your black soflex disc, remove the resin, go back and sandblast and go back again so that you can go deeper with it. Otherwise, it’s incomplete infiltration. Even-

[Jaz]
So this is like a repeat icon resin infiltration. Like a few weeks after to fix a halo that because you know, you missed it, whatever. We’re human whatever. Yeah.

[Linda]
So, that can happen as well, just so that you know that you can go back and remove it. But it’s always, that’s why you can go up to seven times, you’ve got all this time to make sure that you completely infiltrated and the use of the scalpel to take the chalk dust off also helps you to go deeper. So.

[Jaz]
Amazing.

[Linda]
That’s good. And in terms of predictors of success, we spoke about the size of the lesion, the color of the lesion, and the opacity of the lesion.

Super duper opaque will probably need. Mega abrasion, which you might want to take a handpiece a little bit and take the lid off more of the air bubble so that you can go deeper with the resin. If you see that it’s not great, you go deeper again and you’re going to score art with a little round bur a little bit there.

So then it comes back to a really important thing, which composite do you use? Over the icon over the, because there’s a whole lot. And the recommendation from Professor Jean-Pierre Attal is not to use an enamel composite. Cause enamel composite is translucent and you’ve got a white lesion, opaque lesion. You would use a body composite.

So look for a, like a dentin composite that’s ultra white. So that’s why we do the whitening to blend in to the opaque, to blend the white to the surface around. So you want to do that and then you choose your composite. We would use a bleach to shade composite, but not a translucent. Always. There’s a Tokuyama, A1 body, which Jean-Pierre Attal uses.

There’s a brilliant composite from DMG where they’ve got a bleach shade composite, which is fabulous. There’s another one from SDI, which is called Bleach Shade. Bleach dentin, which blends over. So you need to, again, like you’re doing, you know if you’re going to do the technique. Now, what we didn’t discuss was that, you don’t, after you’ve done your resin infiltration and you’re going straight onto your next step composite, you don’t have to re-etch and you don’t have to rebond because you’ve used the TEGDMA bond. The TEGDMA is an unfold resin. You go straight on and you put the composite straight over and you scotch it.

[Jaz]
But you can cure though, right? You can cure it to see where you are or don’t even cure it. You put the concept over the uncured, TEGDMA.

[Linda]
No, no. So, you cure it and you do your three minutes of resin curing. But then you go straight with your composite. So before you even start the case, before you’ve even isolated, before the rubber dam, I’ll just put some cotton wools in and work on your composite shade. Just check your shade if you’re going to go on with a bond. Check your shade before you even start where that white lesion as is.

Look at enamel shades, look at body shades, look at dentin shades, and just choose which composite is going to be the one. Because there is a defect, you have to do it and then you go back. Cause otherwise it’s going to mess you up in terms of the color afterwards.

[Jaz]
Brilliant. I think that’s so many real world tips here, including the actual, that was a question I was going to say for the hands on. I was like, okay, which composite? And also how do I put the composite on? Do I use Universal Bond afterwards? But you’ve answered that brilliantly. We don’t need to do anything, we just add the composite on.

[Linda] But you need to sculpt it nicely.

[Jaz]
Sure. I like to use like some of the brushes from cosmedent and whatever, just to get a nice blend. And then obviously the full polishing protocol, amazing. What is this common question again? What’s the expected longevity of this? So some dentists say, I’m a little bit concerned, do we have enough data or how it’s going to look like in five years and 10 years? What is the evidence suggest or clinical experience?

[Linda]
The research has shown that it’s predictable with the following discussions that we’ve had with all the different basic case, intermediate case, advanced case. Longevity, it doesn’t come back unless incomplete infiltration. In terms of stain, you know, some patient with poor oral hygiene, if you’ve done a beautiful composite bun, you get a black line or a brown line where the joint is, you don’t get that, but you may, which I’ve been doing it for the last nine years.

Now you make it like a tea stain, a very light tea stain over where the resin is, and all you do is just polish it with your rubber wheels and that’s that you don’t need to redo it. Don’t need to redo it. So that’s-

[Jaz]
Do we have, I imagine success rates are a difficult one to gather because every lesion is unique in terms of depth. So do we have enough sort of success rate data based on the how variable it is?

[Linda]
When I first learned the technique and saw teaching the technique, one of my students came up and said, no, it doesn’t work. But now we know there’s modifications. Every lesion is different. And they said, because MIH has got different chemicals, it doesn’t really work on MIH.

So we’ve modified the technique, and by modifying the technique, you get a much more predictability, and you’ve also got the predictability of doing a composite bond. So with all that, the success rate is high on it.

[Jaz]
Amazing. I mean, you’ve answered all my questions and now I’m really excited for this, this hands-on session, to do molars and anteriors for those who haven’t done it before. Are there any other messages that you want to pass on to dentists who are maybe learning about icon resin infiltration for the first time?

I feel like we’ve covered the assessment of the lesion, the actual clinical technique itself, and you’ve gone way well and above and beyond in terms of the nitty gritty details. Any other messages you want to pass on to dentist while you have the microphone?

[Linda]
I think that also from our point of view, the etiology, which is unusual that you’ve gotta ask patients or their parents their birth history. So you want to know, for example, were you born early? Were you on time? Were you late?

Because early preterm babies, they’re premature more likely to get white spots. Another interesting thing is celiac disease, for example, celiac disease also results in white spots, again, because there’s calcium absorption deficiencies, right? From an early age. So medical history is important, is relevant, and you want to show that you’re a caring practitioner and that’s really important.

But basically the technique is, you know, whitening resin infiltration, composite bond. But you still want to get a more understanding of the medical history because from our point of view, we also scientists as well as clinicians, and we also need an empathy factor that’s really a very important, the care factor.

A patient is a human being and so we need to modify, communicate really well. Expectations, pre-op assessments, paperwork, really key Jaz. You must have your paperwork, you must have explanations, and then you can build up your photo library. That’s why I created these books.

Again, it’s available if you want me to send for you to see. It’s nice as a clinician, when you starting, start on basic cases, start on an orthodontic demineralization case. You know, one tiny flick. Just get used to the technique. Also younger kids, the younger patients can be a little bit easier, just depends.

And then you build up a library of cases, in your experience so that you’ve got a whole library. And that’s why I show my patients this case looks like this little boy and we, for this little boy, we did X, Y, and Z. Yours looks like this. It’s not so severe. Then you can show them. Some of the severe, you know, because some patients are so distraught that they’ve just got a one tiny little white flick on the tooth that when they see other cases that is really much more severe than, it’s not so bad, but communication, paperwork, financial planning in terms of the costing, the signed consent form.

In terms of consent, patients always have to have a 24 hour cooling off period. All the risks and benefit all the options. And the whole beauty about resin infiltration is that the option is veneer or a crown, I mean it’s very severe. It’s like so minimal invasive. That’s why for me it’s like why wouldn’t you? If this is, if it would you do it for your daughter.

Absolutely. So, you know those kind of things, but you must explain the ramifications. Some dentists charge per arch for the whole lot or some dentist charge per tooth, whatever works for you. But sign the consent form, sign the financial arrangement. Make sure at your treatment planning discussion, a financial arrangement has been made with a parent and they understand the five different options in your practice of how you take care of fees, et cetera, so that it’s all run smoothly and that’s taken care of it. The admin’s taken care, and then you just go onto the cilinc.

[Jaz]
Amazing. Linda, thanks so much for, I know you’re such a busy woman, and I really appreciate your time and giving so much information. I’ll be in touch with yourself and Rachel to get find a date. We’ll do this. It’s going to be great to do a Zoom session.

I’m actually excited. I’ve done fair few anterior cases with great success with Icon Resin Infiltration, but I’ve never done a posterior and I’m actually really excited to learn that and be able to offer that to my patient, so we’ll be in touch guys. Stay tuned for that. Linda, thank you so much.

[Linda]
Thanks so much. Thanks, Jaz.

Jaz’s Outro:
Wow, there we had it. Was that absolutely mind blowing? This woman is just so full of knowledge and the little nuances that she covers is why she’s number one at what she does. Guys, I’m a huge fan of Linda Greenwall and so if you want to do some hands-on training, DM us on @protrusivedental on Instagram and let us know.

And so if there’s enough interest, I will get in touch with Linda and we will make it happen. Just like we made the Portugal trip happen, we can easily make this happen. Do you remember if you’re a Protrusive premium member, not only can you claim CPD for this full episode, which was full of educational gems, but you can also head to the Protrusive Vault to download the treatment guide with all our Protrusive masala.

Just like I said before, It is phenomenal. I hope you love it. I hope you use it. I hope you’ll be extremely practical. You should print it, laminate it, keep it the surgery so that you can successfully assess and treat any type of white patch. Thanks to that document. Listen, if you found this episode useful, do send it to a colleague and I look forward to catching you in the next episode. Thank you again.

View Details

‘Doing’ Social Media is HARD work!’ Do you find it difficult to make time for this?

Do you worry about professionalism and ethics on social media? How about the blurred boundaries between professional and personal life?

Dentistry is no exception to the trend of using social media in today’s culture. Dentists are using social media to connect with their patients and create new opportunities for patient education. However, dentists face ethical challenges such as how to best communicate with patients online, and what is the best level of consent to get from patients when we post their photos and videos?

In this episode, Dr. Alessandro Devigus also suggests how to use social media as a business tool and how to keep your personal life and professional life separate.

https://youtu.be/TEBmlDlybLECheck out this full episode hereDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

“React and interact with your audience how they WANT you to see” – Dr. Alessandro Devigus

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

1:19 Dr. Alessandro Devigus’ Introduction
4:20 How Dr. Alessandro started on Social Media
6:30 Drawing the line between personal and professional account
9:41 Importance of having a social media for Dental practices
14:38 Dentists posting full protocol cases on social media – good or bad?
20:14 Spotting fake dentistry
24:57 Making time for social media
31:59 Consent from Patients for sharing their photos – how to do it?

If you enjoyed this episode, you may also enjoy Personal Branding for Dentists, Logos, and Websites with Shaz Memon

Click below for full episode transcript:Jaz's Introduction: You don't need me to tell you that SOCIAL MEDIA is absolutely huge in all of our lives. If you're listening to this, I'm sure you're involved in social media in some way or another.Jaz’s Introduction:It’s NO EXCEPTION for dentistry, but this creates new problems and dilemmas, new ethical dilemmas for us dentists. How do we best communicate with patients online, and what is the best level of consent to get to patients when we are posting their photos and videos?

And where exactly do you DRAW THE LINE between PERSONAL and PROFESSIONAL? These are the burning questions we cover with Dr. Alessandro Devigus, who not only has a huge following on social media, but he’s such a level-headed guy as an extremely experienced, successful clinician. One of the topics we discussed, which you may resonate with Protruserati is HOW to MAKE TIME for SOCIAL MEDIA.

Many of you are struggling to find the opportunity throughout your busy lives to actually have a presence online. And so when I ask this to Alessandro, he had a really good answer, and it involves doing a bit of work, a bit of an audit of your time. So that’s something we cover towards the middle and end of the episode.

Hello, Protruserati. I’m Jaz Gulati. Welcome back to an Interference Cast. This is like a nonclinical interruption. If you’re new to the show, then thanks for joining. Do check out all the other episodes. Mostly a lot of ’em are clinical and they’re very geeky, and I get very excited about teeth and dentistry, and hopefully that gets passed onto you. But we talk about some varied themes. So hope you enjoy this episode with Dr. Alessandro Devigus and I’ll catch you in the outro.

Main Episode:Alessandro. So I know this podcast we’re recording today is about social media, but we must know what is your secret to looking so youthful?

[Alessandro]
It’s my wife. I’m married for 33 years, so happy wife, happy life.

[Jaz]
Happy wife, happy life, and somehow good skin.

[Alessandro]
Yeah and it’s my Sardinian roots. So, Sardinia is known for people getting very old. So my father is now almost 90. There are a lot of people there. And I think the number one secret of getting old and looking good is reduce stress.

[Jaz]
Mm-hmm.

[Alessandro]
Stress is the one or the number one thing making you older quicker, let’s say, mentally, physically with all aspects this is from my point of view. It’s not that I’m a super healthy food eater doing sports every day. I don’t smoke. I drink alcohol, but I don’t smoke. I think smoking is one of the number one. Things all smokers always tell me, yeah, but you drink red wine and whiskey. Say, okay, but I don’t drink bottles a day.

So I think I have under control not to drink too much, and yeah, and again, having a good family, a good social network that helps you if whenever there’s an issue. I think these are the key elements creating this, and in this atmosphere or in this context. I think you show, or you look younger to the other people. Although you are not young, you know what I mean? So, it’s-

[Jaz]
Mm-hmm.

[Alessandro]
Maybe you have seen this also with patients. Some patients they come, and they are 40 and they’re saying, oh, life is awful and blah, blah, and then they look and feel and express being much older-

[Jaz]
And tired.

[Alessandro]
Yes. And then you see 85 year old guys, not walking straight, but smiling and are being happy. And then you feel the spirit. You feel the youth coming out and they say, okay, maybe tomorrow it’s over, but I will enjoy my life. Life is too short not to enjoy it. So this is a very important point, I think.

[Jaz]
For those guys listening. Alessandro sounds great for those watching. He looks great as well. You have to take my word for it. And if you don’t already watch the episodes, you can catch him on YouTube and Instagram, whatnot. Just remind everyone, you came on the photography episode, and you talk a little bit about your roots, your interest in photography.

Today we’re talking about social media. And I mean this in the most kindest way possible, Alessandro, right? I just told you, you look great for 60. Okay. Most of the six-year-old dentists I know they steer well away from social media, yet you are blossoming on social media. What you do on social media, I don’t see many of this doing.

You are wonderful at social media. So, tell me about how you got into. Just the habits that you have on social media, your presence on social media and I mean, again, I mean this in a nice way despite your colleagues who maybe your age have probably don’t even have an Instagram account. So, tell me about that.

[Alessandro]
So basically, I restarted my social media career three years ago. So I was on social media when everything started because I’m a computer geek. So I was one of the first Twitter user. I was in immediately on Facebook, on all these channels, but then realized that I made a big mistake.

And this is something, let’s say the first important message goes out to everyone, young, old, whatever, women voice man. Don’t mix your social media and your private life. So be aware you can have a private account whereas a young girl, who show bikini photos of yourself, or as a young man pumping in the gym, that’s fine.

I’m not against this, but don’t mix these accounts with something that you want to be professional. So if you have an account for your dental office, don’t show yourself too much in your private life driving your Porsche or whatever because this creates a wrong image. Even if you have achieved something in your life, making it possible to buy a Rolex or all these gimmicks that people think, wow, if I have a Rolex, if I have a Porsche, I’m a bigger, I’m more important.

But if you feel doing this or wear expensive clothes, don’t show that to your clients. It’s like my brother, he has like four Ferraris. He would never take a Ferrari driving to a client, never. You know, then you take your normal car, you dress yourself like you have to in a business suit or in your office. So react and interact with your audience how they also want you to see and this is the number one message of how to start or how to think about starting your social media career.

[Jaz]
Alessandro, I wholeheartedly agree with you on that. What about, I’m gonna play devil’s advocate. What about the situation whereby like I, myself, I do this whereby, I post a dental stuff on my, not Protrusive Dental, but on Jazzy Gulati, I post a Teethy stuff.

But now, and again, I have family because for me, family is one of the highest values. And what I think that does is it humanizes me. So when prospective patients come say, oh, he’s a father, he’s a husband, I want to go to a family man. Do you think that’s okay? Showing your children, showing yourself not necessarily in bikini and whatnot, not necessarily luxurious, but in a family environment or, I like football, Mans Tonight, cricket. What about those things teach us about.

[Alessandro]
Yes, I think this is important to show yourself then it’s your decision in what extent you want to integrate your family. I always tell people, look, have you asked your children if they want to be on social media? Do you have the written consent of your three-year-old boy or girl jumping around, making a fool on your Instagram account?

So these are the points. I think it’s important to show people that you are a father, that you have a family. You can share these facts in short things, but don’t overdo it. Don’t overdo it. What I do is this is something important. From time to time, I do a new story. Talking about who I am. So I tell people, look for all those, for the new followers, for all people not knowing me.

My name is Alessandro Devigus. I’m a Swiss dentist with passion for digital technologies and I want to share this and this and this and that, and that and that with you. And so it’s like a refreshment on people not knowing who I am. You cannot expect that over, because social media is very short life information, so from time to time you have to repeat, and I agree with you that you can integrate your family, but your family has to agree on that.

So this is an important point. Just don’t, just take your smartphone, shoot the videos and post them. And then after that, your wife might say, ‘Hey, come on. What the hell are you doing?’ You know. So I think this is important that it’s in agreement. And again, be also aware that your children might in some years say, ‘Hey, Dad what the heck did you catch me when I was falling down the clip? And now it’s there and my colleagues are sharing this video, showing me this video of me failing.’ So be careful. Be aware of all these facts. But again, I agree. Show your audience. Show your clients. Show your patients that you are married, that you have children.

[Jaz]
That you’re human.

[Alessandro]
Yes. That you’re a human. Yeah, absolutely. But don’t overdo it. Do it on a regular base, but not every day. So let’s say 5%. 5% or max 10% should be personal stuff and the rest should be professional stuff.

[Jaz]
And that’s different to your other personal account, which you may have, which could be private, for example. And that’s where you could just do expression of yourself as an individual rather than you, the dentist who’s now speaking to patients all along which is great advice, I think. And that’s really good. Let’s switch gears a little bit to the main first question I wanted to ask on this episode, which, and we kind of touched on it already, is that we are at a stage now where I would say 99% of general practices have got some sort of a website.

Not all of them are good. Yeah, I know some practices who don’t even have a website at the moment, still to this day. Okay. And then fine, but most of them do. But a lesser percentage has social media. Now, one thing I truly believe in over the last year or so is like with Protrusive Dental, social media. I don’t do much on Twitter.

Okay. And actually, I’m thinking that I’m not gonna do much on Twitter because it is just, I don’t resonate with it as much. And I truly believe now that if you’re gonna have a social media, then do it properly. There’s no point in having a social media and doing one post a year on that account, because someone else might come on and check the Twitter and be like, oh, this isn’t very active, this isn’t very good.

And then be like, oh, this is not representation of that brand. So one mantra I follow is that if you’re gonna commit to having a Twitter, do it properly. If you’re gonna commit to having Instagram, do it properly rather than just having it for the sake of having it. So where do you see social media for practices who have websites and then maybe for them to get to a social media presence now is too much of a big step. What would you say to that dentist listening now who hasn’t embraced social media yet?

[Alessandro]
Basically there, there’s some research and dentists are also visual. Let’s say visual people. So what we are doing, what we are communicating is our patients want to look better. So they want to change something. They have problems we solve.

So it’s a visual thing. So Twitter for sure is not the right channel to interact with your patients. Then we have like in Instagram, TikTok, and Facebook, there are others like Snapchat and WhatsApp. WhatsApp is almost an underrated social media tool that you can integrate also in your marketing campaign interacting with patient.

But be careful with communicating with your patient on all these channels. Watch out for the legal issues. So I tell dentist, don’t share too much information via smartphone with your patients. There you should use safe channel. Safer channels. So a patient might send you an image of a broken tooth, that’s okay, because he sent it, it’s his information.

If I took a pic, if I take a picture of myself and share it, it’s my problem. But you as a dentist, you cannot just take pictures or receive images and share them with others without asking the permission of the patient doing so. So this is the side effect coming back, I would say today, you should focus on Instagram.

If you are a younger generation dentist who wants to fool yourself a little bit and you have a young team that also wants to dance, TikTok might be an alternative. I’m not so much into TikTok. I tried doing so, and I found that what works on Instagram doesn’t really work on TikTok, so my main focus is on Instagram because what I found out, Facebook still is the largest community.

But not really engaging. So you easily , I call it and we discussed it already for me. Facebook is the happy birthday platform. If somebody says, oh, it’s my birthday today, then you get wow, hundreds of comments. If you post some valuable content, nobody interacts.

So this is the situation. Facebook is great if you want to promote your office with advertisment because you have 2.5 billion people. It’s easy. And it’s interesting if we have done some research, there are more dentists having a Facebook page than having an Instagram account or other social media.

So in the dental community, if you ask them, number one is I have a Facebook account because at the end it’s also mandatory to have one if you want to have an Instagram account. But still the dental community or the medical community is still number one on Facebook not being really active. This reflects also the average age.

The dental community is getting older and Instagram is like, oh, I have an Instagram account, but I don’t know where to start. So the thing that I felt browsing over the last two, three years, many dental accounts is. I would say 90% have no plan.

[Jaz]
I agree Alessandro and one observation I’ve made, and something I spoke about in a little mini webinar that the BDA did recently to young dentists about social media is, and please tell me if you agree or disagree with me, is that I want dentists to decide who their account is for.

Is it for dentists or is it for patients? Because a lot of the time dentists are posting up shots that only a dentist would appreciate and labeling perikymata, et cetera. Whereas a patient would be like, what the hell’s going on? Whereas patients wanna see full faces and other types of videos, which the dental community may not engage with as much.

Basically, they still would. So would you agree that, you know, as a dentist or dentist office, you need to first cite, okay, are you actually making content purpose-built for patients and the public or other dentists and you wanna show them your line angles, et cetera. Would you agree with that?

[Alessandro]
Absolutely. And this is one big mistake a lot are doing. They want to do both on one account and this doesn’t work.

[Jaz]
And some do, but there’s they’re few and far between. And you alienate the one or the other sometimes.

[Alessandro]
But if you look at the successful accounts, they’re not really showing. Nobody shows blood images because patients don’t want to see any blood, any that a dentist might even like, but the patients don’t. But what, I also must say this before and after, before and after, before and after thing gets a little bit tiring. Some patients might jump on this, but you see also on this more successful account that they’re mixing more and more personal stuff with this.

So they do less before and after. And show more behind the scenes what services they are offering, showing up themselves. So this is the thing, because I had an interesting discussion in life with Miguel Ortiz, dentist from Boston about all the fake dentistry we are seeing on social media.

And nobody cares. Nobody cares. Not even the dental community. They give likes to photoshopped images and it’s amazing. It’s amazing how uncritical the audience is towards the information posted on social media. But again, I agree and this is an important information and message to the dentist out there.

You have to decide, is my account for my patients and potential new clients, or do I want to share how cool I am or not even how cool I am. I think I have to share my knowledge with the community but then please share the knowledge before and after is not sharing any knowledge and what I have experienced over the last three years. I have posted thousands of comments asking, can you please share more details on this case? You don’t get any answers. What does this mean? They know that they’re a fake.

[Jaz]
Okay. I mean, I think it’s a platform issue as well.

[Alessandro]
Or is it an arrogance? I don’t know because it’s called social media for a reason, and I see that especially the dental community is missing out being social on social media. If you post, then you have to be ready to answer questions. Otherwise, turn off the comments. You can turn off comments in your post. So then if I look at the picture and I seek, there’s no way to post a comment. So the person who posted this image or this video doesn’t want any interaction.

But if you post and anybody is able to post a comment, then please, please, and this is a message and I want to everybody to listen to this. If I ask you a question, I want an answer. I tell people, if you don’t ask questions, you will never get answers, but I have to modify this. If you ask questions on social media, it’s most likely that you don’t get an answer.

And this is sad for me. This is really sad. If we don’t communicate, if we don’t talk to each other, we will not grow. I don’t learn from a cool before and after a while I say, wow, I will never be able doing this. I want to learn. And if I ask a question, you can answer, I don’t answer this question, but please give me an answer. And I always ask in a polite way, you know.

[Jaz]I have seen that and I can vouch for that and I think I personally think Alessandro, while we’re talking about it, could be a difference, innate difference between Instagram and Facebook. So firstly, I agree with you that the reach is different when I share a video.

I did share a video the other week about this cool suction tool about cleaning crowns. It got 1700 views on Instagram and 201 on Facebook. So I definitely agree with you in terms of how content and media is consumed and reached on the different platforms. But there may be a difference. So when, sometimes when I share full protocol cases, A) Instagram only limits me to 10 images and I can’t individually caption each image. Whereas on Facebook, I can post the entire series of 125 step by step, and under each image I can write a caption.

So I do feel as though that these are fundamental differences and it becomes more difficult. However, I do agree that when someone asks a question, it’s good for engagement. It’s good to grow our community of practice by answering questions, and I do feel that Facebook sometimes does this better, and I think that’s something for us to learn and grow from. I think overall, taking a step back, I have learned so much from social media in terms of dentistry.

It’s actually amazing, I think. Are you used to say more from Facebook than Instagram, but nowadays, I think from Instagram as well. I think there’s so much to learn, but you’re right, we should maybe be a little bit more critical of the stuff we see and too fair. I don’t even consider. When I see photos on Instagram, is it been Photoshop or not maybe it’s just me being rose tinted glasses or whatever. Any ideas on how to spot a fake?

[Alessandro]
I think if you are a decent dentist, you immediately see that papillas cannot grow, that something looks too perfect than nature.

And I have to tell you. Maybe you can see some veneer cases that have done that really look like nature. But if you go close, then there are only a few things that are really perfect and the larger the things get, the more you see that it’s not nature. But the thing is that most people don’t want to see it.

It’s like going to Cirque du Soleil, you know that you are in a Dream World and for two hours you go and watch the show and dream on, let your mind flow. And I think too much people are consuming social media that way. Again, they’re not critical. They’re giving likes for things. I sometimes also scroll the feed and then double tap, and then I go back and say, no, no, I don’t like this. I don’t like this. So then I remove my like, you know what I mean? And people-

[Jaz]
Because the algorithm responds, it’ll show you more of what you like in the future, which is-

[Alessandro]
Or people tagging you and then you feel like forced giving a comment. And now I’m really starting to sometimes also being critical, but again, always in a polite way to start interaction.

And what I get sometimes that I get a direct message telling me, why are you so critical? Why are you posting negative comments? Say, no, this was not a negative comment. If I ask you a question, why have you selected this material? This is far off by being negative.

[Jaz]
It’s gonna help to, for everyone to grow and learn and share.

[Alessandro]
I want to start the discussion, and again, a lot of people are afraid of starting discussions on social media.

[Jaz]
Again, I do think Facebook lends itself better to discussion. That’s how I feel.

[Alessandro]
Yes. And that’s also why you see a lot of Instagram accounts of dental Instagram accounts are still private.

[Jaz]
Mm-hmm.

[Alessandro]
They are still hiding themselves because two reasons. They don’t have a strategy, so they look at other feeds and see, ‘Oh, my feed looks strange.’ Or don’t know what’s wrong. So they keep it private or they are afraid of entering the discussion. So these are the two points, and I always tell people, ‘Hey, come on, show yourself.’ I want to see what you’re posting. I cannot follow everybody who is private, just to see what’s behind the account. If it’s just a private account, showing family picture or is it, and this is coming back, the importance also of how you show, how you present your account on Instagram. The importance of the, of your profile page, of your bio that you write there, who you are, what you’re doing, what your goals are, and then try to be consistent in your feet.

And so I’ve personally, for example, also started reposting pictures of others dental photography. So, reposting artistic photographers, especially from people from South America that they’re great in doing all this artwork. I don’t know where they find all the time to do so. And then I say, okay, if I just repost clinical images or let’s say artistic images or try doing artistic images myself, I’m one of a million. You know what I mean?

[Jaz]
Mm-hmm.

[Alessandro]
So it’s nothing special. So then I started, okay, why not share my knowledge with the audience? And this is then finding this is then the topic, finding your niche. So what you want to share, what you like sharing with others. And I think this is the way to go on your social media if you want to show yourself as a dentist, as a private person, so on.

And again, coming back this is then one, one thing, and the other thing is showing your office, showing what you are doing, showing what you are, offering your services, et cetera. Two, be like the window, the showcase of your office attracting potential clients.

[Jaz]
Absolutely. It should be an extension of you. It should be a projection of you and your values. I totally agree that. I remember being in a lecture in 2014 of some dental marketing expert, but there’s a group of dentists in the audience. So this was like eight years ago. And I remember the biggest objection that my colleagues, which are, who are mostly my senior at that stage, of my career, were saying that, where do you find the time?

I don’t have time, you know, amongst children, clinical dentistry, life, and everything that happens. Where do you find the time to post? So what would you say to that dentist who has this as their number one objection? How can they magically find the time?

[Alessandro]
Just check, start checking your agenda. And then it’s like, uh, if if somebody tells me I don’t have time, then I ask him, okay, for one week, write down what you’re doing when. So when are you getting up? What’s the first thing you’re doing? What’s the second thing? And just write down how your days are going, and then you might see, ah, in the morning, I’m just sitting 30 minutes on the toilet. Maybe if you take that much on the toilet, use this time to do something.

You spend 30 minutes drinking coffee. Or whatever, or in my dental office, I have the routines. Most of the dentists then say, okay, from eight to five I’m totally blocked, and after that I have some time. But if you then after analyzing your schedule, still realize that you don’t have time, then it’s mandatory to look for professional support in the sense, look for a coach, for a social media manager that helps you.

If you still want to present yourself or your dental office. And this makes totally sense because if you then calculate, you should cut off two hours a day from your dental schedule to become a social media manager yourself. This doesn’t make sense, and this is way, way too expensive.

Your fee, or at least the loss of working hours over the whole year is worth thousands of pounds or dollars or Swiss Francs or whatever. And if you calculate this, I agree, and this is why, I don’t know why not more dentists are coming to me. I’m offering these services.

I have some people behind me helping me with producing content or giving me ideas. There are some tools you can use. By the way, I’m now setting up like a mini course that will be free, how to start with all this, but it ends up-

[Jaz]
Amazing.

[Alessandro]
It ends up with a decision, okay, I have the time to do it myself or with some members of my team, or I don’t have the time, and then don’t wait too long. Then get in touch with me or other people who are offering services, coaching services.

So I have some dental practices I’m coaching, and we have a coach, a call once a week to discuss what are the next steps, what can be improved. And then you find so many small things that are not working. And at the end it’s slowly the engine starts running and then you’ll get happy and don’t spend, don’t do anything that you don’t like to do. So if you feel forced being a content creator on social media, then stop doing this and look for professional help.

[Jaz]
I think that’s great advice and I’m glad you mentioned about how to get more help. Ie reach out to you. Is it @dentist.Camera that you wanted them to reach out or where is the best way?

[Alessandro]
Best way is my Instagram account and maybe I’m allowed to do a small advertisement at this stage.

[Jaz]
Please. No, please. I insist you’ve helped me so much. Please do. And reach out to Alessandro and learn more about this and his website’s wonderful. He’s all, everything he set up is just wonderful.

I know he’s got a team behind him and actually I’ve got a team behind me as well. So a lot of people me messaging me saying ‘Jaz, how do you find the time?’ Leverage, you know, I needed a team. I want to be a father; I want to be a dentist. I can’t spend my whole life in front of a screen. So you have to then get other people involved in your team.

[Alessandro]
Absolutely. So, we are now launching on September, The Dental TV. So this is like an initial naming, but maybe we will rebrand it because it started as the idea of having a dental photography conference. Then we had to postpone that we had to cancel.

Then we thought about going on an online conference that was saying, okay, we have so many online conferences. This would be just another one. So, I started inviting more people. So now we have over 30 speakers. And what I have decided, because I’m also now collaborating with Sony and Vimeo, that I will start my own Vimeo OTT channel.

So basically, this is like Netflix for dentists. So, I will have an own video channel and we are now setting it up with an app for iPhone and Android so you can watch and consume and subscribe from all platforms. That’s pretty cool. And you will have then there all the content and we have four pillars, photography, video, communication, and social media.

And I’m reaching out to experts in all these fields, giving you and let’s say the dental community a platform where they can learn all about these topics. And this is the goal to really create something, to build up a community there. And I’m pretty confident that this will be something successful.

It’s basically a lot of YouTuber go over then to this Vimeo OTT or other platforms because you have better control. You can monetize better because then I will like create, like for Netflix, it will be subscription based. There will be some free stuff you can host online events. I will post there my webinars.

There’s so many things and the industry are also interested in participating, for example, posting information about their latest software they have or whatever. So, this will be a good mix for the dental community for sure. So, thank you for giving me the time to explain.

[Jaz]
No, no, please. I think this will be great. I look forward to you to be part of it. I look forward to joining Dentist TV. I think it’s a great idea. We’re having something similar with the Protrusive App, but it’s in a different way. So, I think we need more of these channels to be creative. And you are prolific content creator, Alessandro, and you need to have a dedicated channel.

So, I’m so glad you’re doing this. So well done. My last question for the day now, and I’m gonna sort of tease everyone the out intro for this question. This is another pain area. So we discussed about the time issue and you covered that beautifully ie to revision. Guys, if you’re having issue with time, you need to audit your day.

And then once you’ve audited your day and you can’t find any time and you don’t wanna be a social media manager, then get some external help and reach out for coaching with Alessandro, @dentist.camera. Now my last question is consent. Dentists worry, and rightfully so about getting the right level of consent before posting a video or photo of their patient, or their smile, their teeth, or of their step-by-step photos. How do you gain consent in 2022 from your patients to post their mouth online?

[Alessandro]
That’s an important question then for us, it’s like a multi-step procedure. Step one, when a new patient comes in, they have to fill out their anamnesis

[Jaz] Fine. Like a medical history form.

[Alessandro]
The questionnaire. Do you have any diseases and whatever you call that anyway-

[Jaz]
Medical history. Yep, absolutely.

[Alessandro]
So, and at the end of this, they have to sign it anyway, and there’s a point where they can cross, they can mark this. I agree that my information is shared with other dentist. Because I have to share it with other dentists if I’m doing consultations or I need support. I work closely with the University of Zurich. In more complex cases that we exchange information and that pictures taken can be used for publications, lectures, and on social media.

[Jaz]
Okay.

[Alessandro]
So this is number one. But then if somebody signed that-

[Jaz]
But is that like a tick box or is that there by default? Do they have to tick it?

[Alessandro]
They have to tick it so it’s something active, so they have to do it actively. Second thing, if I have a case that I think I want to post it or use it for a lecture, so it starts most that I use it for a lecture or a presentation or a publication.

Then you go again to the patient and say, look, I recorded this case. And I would like to use it for educational reasons so other dentists or the community will see it. Do you agree? And then you put it in your medical history, say, okay. I ask the patient if she or he agrees that I can use the pictures and then they say, I had only one patient disagreeing. And then I say, okay-

[Jaz]
And just to clarify. The first one was written. It was a tick box. The second time from the same patient you ask verbally.

[Alessandro]
Yes.

[Jaz]
Okay.

[Alessandro]
But I write it down in my medical history. So you have like the thing open and you record everything that you’re doing with your patient, and then I take a note and say, okay.

I ask the patient if it’s okay to use these images for an article and then write the patient agreed. So there’s no need to sign again or whatever, but it’s important that you ask the patient and you get this agreement or this okay from the patient. And again, I think if you ask politely, most of the patients agree.

[Jaz]
In my own experience, yes. I mean, if you just say, look, I would love to use the images to show other patients, or I would love to share this with other dentists because I think there’s a lot to learn here. A lot to share here. Yeah. Maybe had zero or maybe one I can think of that said no ever in the last, you know, nine years. So I agree with you.

Patients are usually very happy for this. And then sometimes the odd one will say yes, but don’t show my face. And that’s totally cool. You need to respect that. But yeah, very rarely will they say it an outright no.

[Alessandro]
I have many patients asking. For their portrait pictures. So when I shoot my portraits, there’s a lot of patient asking if they can use them for their social media so-

[Jaz]
Yes, I had a male model actually. I took some portrait photos and then he actually now use it as part of his portfolio for his modeling. Why not?

[Alessandro]
Yeah. Yeah, why not? No, no. But again, important, ask your patients for the permission before doing so, not just post it. And then you get like the letter from the lawyer saying, okay, dear, your doctor, what have you done? So, the problem is if you have posted something, it’s almost impossible to delete it.

[Jaz]
Yep. And also, when you post it, it now becomes property of Instagram or property or Facebook. So, you need to respect that. The social media then owns it. So, it’s really important to get that level of consent, I think.

[Alessandro]
Yeah. This is also an interesting question. I have to ask someday the editors of books and journals. Because many authors publish them, they’re pictures of books out or articles on social media, and basically, they would not be allowed to do so because the property is on the editor of the book or the article.

So, if you publish articles, the copyright goes in most cases to the editor and you agree with that in this small letter text that nobody reads.

[Jaz]
Yeah. It’s true. But the scary thing though is, and something, the reason why we take it seriously is that there’s nothing stopping anyone. Like you post up a video of your patient and then someone can just download that video, put it on TikTok, and make and perverse the meaning of that, you see? So this is a little bit of scary time, so we just have to proceed with caution. I think that’s important not to forget this.

Alessandro, you’ve been absolutely brilliant today. We’ve talked about photography before. We talked about social media. Are there any closing remarks that you want to give to dentist before we send this out to the big, wide world? And hopefully lots of people join you on your Dentist TV. I look forward to that. Please give us your closing thoughts on the topic of social media and dentistry.

[Alessandro]
Basically it’s social media in general. So number one, be social on social media. So this is my number one thing I want to spread out. Second thing is think about if you really want and have the time to start a social media career or a social media journey, look for professional help if needed. So don’t say, ah, this guy is doing better than myself.

Ask these people, what are they doing? Being consistent is one of the fact, let’s say in the dental office, I would highlight the words love and passion. So you have to be passionate about what you’re doing. You have to love what you do on social media, it’s a little bit passion, a little bit love, but the most important thing is consistency.

You see a lot of burnouts on social media that you don’t see in the dental office in that extent. So social media is something that can be really demanding, taking a lot of energy from you. So there again, try to be consistent and if you feel like running out of ideas, not knowing what to do, not having any goal or plan again, look for professional help. So these are the key elements on being happy and social on social media.

Jaz’s Outro:
Guys, enjoy social media. Have a presence for your practice. Have a presence for yourself if you think that’s the right thing for you. I think what social media has become is, yes, there’s bad points about social media. We kind of touched on a little bit.

It’s always important never to compare yourself to someone else. I think Alessandro just mentioned that. And don’t compare your uncut life to someone’s highlight reel. Right. That’s like number one pathway to depression stuff. So remember that everyone’s always projecting the best and sadly Photoshop stuff as well.

But, have a presence. Enjoy, have fun with it, and if you’re not having fun with it, get some help. I think that’s that’s a message there. Well, there we have it guys. Hopefully you feel a little bit better about your interactions on social media, but also how to portray yourself on social media. It can be a dangerous place.

It can be a minefield. So some of the guidelines that Alessandro presented to us, I think are really helpful. Although this episode wasn’t eligible for notes, this is eligible for CPD because ultimately social media is a form of communication. So if you’re on the Protrusive App, scroll down below, answer a few questions and get your CPD.

You’ve come all this way after all, and as ever, I thank you so much for listening all the way to the end. If you wanted to join our community, there’s one on Facebook called Protrusive Dental Community, and it’s just got the loveliest people with a self-selecting bunch who listen to podcasts, and it’s absolute pleasure to read the discussions we have.

Please do join us, but if you’ve been trying to join, I’m not accepting you. It’s because you haven’t convinced me enough that you’re a dentist, so you kind of have to message me on Instagram or something to convince me that you are a dentist. And sometimes you might ask for proof and whatnot, but it’s only because you wanna create a safe environment for our community. Thanks again, and I’ll catch you in the next episode.

View Details

There are a billion people globally who have sleep-disordered breathing and only 20% of them have been diagnosed and treated. In this episode we revisit sleep-disordered breathing and how it is connected to Dentistry.

Dr. Aditi Desai, from British Society of Dental Sleep Medicine is just the most passionate Dentist ever about this crucial and often overlooked topic. You will hear the passion in her voice or see it in her eyes if you watch the video version of this podcast.

https://youtu.be/0aG8iQdbkeYCheck out this full episode hereDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

The Protrusive Dental Pearl: Removing Aligner Attachments – A step-by-step protocol including the use a UV torch to see if there’s any resin left and which different burs and polishers I use.

https://youtu.be/SP1irVhyzRwHow I Remove Aligner AttachmentsNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

1:27 Protrusive Dental Pearl – Removing Attachments
4:31 Dr. Aditi Desai’s Introduction
7:25 What is Sleep-Disordered Breathing?
14:51 Mandibular Advancement Splints for Snorers
16:14 Signs and Symptoms of SDB for Dentists
20:24 Referral Template for General Dentists
24:55 Adverse Effects of Oral Appliances
28:15 Link Between Periodontal Disease and Obstructive Sleep Apnea
31:05 GDP Referring Directly to a Sleep Physician
33:48 Home Sleep Testing
36:18 Patient Compliance with CPAP
41:32 Learning Basics about Sleep-Disordered Breathing

Check out Dr. Aditi Desai’s website, aditidesai.co.uk. And if you are in UK, you can check out British Society of Dental Sleep Medicine and support their upcoming event on March 4th. If you’re interested in getting into space now, you should check this out!

If you enjoyed this episode, you may also like Airway – Dentistry’s Elephant in the Room with Prof Ama Johal

Click below for full episode transcript:Jaz's Introduction: Sleep disordered breathing, sleep apnea and airway problems dentistry. These are some of the things that have become quite an area of interest in dentistry and for all the right reasons, because as dentists, we're in such a brilliant position to SCREEN for AIRWAY ISSUES beyond just snoring. Like we don't wanna just treat snoring.Jaz’s Introduction:
We want to ADD YEARS to our patient’s lives. And if we can diagnose or we can’t diagnose, but we can screen for sleep apnea and airway issues and get the patients the help, and then we can be involved in potential therapy such as removal appliances to bring the mandible forward and that way we can have a huge impact in someone’s life.

I was always taught that the two times you can save someone’s life dentistry is A) if you detect or diagnose a mouth cancer, or B) a barrett esophagus or someone’s got acid reflux and for them to get investigated and have a camera to explore that area. However, I think a third one that wasn’t mentioned to me in dental school, but definitely should be there is sleep disorder breathing or sleep apnea because on average that can take 10 years off of your life expectancy.

And in case you think that sleep apnea is a disease of the fat old man, you are totally mistaken. So whether it’s in children or in adults, this episode with Dr. Aditi Desai, who’s just the most incredibly passionate woman ever on this topic, it’s gonna open your mind. So please lend me your ears.

And for those of you on YouTube and on the app, your eyes to this Protrusive Dental Podcast episode. Hello Protruserati. I’m Jaz Gulati.

Protrusive Dental Pearl:I’m your host and I’ve got your Protrusive Dental Pearl for you today, which you can access in the show notes. So essentially the Protrusive Dental Pearl I have is my sequence for removing Invisalign attachments.

So it’s like a video. I’ll show you exactly what I do, how I use a UV torch to see if there’s any resin still left. The different burs I use and the polishes I use. I don’t think I have the best, I don’t know about different protocols and stuff. I just do what I’ve been doing for many years and it works really well now and then we get the Optragate in.

We use a series of burs and polishes. We get a really nice result. A few of you did ask me for a video on removing attachments, so you got it. The Protrusive Dental Pearl will be in the show notes. Just scroll down wherever you are listening or watching, scroll down and you’ll see that video. And if you like that one, give it a thumbs up and let me know.

Do you do anything different? Is there a hack that I’m missing that you want to share with the Protruserati? Let’s join the main episode with Dr. Aditi Desai, and I’ll catch you in the outro. Occlusion is just so confusing. Does occlusion even matter? Wait, don’t you just grind away all the blue marks, right?

You mean like plant it low, let it grow or leave it high and let them cry. Listen, one of these interferences even interfering with, is it safe to lengthen teeth? How much can I raise my patient’s bite? How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs?

Is canine guidance always better than group function? Why can’t I just use the DAHL technique on all my wear cases? Can I stop my patients from grinding? What the bloody hell is crossover? What should the occlusion look like after orthodontics? How and why do you check for fremitus? What on earth is a custom societal guide table?

How do you use a leaf gauge? Do you always need to use a facebow? Does everyone really need a perfect occlusion? What is the difference between edge wear and pathway wear? Is it naughty to adjust the opposing tooth? What the is centric relation? Occlusion is covered. One does not simply just open the bite. May the force mitigation be with you

To make sure you don’t miss the crucial update about the launch of our occlusion course, OBAB, head over to occlusion.wtf. That’s right. It’s actually occlusion.wtf. It’s almost released and you’re gonna love it.

Main Episode:Dr. Aditi Desai. Welcome to the Protrusive Dental Podcast. How are you?

[Aditi]
Thank you very much for inviting me, Jaz. I’m pretty good. I think.

[Jaz]
You just told me you’d like to run your admin sessions and do your zoom meetings and stuff, so I’m very glad to catch you on a productive day because we want to fill the ears and the eyes of dentists, those who are watching with a very important topic, which is on the huge list of topics that are barely scratched at Dental School.

And so many dentists I know, they will gladly admit that, you know what, when it comes to airway, I have zero idea. It’s something that we’re openly saying that, you know what? We don’t know at the moment. And I feel as though, I dunno how you feel, but as a nation, we are so far behind the States and Australia. Is that something that you feel?

[Aditi]
You know, I thought that we were much further behind the States and Australia, but actually we are not. I think we are a little bit more measured in how we actually conduct ourselves. You know, we are not sort of trick in our presentation, our presence. So I think dental sleep medicine in this country has been around for a very long time.

But what we don’t have is we don’t have the regulation that we require. And for me, I think that is the most important aspect of it because we need to establish that credibility. And until we have that credibility, how are we going to actually close that gap between medicine and dentistry? Because I think that the subject matter is such that this is the one area in medicine and dentistry that’s gonna bring the two fraternities together, which I think is important. I mean, how can you possibly dissect the head from the rest of the body?

[Jaz]
Yes. It’s often the way that dentistry is like completely segregated. And I agree with you. Sleep is such a great connector of both the medicine world and the dental world. But before we dive into that and we talk about the guidelines and the changes and how dentists, no matter where you are in the world, I mean particularly UK cuz talk about UK based guidelines, but wherever you are in the world, how you can get involved, what are the things they need to look out for in general practice and how to better serve our patients.

That’s the mission of this podcast episode. But I wanna learn a little bit about you. Tell us about your journey, how you ended up interested in this niche field of dental sleep medicine.

[Aditi]
You know, I’ve been a dentist graduated 45 years ago, and I’ve pretty been, I’ve been a very lucky person. I’ve had a wonderful career.

I’ve done dentistry in every field that you can think of. But the one spot of dentistry that really rang my belts was airway and I actually came across this when, many years ago when asked the BBC dentist, a patient, came into my clinic from Australia, gave me some really stinky, smelly silicone monoblock and said to me, ‘Can you fix this?

And I looked at it. I thought, what is this? And he said, it helps me sleep. And you know, he wasn’t a pleasant man. So I thought, well actually I don’t know what it is. So I think it’s better to say you know, to learn to say no is so powerful. So I said, I’m really sorry, but I can’t.

But my mind took me back a little bit and I thought, you know, what was that? What do you mean silicon monoblock that helped you sleep? So I started looking a little bit into it that I came across a British Society of Dentist Sleep Medicine, and that is my journey. And I started to learn a little bit more, you know, attended a course, then they invited me to join the board and then, I think about seven years ago I was elected president and I remained president.

I wish somebody would want to take over my job now. But we’ve been very lucky because it’s actually given me an idea of how dentistry goes beyond drilling, filling, restoring, whitening, and aligning. I think all of that is very important of course, but to be able to actually look at a patient and be able to help them with their quality of life is as important as whitening somebody’s teeth. And making them feel good about themselves. So that’s my-

[Jaz]
Agreed. This is something that can add years to our patients’ lives and improve their quality of life. How I am early on in my journey, but definitely something I’ve looked at thought, wow, I need to start screening my patients more. And the way it happened with me was a similar experience to you.

I was at Guy’s Hospital, I was a DCT, and I was working on the consultant clinics and we had one clinic. About once a month, every two weeks where we would see patients who had a positive diagnosis from the sleep condition of mild to moderate sleep, to breathing or sleep apnea. And then we would be making the exact same.

Can you believe it? This was 2015, the monoblock silicon appliances at the hospital. And then I was like, what on earth is happening here? And then as I delve further into the world of bruxism and TMD then I realized, whoa, this is connected so much to sleep. And we’ll touch on that. So, it is great to hear of your drive and your passion to spread the word.

So I guess the first starting point for the dentist listening to this, who has no idea what’s going on, what is this sleep apnea? Can you just start by probably saying something that you probably say to a lot of introductory talks. What is it that we’re up against? What is the main issue? What is sleep disorder breathing, essentially?

[Aditi]
Right. So sleep disorder breathing is a syndrome. It’s a collection of disorders which create a syndrome where people are not able to sleep and breathe efficiently enough when they do try and do that together. So it’s really a disease of sleep. It’s also a disease of breathing together. So whether you sleep in the day or you sleep at night, whenever you sleep, you have a problem.

It’s really all about the collapsible airway. It’s the unsupported part of your airway, which has no bony or ligamental support, which tends to collapse now when you have complete collapse, for 10 seconds or more, that’s called a sleep apnea. An obstructive sleep apnea. Now, that has got to be distinct from central sleep apnea, which is a neurological condition.

So that’s got nothing to do with us, and we don’t get involved in treating patients with central sleep apnea. So for us, obstructive sleep apnea is at one end of the spectrum, and at the other end of the spectrum are people who snore. So you know, we all snor. Now and again, we have a good night out. We come back, lie on our backs up.

You know, we’re snoring away. That’s okay. That’s benign snoring. But when somebody’s snoring every night through the night, that actually becomes pathological. So if somebody’s just snoring all night, they still can wake up in the morning feeling tired, because the brain is being aroused constantly through the snoring.

And not only is it affecting them, it’s also affecting their bed partners and people who are in the house. So it’s almost like treating two or three for the price of one. When you treat somebody snoring. And when you try and think about, I think there are a billion people globally who have this disorder syndrome, and only about 20% of them have been diagnosed and treated. In this country, we are looking at over 2 million people who have this disorder and only 20% may have been treated and diagnosed.

[Jaz]
My son is actually in that category. He’s only three. He’s having his adenoids removed in two weeks. He had a positive diagnosis. He had a home sleep test.

It was 21 seconds where he was not breathing, actually. They found that. So, again, from my own experiences, again, another reason I’ve taken an interest in myself. So, the dentist might be thinking, wait, what has this got anything to do with teeth?

[Aditi]
When I mentioned the number of 2.2 million, I was talking about adults. And children, men are managed differently, although their symptoms may be the same. You know, they don’t perform that well at school. They are sort of somewhat, they might even have bad, bad wetting. They might have behavioral issues. You know, all of these are part of a child’s sleep apnea problems and they always get put away as the naughty child or the difficult child because they may even have ADHD.

But, you know, to treat a child patient who has deep apnea as a result of tonsils. It is actually, it’s amazing cuz I’ve seen some of my patients, one or two child patients who’ve had their tonsils removed and by the time the GA is gone and they’re awake again. They’re a different child. It’s as remarkable as that.

[Jaz]
I’ve heard that a lot myself, a load from dentist, parent dentist whose own children, have been through it. They’ve told me that they’d actually have to keep checking if my child is still breathing because what they realize actually their breathing is much quieter.

[Aditi]
Yeah.

[Jaz]
That’s the first thing that people / parents told me actually.

[Aditi]
So, but you see, this disease is no longer a fat and 50 man’s disease. I mean people used to, when I first got into this field, any man that walked into my clinic had a big punch of big fat neck and his posture was trying to open up his airway.

I kept thinking, he’s sleep apnic, he’s sleep apnic. I could be on a bus, on a train. I said, he’s sleep apnic. But I’m very wrong. It was almost like a hammer and nail situation. It was absolutely not that at all. But now I, the majority of my patients are not fat and 50. They’re females. They’re males. They’re very young.

My youngest patient is 17 years old. You know, adult. When I say adults, 17, almost 18 years old. They are slim. They’re incredibly thin. They have very long, thin, narrow face. They’re very slit noses. These are the things that we look at, the very sort of narrow arches. And these are the patients that I see a lot of.

So it’s no longer a fatten 50 man’s disease. Of course there are fatten 50 who are sleep apnic, but you can’t stereotype them anymore. You can’t just look at a thin person and say, well, you’re tired, you’re snoring. It’s fine. You’ll be fine. They may not be fine. They may have serious sleep apnea. So that’s where, I’m very keen.

Every dentist who looks at a patient, looks in the mouth and sees their telltale signs and has the telltale symptoms, they should just have their red flag up thinking, let me just assess them mentally. Once they’ve done the mental assessment, then they can ask a couple of pertinent questions and then get them screened officially and formally diagnosed by a Sleep physician and then treated.

So if a patient comes in, for example, and says, ‘Mr. Gulati, I’m actually snoring and my wife will not sleep with me anymore. Can you please help me?’ And you say, of course. You know, let me make your mandibular advancement device or a mono block or whatever you decide to make them. You will be actually working against guidelines.

Because our guidelines have changed. We have to assess these patients, have them formally diagnosed by a medical professional, that medical profession will then give us an outline of what they believe to be the right pathway. But that doesn’t mean that you don’t treat the patient while they’re being assessed.

[Jaz]
Mm-hmm.

[Aditi]
Because remember we look at the NHS pathways and the NHS pathway we’ve got a long, long waiting list.

[Jaz]
Absolutely.

[Aditi]
You get these patients to wait for two years before they’re seen. In fact, I spoke to one of my ENT consultants this morning. He said he has a five year waiting list in the ENT Hospitals.

[Jaz]
Wow.

[Aditi]
Five years. Now, whether that is for surgery or whether that’s for CPAP, I don’t believe that CPAP will be five years. Although we have had this latest CPAP debacle where the Phillips recalled all their CPAP machines, so there’s been a huge shortage. Now, these patients need treatment. If you’re a snorer, yes, let your wife sleep in the second bedroom for a couple of nights, you know, maybe a couple of months.

That’s okay. That’s not gonna be too much of a slippery slope, however, these patients giving them treatment with a mandibular advancement device while they’re waiting for their CPAP Machines giving them some treatment rather than no treatment at all.

[Jaz]
Can I just stop you there cuz I think we’re touching on something really, really good and I like how you’ve gone right in and this is gonna be very, very good, but let’s make it even more tangible because many dentists actually have been on a course to treat snoring and then maybe fell into, oh, hang on, if I’m treating snoring, I also need to do this tickbox of exercise of screening for obstructing sleep apnea.

And then they sort of back off and refer. if it’s high risk and then medium risk, they just go ahead and treat. So with the new guidelines, I think it’s August, 2021, right?

[Aditi]
Yes.

[Jaz]
So we’re referring to the same guidelines here, and I’ll share that in the show notes for those listenings so you can download those.

So if you’re wanting to treat a snorer and you have done your screening and you feel as though that this patient is a simple snorer only and you feel as though that they don’t have the high risk signs of obstructive sleep apnea, can a dentist go ahead and make that mandibular advancement splint without referring to the gp? So that’s the first thing I wanna unpack.

[Aditi]
So what the British Society of Dental Sleep Medicine have come up with is it’s almost like an algorithm. It’s a guideline. You know, it’s giving you a pathway of risk, high risk, low risk, moderate risk, and you know what to do. See, if a patient is low risk, asymptomatic, the word is asymptomatic.

That is the most important one. Okay. And as soon as they’re asymptomatic and they’re snorers, yes, go ahead and make the device, the mandibular advancement device. But documented record that says that you made this only for snoring and advise their GPs that you’ve actually made a splint for snoring only.

The next important thing is these patients need to be followed up because this disease or syndrome is one that gets worse over time, age and weight. So somebody is just a benign snorer or a pathological snorer and asymptomatic may get worse as they get older and fatter. And we all get fat as we get older. Now I’m also, I’m a little bit floppy as we get older. You know, that’s a fact of life, unfortunately, much as I deny it. But there we go.

[Jaz]
With those in the medium and high risk, now before we follow the algorithm and you can share that, what are the symptoms that we are listening for and what are the signs that we are looking for as a general dentist so that we can start to have an involvement in this very important area of what is the interface of medicine dentistry?

[Aditi]
So a patient will not come to you saying, I’m going to the bathroom three times a night. Cause we are dentist, they’re not gonna come to you and say, you know, I may come to you with a headache but they’re not gonna come to you and say, you know, I wake up feeling terrible every morning cuz that’s not what we do.

But they will come in and say, I snore. And they might so say, gosh, I just feel so tired. Or you are treating them and suddenly fall asleep. Or they might start snoring just that they’re go into that light sleep. They might just start snoring. These are telltale signs. The other symptoms are that they might be tooth grinding.

They might be complaining to you of TMD or facial pain or headaches. These are the most important cardinal symptoms and signs that they would present to a dentist with. If on the other hand, a patient is coming in to see you and you think that they’re looking red-faced, they’re punchy, they’re fat, and they’re on a cocktail of hypertensive drugs.

Or they’re diabetic or they’ve had a stroke, and you look in the airway and you can’t see the airway. These are things that you need to look at and say, well, okay, maybe let me just ask the question. By the way, how do you sleep? How do you feel when you wake up in the morning and he says, oh God, I feel terrible when I wake up in the morning, when I wake up with a headache.

Or people are not aware. They don’t know what to say to a dentist when they come in. It’s all about education. It’s all about education, raising awareness, and then providing access to treatment. For me, that’s my mantra. Raise the awareness, provide the education, and then give them access to treatment.

That treatment may be something that we are providing. Or provided by somebody else. Now going down the algorithm. So if they’re asymptomatic and snores, you provide them with a mandibular advancement device, but make sure that it’s documented that you’ve done that and advise the GP that this has been done so.

[Jaz]
Got it.

[Aditi]
That’s the most important thing that we have to look out for. If, on the other hand, they come in complaining of snoring, but they’re symptomatic and they’re very tired and they’re sleepy in the day, then they must go for a formal diagnosis.

[Jaz]
Formal diagnosis. Even before you’re make an appliance only for the snoring.

[Aditi]
Yeah. If you make that, well, not the diagnosis. If you think that this patient is symptomatic, they are at risk of OSA. The guideline says that you refer them on for a formal diagnosis, okay?

[Jaz]
Mm-hmm.

[Aditi]
But you can make them a mandibular advancement device just to combat their snoring while you send them off for a formal diagnosis and make sure that you advise whoever you’re referring to or the GP that you’ve actually made that the splint only for them to be able to sleep or sleep with a bed partner for snoring. That’s it.

Not because you’re saying, oh, actually the treatment for this patient is a mandibular advancement device. Because doctors do not like us treading on their territory. The other message is to make sure everyone realize it, this is not a dental condition, it’s a medical condition.

[Jaz]
Mm-hmm.

[Aditi]
It’s a medical condition that needs dental intervention. And this is the first time that the NICE guideline actually acknowledges the role of dentistry. It’s taken me almost 10 years to get recognize that actually dentistry has a pivotal role in managing these patients. And not just dentists, but also the whole dental care professional.

The hygienist, the therapists, cause who sees the therapist and the hygienist more than anyone else. The patients will see them more often than us. Right?

[Jaz]
Absolutely. I think you’ve covered a really wonderful thing there. How we should not be writing in our notes the diagnosis of obstruct sleep apnea.

That’s for the medical, that’s for the physicians to do. We can write, screened for, and moderate high risk and then arranged the referral. So the first question is, in the, in the UK obviously it might vary in different country, but in the UK we need to be referring this to the GP. Now I use our little S4S, have a little docket that, that is a very nice little template to GP. Do you guys have something to give the dentist to help the referral?

[Aditi]
Absolutely. So the British Society of Dental Sleep Medicine, we’ve actually just about to launch us, our new website. And when people become members, you have access to not only the, the algorithm, the pathway.

And we also, and that pathway by the way, is accepted by the ARTP, which is, you know, the British Sleep Society, ARTP, where they will actually they’ve actually said, yes, we recognize this as an acceptable pathway for dentists to follow. And that’s also very powerful. So it’s not just dentists telling dentists that we are okay.

It’s the medical fraternity that’s telling us that yes, actually what you’re doing is correct. So we’ve got that pathway. They also have access to screening documents. Screening questionnaires, and they also have access to consent form that we have actually gone through over and over again to make it fairly robust to make sure that we don’t fall into the pitholes because, you know, now this is now on the actual radar of certain, maybe even some of the indemnity insurers we need to make sure that everyone who is protected, you know, we may think that a bit of tooth movement, a bit of jaw pain may be okay, but actually there’s no need for that to happen.

We can do everything we can to mitigate those side effects with the use of the appropriate device. So the one thing I always stress to all my members and to anyone who comes to me for any advice or help is yes, go ahead and do your courses.

Go ahead and get industry led courses if you want to, but if you really want to do the right thing, learn to use more than one device because one device does not fit all. There’s no such thing as one device. It’s almost like the CPAP masks, right? One CPAP mask does not fit every person, so each one has to be personalized. We have to do the same thing for oral appliance therapy, so we are about to create a consortium of Oral appliances that people will be able to pick and choose from.

[Jaz]
This is brilliant. And just wanna add I have the same philosophy with occlusal appliances. I manage a lot of bruxism stuff and part of the very first thing I do is an airway screening.

So if anyone is as high risk, I would not make that occlusal appliance, cuz from what I believe and what I follow in the literature I’ve read and occlusal appliance for bruxism can make your obstructive sleep apnea worse by opening the OVD and distalize manual, making someone more class two. So, if anyone’s high risk, I’ll always refer them on before making the appliance or because the correct appliance made for them may be something that will also help the airway. So yes, it’s not just everyone gets a Michigan spin or everyone gets soft bite guard in that regard as well. So it’s very similar.

[Aditi]
You can make a splint upper or lower or whatever you wanna make for every patient, but if there is a risk of sleep disorder breathing for you, like you said, make it protrusive.

If you’re making a protrusive splint, then the patient will be fine. But you know, we have so many patients that have been treated with Michigan’s and tanners and we’ve made them apnic. I’ve just seen a medical legal case that I’ve been treating recently, and this gentleman had a class three jaw alignment, went to Maxfax surgeon.

And instead of looking at his maxilla, which was underdeveloped, they retruded it with surgery and orthodontics. They’ve made that patient severely apnic. Now, you know, we are gonna have to do corrective surgery, so I’ve just made him an occlusal appliance, you know, with all his pins and screws and everything, and it’s gonna be a really long, protected legal case.

But I’m terrified because I, having to protrude that jaw, with all this you know, surgery that it’s had is quite challenging. But, you know, we have to be careful that patient assessment is so important. Making them if you don’t assess the TMD, for example, that’s your baby, right?

So if you don’t assess the patient properly, for potential TMD issues, with the splint, then you are really going to, you know, get yourself into trouble.

[Jaz]
And I had one colleague recently who posted on one of our forums on Facebook that a patient came and he had snapped a post crown on the upper lateral incisor, and the patient felt as though it was from the pressureof the appliance and she wanted to know, is that, is that possible?

So can you please explain about what kind of adverse effects could happen with these oral appliance therapies to bring the mandibular advancement splints because we need to appreciate, just like you said, for there’s main different designs and therefore we need to pick the correct design based on the occlusal features and the dental features that were presented with.

[Aditi]Do you know? You’ve hit a very important point there. I have learned, all have learned through my mistakes. That’s the best way to learn cuz you don’t wanna make them again. I remember I was sent a patient by one appliance company through their marketing and they asked me to make a device for them.

And that device was not suitable for this patient because this patient’s mouth was full of bridges and crowns that I had not provided. And because they were metal ceramic, we took the radiographs, they all looked fine. No problem at all. No root care is nothing. And then of course, in my wisdom, which was not a good element at the time, this many years ago, I provided him with a device that was holding onto the teeth in a different manner to what other devices do.

So he was literally gripping within the triangles between the teeth. So the next day he came, I provide the device. He was really happy off he went. Two days later, he comes back into my clinic and he chucks the device at me with the bridge in the devices. And I looked at and I thought, oh, you know, and it was completely rotted.

It was so badly rotted. And he said to me, you have done this. And I said, no, I haven’t actually. But what had happened is because I could not assess that treatment, and it wasn’t treatment I had provided, I couldn’t tell how good or bad that restorative work was. So we dug the bridge out and we repaired it and we you know, put a root post in, put it back in.

But you know, it never really worked well because of that, I was always worried and the next time, that post came off again and I realized actually that I had made him the wrong device. I should have been a bit more knowledgeable about what kind of device that gentleman needed.

He wanted something that was gonna be easily repaired, easily adjusted to a new bridge. Where there might have been a silicone lining, perhaps, maybe a SomnoMed® device, which would have a silicone lining that is adjunct, that is actually replaceable. Say for example, the S4S device, the SleepWell.

That also has a silicone lining, but that lining is not replaceable. You can’t replace it. So, but this silicone lining in the SomnoMed® devices, you can replace it. So if a patient comes in, tooth breaks, you put a onlay, inlay, crown, whatever you do, all you do is re-scan or re-impression, send the device back to the lab, and they just put a new lining in. So that’s why I go back to the thing. You must have knowledge of more than one device.

[Jaz]
A hundred percent.

[Aditi]
And this thing about TMD for example, you know, it’s a myth that you can’t treat any patients with TMD. In fact, sometimes with the right assessment you actually make these TMD patients better. By opening up that jaw and protruding is slightly-

[Jaz]
Down and forward.

[Aditi]
We can get that disc recapture. So these are facts that we need, so the blanket statement do not touch patients with TMD. Do not make a device for people who are bruxing cause they’ll break it.

It’s not true. It’s just not true. In the same way with periodontal disease, do not treat people with periodontal disease. That’s half the population.

[Jaz]
There’s just other appliances that we need to learn about that you can use the appliance without putting pressure through the periodontal ligament.

[Aditi]
Not only that, but did you know that there’s a bidirectional link between periodontal disease and obstructive sleep apnea?

One makes the other work. Inflammatory Disease. Both of them create inflammation and periodontal disease gets worse when people have always say there’s absolute, there’s quite a lot of work that’s been done by Jill Levine from –

[Jaz]
Yes.

[Aditi]
And also by Maria Carra Clotilde a great friend of mine from Paris. Now, she gave a wonderful talk at the RSM last year on periodontal disease. Now, if you see a patient with periodontal disease, not people that you just blow or click it and the tooth drops out. Of course, these people need a bit more care, but you know, people who have got uncontrolled periodontal disease, you should be thinking, why can I not control this?

Do they have the additional signs and symptoms of OSA? You treat OSA and that periodontal disease can be controlled, not in every case, but they can be controlled.

[Jaz]
It’s another factor to consider, isn’t it?

[Aditi]
Exactly. So I think that if you then have a device that you treat the OSA.

Motivate these patients who are not, who are pretty gently feeling crap anyway, and they don’t want to, they’re not motivated to seek help, make them feel better, and then they can go and seek help. So, I wouldn’t discard every patient with periodontal disease. You have to guard the guideline actually does say that, you know, we guarded with TMD and periodontal disease, but I’ve just written a big document for the transformation services, of sleep services in this country with the NHS.

It’s gonna be published soon. And in that I have actually documented provisors that do not discard patients with perio disease. Do not discard patients with TMD. Treat them with a little bit further assessment.

[Jaz]
Yeah, I think that’s needed rather than a blanket statement. Now, Aditi, just so following on the path, let’s say we have that moderate to high risk patient and we’ve been a very good GDP.

We’ve done the screening, we look beyond caries, and perio. We are looking at a patient as a whole, but we make that referral. Using, let’s say the society sort of pathway and form. And it goes through a GP now, hopefully, and I, I want this episode to be listened to by GPS as well.

Cuz some GPs, they speak to some patients and they say, nah, you’re under 50. Uh, what’s your BMI? Nah, you probably don’t have a obstructed sleep apnea. So this very much, I know you know this. Very much exists in the medicinal world as well. They need more training. I think they realize that as well, actually.

So there’s a huge change and shift coming in terms of medicine and dentistry, in terms of learning more about this condition. Now, let’s say you get a GP who I find that with these referral letters, which are quite nice, they actually give the GP a lot of information to go by and that GP is then able to make the referral to a sleep physician.

Am I right in saying that I as a GDP cannot refer directly to a sleep physician? I have to go via a GP? Is that correct?

[Aditi]
Not necessarily anymore. We are actually looking at direct referral into a sleep service, and that is something I’ve been driving for as well, because-

[Jaz]
Absolutely.

[Aditi]
I’m sorry, but not everyone has the, they’re not, everyone’s not the favorite view. They can afford private care. We need to make the pathway simple and less onerous for the patient. I mean, come on, this is about patient not about us. And the GPs are not interested in a lot of cases. Not everyone, but a lot of GPs are not trying to actually train GPs to make them more aware of what their role is has been a bit of a challenge for everyone.

The RSM, the sleep section of which I sit on the council, the dental section, we’ve all been trying to get the GPs to be a bit more engaging, but they’re so busy and inundated. This is the last thing they want to do.That’s my opinion. Okay. That’s my own personal opinion.

[Jaz]
I hundred percent agree, from what I’ve seen, I know you’ve seen much more, but from my experiences with other colleagues and the fact that one of my patients the other week told me that he had to literally get a heart attack to be able to be see a GP face-to-face nowadays.

So again, another barrier because the times that are actually getting to even see a GP is, can only be slowing down the workflow.

[Aditi]
Yeah. So that’s why we are trying to get these referrals straight into the sleep service. The NHS sleep services and make it less on risk. But again, the other drive is that’s assessment, screening, and diagnosis is actually going to be brought into primary care, and that is why the dental role has become even more important.

So we are looking at dentists. pharmacist, GPs, all of them are gonna be more and more involved in the initial screening and assessment of the sleepy patient. And once that’s been established, then they can be sent into secondary care and then into tertiary care if necessary.

Cause a lot of them are tertiary referrals. They do need tertiary care. I mean, at one end of the spectrum, you’ve gotta be nice snores. At the other end of the spectrum are people who cannot sleep and breathe at the same time. They just can’t do both together. So these are the people who need to be artificially ventilated.

And these are the tertiary referrals. But I mean, we don’t get involved with those. Cause the moment you see someone who comes in and says, by the way, , I’m sleepy. For example, if they want to say, oh gosh, I’m always sleepy, or you think they’re looking a bit sleepy. Did you know that the bags, the bluish gray tinge around the eyes is also a very cardinal symptom of somebody who might have OSA?

So, especially in a child, you know? So if you look in the mouth and you think, you know, airways blocked, tooth grinding, you know, neck is fat, he’s snoring. You know, gray eyes. I mean, isn’t that enough to say to you, let’s get this patient screened. Just to go one step further, Jaz, home sleep testing.

In the states, they have been very adamant to not allow dentists to carry out home sleep testing. That’s the ambulatory sleep testing. You know, the way their patient is given the kit, they either bring it back or they throw it away and you get the result through the cloud , they have actually relented somewhat in some states, but in this country now we can give out home sleep tests as a dentist.

However, that sleep test must be formally reported and assessed by a sleep physiologist or a sleep physician. You know, who has the expertise to-

[Jaz]
Could you recommend a service that you use in terms of a dentist who may a little bit more switched on and wanna start, you know, listening today? Then we like, oh, I didn’t know I could do this.

[Aditi]
Absolutely. So what I do is I use a kit called the WatchPAT One , which is an ambulatory one that you give to the patient, you lock it on the system that do the test at night and then throw it away. I get the results through the cloud, but I also elect for that on the system.

I elect for that test to be reported formally by one of my medical colleagues for example, and they, I’ve got a dearth of them, so I get the report back saying, this patient has, is snoring in this body position is positional snoring or positional sleep apnea stops breathing. So many times the AHI score or the oxygen levels are desaturating to the point where we recommend that this patient should have a CPAP trial or they might just say if the patient is a bit sort of on the borderline, they’ll say, well, actually they could also try a mandibular advancement device. So that’s for me medical legally that keeps me in the clear. If by then, make them a medical oral appliance, that’s fine. The guidance does say that, you know, for anyone sleepy, whether there’s a snorer, mild, moderate, or severe sleep apnic, they should have a CPAP trial no matter what the level of disease.

[Jaz]
Yeah, I was gonna ask you about that because I felt, when I read that in the guidelines, I know it’s great that they’ve mentioned dentists for, in the guidelines, but from reading that it’s like every patient who gets that diagnosis, the gold standard is a CPAP. And then, so what we’re waiting for is really a leftovers.

So, how do we work with the, how do you get busy because you wanna help these patients who can’t get on with their CPAP. How do we filter those patients? How do we get, how do we attract those patients? I guess that’s a big topic as well.

[Aditi]
So that in itself is quite, that’s a very moot point actually. So if a patient is, they’re go into sleep service and they are all given CPAP, we know that we have as much, as many as 50% of people who will either be intolerant or unaccepting of the CPAP. So this is plan B for us, which is why the next one.

[Jaz]
Aditi, can you just mention for those young dentist listening who’ve never heard of CPAP before, why it’s not so sexy, or why it might not be so sexy and what it does and how it works?

[Aditi]
So, CPAP is actually a mask that you wear over your face. All the nose and what it does, it’s like a pneumatic splint. It’s got a big sort of elephant trunk with a little machine that sits on the side of the bed and what it’s doing is actually pumping air into the airway and it’s actually opening up that airway.

What it’s not doing is not pumping oxygen or air into your lungs. It’s only opening up that airway, which has collapsed in order to keep it open so the patient can continue breathing normally. So these are the patients where the claustrophobia of the mask or the nasal, where if they’ve got nasal congestion, they may not be able to tolerate the mask itself, the air going through the nostrils and some people, because it’s quite an unrest thing to wear.

It’s not sexy, like you said. They don’t wanna wear it. And some of machines are quite sophisticated, but they may not be the ones that are available on the NHS, the ones that are available on the nhs. Some people might find them noisy. Bad partner might find them noisy. Pregnant women find them intolerant because you know they have to sleep on the side and the mask keeps on shifting away.

So there are lots and lots of side effects. People talk about the side effects of all appliances.

[Jaz]
Yes.

[Aditi]
If I give you a list of side effects where if you ever come to any of my courses, I’ll give you a list of side effects that have been shown for CPAP, including skeletal changes, including dental changes. These are important points that one needs to remember. It’s not just your appliances that have side effects. Everything in sciences has a consequence.

[Jaz]
I guess the other thing worth mentioning is I know of some colleagues who spoke of some patients who might travel a lot and they can’t take their CPAP on their flight with ’em, and they’re afraid to fall asleep on their flight because they’re worried about the whole snoring and whatnot.

And the fact that if they go camping and whatnot. So sometimes, these patients may be in a situation where they rely on their CPAP at home cuz they get along well with it, but for holidays of other times, they may well benefit from an oral appliance. How do you see that fitting into it?

[Aditi]
So that’s actually quite a good way of describing it because I think it’s all got to do with raising awareness. If you let the public know that there’s hope beyond CPAP, then they will come to you for help. People don’t always want to wait for the NHS. They’re long waiting lists. They’re fed up.

They feel that the wife or the husband, and I don’t wanna be sexist here, if one of them gets into the second bedroom or sleeps on the couch, they see that as a slippery slope for their marriage. And I think for them, they need help. And they need help desperately. So when they come and see me, for example, they never say to me, oh my God, I just want you to treat my snoring.

I’m fed up with it. They will never say that to me. They’ll say to me, look, I’m doing this for my bed partner, my wife, my husband, or girlfriend, or whatever, because she is not getting a good night’s sleep or she’s fed up or she’s in the other room, you know, so they’re doing it for others, not just for themselves, but they don’t care whether they’re snoring or not because they don’t wake up if they are waking up constantly and they’re waking up choking as a result of, because all snorers are not sleep apnics. But all sleep apnics are pretty much snorers.

[Jaz]
Yeah.

[Aditi]
That is a distinction you have to make. So if you’re treating a snorer, are you treating just the snorer or are you treating the sleep apnic? If you’re treating the sleep apnea, the byproduct of sleep, treating the sleep apnea is they’re gonna treat their storing as well.

So that’s more important to remember. So you were asking me about how do we get these patients, well, you get these patients by raising awareness, providing the patient with knowledge of what is available out there. And if the patient then decides and elect not to try the CPAP, as long as it’s documented, then you can safely make them an oral appliance. But everything has to be documented. Remember, medical legally, if it’s not written, it did not happen.

[Jaz]
Yeah.

[Aditi]
I cannot tell you how important that is.

[Jaz]
Well, I really appreciate everything you covered and also for sharing that difficult experience you had with a patient with a bridge. I think that’s so real world for us as general dentist and restorative dentists it’s great to really be nice to hear over your experiences and your learning journey.

The main thing we wanna wrap up with is getting this information to the dentist so that. I’m hoping was a real eyeopener and an ear opener for dentists who are just very new or haven’t heard of steep soil breathing and how we have a role in screening. And then for those patients who do not get along with their CPAP or as an adjunct too for when they go on holiday and stuff, may need a mandibular advanced splint.

We need to learn more and we don’t need to just go on one industry led appliance and give that same appliance to everyone. We need to give a few different appliances. So please, how do we get involved in the UK as a dentist and around the world? How do we get involved to learn more from you guys?

[Aditi]
Call me, I think, no. I think the most important thing is get on the British Society of Dental Sleep Medicine website. There’s a death of information there. Yes. You know, we’ve got a new website coming. It’ll hopefully, I hope it’ll be launched by the end of the week or next week. If it doesn’t, it’s not my fault. But to attend a course that’s led by a credible society because we are now part of the British Sleep Society. So we are actually working with the medical people. Not just dentistry on its own.

[Jaz]
Perfect.

[Aditi]
It’s not a coffee club anymore. So I think for me that is important, having industry led courses, which are, you know, industry is so desperate to get into since the publication of NICE Guideline Industry is in here, running courses, you know, showing them how wonderful their devices are, of course they are.

Please, let’s be measured about this. Learn about the basics of sleep disorder breathing. Learn about how to treat this patient effectively and safely, and then learn about the various devices afterwards because you know you will find your own favorites. You’ll find the ones which were favorites.

I mean, for example, I was the face of Novel. You know, I’ve done videos with them, I’ve done photographs with them. I’m on the internet, but you know what? I don’t make any of their devices because I’ve had more problems with those than any others. But that doesn’t mean I’m stating it. It’s in my own hands what works for me.

There are others who will have other devices, but that for me is if you go into the BSDSM website, you will be able to. courses, which are unbiased, totally unbiased, you know, and we have mentorship-

[Jaz]
And there’s one on the 16th or so. I just saw on your Facebook, you didn’t tell me, I just saw the 16th September in Manchester. So that’s an example of one of the courses that you guys run. would the course like that obviously covers a lot of theory in terms of screening, diagnosis, how to work with the GP, but to what extent does it cover oral appliance therapy?

[Aditi]
It covers all of that. The only thing that we are not doing face to face is because of Covid, but now we are going to get back into face-to-face where we’ll have a hands-on element. So on the 16th, although I’m not running that course, cuz I’m doing, I’m not running another course on the 16th, the people that are running the course, that my board members, they are very experienced.

And they will show everyone how to take a George Gauge registration, for example. Cause if you get that wrong, scanning and taking impressions is pip squeak. We all know that. That’s not skill. The skill is getting that jaw registration correct. Cause if you have any aviation, then you’re running into trouble.

And that’s what is the most important thing, especially when you’re working with precision devices that are so accurate. You’ve got to make sure that absolutely.

[Jaz]
Like the Somnowell, right. I’ll just name a brand. Is that classified as a precision device?

[Aditi]
I wouldn’t call the Somnowell, a precision device. I haven’t used Somnowell for the last 10 years, maybe. I work with ProSomnus very closely. They’re the American company. I work with Panthera, which is from Quebec. I do provide so devices as well. They’re very good. They’re market leaders too, but I think those three are probably the ones that I work with most closely.

[Jaz]
Mm-hmm. And I like that. And just like, and it very much backs up what you said, you know, and I’ll say it’s, look, I’m friends with S4S look, I’ve used our appliance for, but I just feel a lot of my colleagues are GDPs because they’re so good at marketing GDP, all they know is a Sleep Well appliance.

And that’s it. and so, I think we owe it to the presion in our patients to, to think, you know, beyond the soft sprint for everyone, beyond the Michigan for everyone beyond the sleep well. So we need to do that. And I think BDSM is a great place to start. So I’ll put all the links in a show notes.

When I email out my list, when I launch this episode, I’ll make sure there’s a direct link to go through website so you can learn more. So this could be the starting point, at the very least, if you can screen patients and start making those referrals and having those conversations, I think we’re gonna improve the health of the nation.

[Aditi]
Absolutely. And Jaz, one other thing before I go. So we also have an Academy of Dental Sleep Medicine, of which I’m also the president. And what we are doing is we are actually working with the Academy on behalf of the society to run courses, which are not just foundational courses, but you know, going that little bit more.

Cuz what I don’t want to do is end up like the, when you ended up years ago, becoming an implant dentist, you went to a table, you had a pig jaw, you drilled a hole, you put the screw in, and you thought, I’m now an implantologist on Monday morning. We have gone beyond that now, and we want to teach, I want to teach the members what can go wrong and how to manage it and what not to do more than how to do the right thing.

Because you know, like I said, scanning and impressions are not that important. So we have a website for the Academy of Dental Sleep Medicine as well, and they’re gonna have modular courses online. And then eventually, very soon, we are about to launch. Well, we, we’ve got the master class that we launched in 2019, but then Covid hit.

So we are gonna relaunch it in October, September, and then the PG cert also goes out, hopefully.

Jaz’s Outro:
Brilliant. I’m gonna share that link with everyone. Check it out myself as well. So, amazing. You’ve been, you know what? I love your style, Aditi. You’re so direct. I hope you hear that.

I hope people praise you for this, because I just love, like, boom, boom, boom, boom, boom. You’re so succinct. There’s no waffling. I love that type of educator. I definitely wanna learn more from you. Really appreciate you coming on and sharing so concisely, so beautifully with all the dentists listening, and you are more than welcome to come again.

Well, there we have it guys. Thank you for listening all the way to the end, and if you did so then just answer a few cheeky questions and get some CPD. My team will email you certificate and we’ll keep doing so for as many episodes as you want. It’s just one of the many benefits of being Protrusive Premium Member.

So if you download the app or go on the app on Chrome, if you just use type in on your URL browser protrusive.app, it’ll take you to the app homepage. Once you actually have an account, you can actually access the app through iOS, Android, and the website using that same login. Because let’s face it, some people just like to learn on a laptop and not on their device.

If you felt inspired by Dr. Aditi Desai to learn more, then the best thing I can recommend wherever you are in the world is to attach or align yourself with your local dental Sleep Medicine Society. Now in the UK we do have the British Society of Dental Sleep Medicine, and they’ve got an event on the 4th of March.

It’s like a member’s day. And if you’re interested in getting into space now, you should totally check this out. I’ll put the link in the show notes below. But like I said, if you’re in the US or Australia or wherever you’re around the world, there’s some lots of great societies to align yourself with. If you found this episode useful, please do leave a thumbs up if you watch you on YouTube, and don’t forget to hit that subscribe button. Thank you again, my friend. I’ll catch you next time.

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Some dentists disagree with the use of Caries Detector Dye in Restorative dentistry. They say that they are experienced enough to know what is infected dentine and affected dentin. However, this episode might change your perspective— CCD can be an incredibly useful tool to provide objective data and increase your bond strengths!

In this episode, Dr. Germán Dorgan spoke to us about caries detection dye and helped us understand how to use it properly. He also shared the evidence base behind this test and how to interpret the data that you get by using it.

https://youtu.be/L8fScyRTet0Check out the full episode hereDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Protrusive Dental Pearl: How can you remove the appropriate amount of caries to get the best bond strengths possible WITHOUT risking removing too much dentine and causing a pulp exposure: Use your perio probe and measure key landmarks. Measure 5mm from the cusp tip and 3mm from the adjacent marginal ridge – do not remove caries beyond this point. As a guide, this will help you not expose the pulp so you achieve very clean dentine for highest bond strengths, without worrying about ‘when to stop’.

How to measure caries removal extent using a Periodontal probe and dental landmarksNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

1:20 Protrusive Dental Pearl
4:27 Dr. Germán Dorgan Introduction
7:32 Caries Detector Dye
9:40 Rationale behind Caries Detector Dye
15:14 When should you use Caries Detector Dye?
19:49 Literature for reliability of CDD
22:19 Difference between color gradient of caries detector dye
23:28 Caries removal guidelines using caries detector dye
30:22 Additional Literatures and Top tips

Check out the 3-day course about Biomimetic Dentistry with Sami Sherif, Germán Dorgan, David Alleman, and Davey Alleman. Hosted by Get Bonded and Stay Bonded on March 3, 4 and 5, 2023

Check out the literature mentioned by Dr. Germán Dorgan

Contemporary-concepts-in-carious-tissue-removal-A-reviewDownloadA-systematic-approach-to-deep-caries-removal-end-points-The-peripheral-seal-concept-in-adhesive-dentistryDownloadPHYSIOLOGICAL-RECALCIFICATION-OF-CARIOUS-DENTINDownloadBonding-of-self-etch-and-total-etch-adhesives-to-carious-dentinDownloadYou might also enjoy another Biomimetic Episode: I Can’t Believe This Sticks – EXTREME BONDING EXPOSED with Dr. David Gerdolle

Click below for full episode transcript:Jaz's Introduction: Is CARIES DETECTOR DYE, BS? Like I know lots of dentists who've seen it and they think this is just a fad. This is as useful as those photos of people holding cucumbers between their teeth.Jaz’s Introduction:
Is there actually any sign or useful applications because caries, as some colleagues would say, I just use my high magnification, my good lighting and my probe.

I don’t need a fancy dye to tell me if I got caries or not. I’m experienced enough to know that I’ve removed caries. Now, you know what? I kind of felt that way. I was like, do I really need a dye? I’m think I’m pretty good at moving caries and too fair. Since I’ve been using it, it’s kind of confirmed that I’m pretty good at removing caries.

Okay. I’m happy to say that I’m proud enough to say that. However, one in five, one in six times I see a pink haze where it shouldn’t be. You’ll find out what that pink haze means in this episode, but it’s really useful objective data. So we’ll speak to Dr. Germán Dorgan, all about caries deck to die, how to actually use it properly. What is the evidence space behind it, and how to interpret the data that you get by using it.

Hello, Protruserati. I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. If you’re new to the podcast, welcome, it’s great to have you.

Protrusive Dental Pearl:Every episode, every main episode, I do a Protrusive Dental Pearl, some good tip, often clinical, sometimes non-Clinical that’s gonna help you in practice tomorrow.

The one I have for you today is very much linked to the theme of this episode. Ie how not to expose, how to remove the appropriate amount of caries to get the best bond strengths possible without risking, removing too much dentin and causing a pulp of exposure. So how do you do that? You use some landmarks, use your perio probe and some landmarks and the zone that should be ultra-clean.

The zone where you should be aggressive in caries removal, if that’s a fair enough term to use, is if you measure from the cusp tip down five millimeters. In that zone, you’re not gonna hit the pulp, so please remove the caries and from the adjacent tooth. So let’s say you’re doing a first molar, you can measure from the second molar.

The marginal ridge of the second molar, three millimeters into the first molar distal, then that is your zone that you should keep super clean. And in those ranges, in those five millimeters from the cusp tip and three millimeters from the adjacent marginal ridge, you’re not gonna risk exposing. And so therefore you should try to get this really lovely, clean peripheral zone.

But you’ll hear more about that in the main episode with German. So next time you’re wondering, should I remove some more? Should I not, will I expose? Maybe you can use a perio probe. Just be sure to warn your nurse first because the first time you ever do this, you are sort of a perio probe out of nowhere randomly in the middle of caries removal you’re about to expose and your nurse be like, wait, why are we now suddenly doing a BPE or something? Right? So, make sure you maybe tell your nurse what you’re doing first.

We’ll go ahead and join the main podcast now. This episode is suitable for 50 minutes of CPD. It’s via the Protrusive app. If you’re not on the app already, do download it. It’s on iOS and Android. Even on the web, you can just go to protrusive.app as a website and that will load the app as a web app so you can access it there as well. And for premium members, you can answer a few questions at the end and get your CPD as well as a transcript in pdf. And the premium notes that you see on the side will be given to you as a pdf. I’ll catch you in the outro.

Main Episode:Germán Dorgan, welcome to the Protrusive Dental Podcast, my friend. How are you?

[German]
Very well, thank you, Jaz. Very excited and ready to go.

[Jaz]
Mate, you are. I know you’re buzzing. We had a little chat earlier about the, you’re still buzzing from that World Cup win. I can sense the energy. I was enjoying your social media sort of banter about you and how Argentina was doing. I was happy. I won 150 pounds. I had Argentina as one of my teams in the sweepstakes. So, I won and so I treated my practice to pizza. So I threw everyone a pizza party. So everyone was happy that Argentina won.

[German]
That was really fair. I only won eight heart attacks in the finals, so.

[Jaz]
Now that was, Epic. An epic final. I don’t think we’ll ever see a final like that again, so that’s amazing. But Germán, you are very active on social media. Uh, we’ve been connected for a few years now. What I see you do in terms of your passion for Biomimetic dentistry is amazing.

And you got me hooked to caries detection dye. I love this stuff. Absolutely love it. When I first got the bottle, I was like, I have no idea how to use this. Read the instructions. And now when I use it, I’m like, wow, I was missing so much of it. And I guess we’ll talk about my experiences and your experiences with it.

But for those of you who don’t know you, who don’t yet follow you, tell us a little about yourself, your journey when you came over to the UK from Argentina. Was that after qualifying or?

[German]
No, so I was born in Argentina, but I was raised in Spain. At the age of five, my parents moved, to Spain, to Madrid. And that’s where I grew up. And then I’ve got grandfather, dentist, mom, dentist father, dentist sister, dentist. So I had to follow the steps of everybody. So graduated in 2010, in Madrid after a couple of years of- 2010 was a very, very hard time in terms of economical crisis, and I wasn’t very happy working in Spain, so I decided to just like move to the UK.

I actually came for a couple of years to try to make some money and improve my parents’ practice, but that was 2012 and I’m still here, start working on the NHS and then after a few years, as I was learning, I was finding a few struggles, unfortunately, in terms of use of certain materials. I’m providing certain treatments to my patients.

That all started after doing Tipton’s, Paul Tipton, training. Luckily, I managed to increase my private work to provide this to most of my patients and I focus in restorative and adhesive dentistry with a big background of Biomimetics. 2019, I got in into Matt Nejad’s course when he came to London. That hooked me into Alleman’s mastership over a year.

Then I had the opportunity to train with emulate, but also help them teaching a little bit. And currently I’m taking part of get bonded and step bonded with Sami Sherif . Great course.

[Jaz]
I mean, now, you’re teaching with these guys, right? You’re an educator with them, which is amazing man. Well done.

[German]
Yeah, that’s a great step. We’re doing a good job. We’re actually bringing David Alleman in March for a session, couple of days of Biomimetics and then taking also part of the Mimétika, long, it’s a one-year program. It’s a European program with three huge guides, in my opinion. Filip Keulemans, Hugh Byrne, and one of my great greatest friends and probably mentors, Raphael Wymann, which are helping me to understand adhesive dentistry, like what element will call, get bonded and stay bonded, if that makes sense.

[Jaz]
Amazing. And from speaking to Taylor Paton, the previous episode, it is really, you know, get bonded, stay bonded is such a great way to summarize the field of Biomimetic dentistry and part of achieving those great bond strength is actually your caries management, your caries removal. Because if you’re gonna bond the caries, it ain’t gonna stick. You’re gonna be disappointed. And we spoke on social media. You recommended caries detector dye I asked you about it and you told me which one to get.

So let’s start with that. You know, what is caries detection dye? It looks pretty on social media, but is it BS? Is it any good? I know you have a bias, but the bias is led by literature and it’s led by some time of you using it and your mentors using it. So, just start from the very basics. What actually is it?

[German]
So, yeah, it’s a very good point, what you said. You cannot bond if you foundation is not good. Okay. So imagine building a house and the base is really soft. The house is gonna crumble down, so we really have to find a way to see what we have underneath. And caries detector dye is a disclosing agent, red fuschin on a glycol solution.

The main purpose is to stain DENATURALISED COLLAGEN. Okay? And this is a very important point because it’s not a staining bacteria, okay? We’re not looking for bacteria. We’re looking for the naturalized collagen, okay? We know that the bond strength-

[Jaz]
So to make it clear, Germán, it is not a plaque indicator. It’s completely different from plaque indicator.

[German]
Correct. Exactly. So we know that if we have the neutralized collagen, the quality and the bond strength of that dentin is not gonna be as good as if we have sound dentin. So, the caries detector dye, basically it’s the excavation of the outer decalcified and infected dentin.

Okay. And that basically allows us to have an optimal caries removal. Okay, so if we have a good caries removal, we are gonna achieve good seal and more important prevent issues like losing pulp vitality. So it could be a problem because if we are not sealing the caries properly, it will keep going down and eventually we’re gonna end up with irreversible pulpitis or farther problems.

[Jaz]
Yeah. Some people who are not very open-minded and me as a practitioner, I’d never been taught about caries, the use of caries detection dye. I’d only ever seen other people using it, and I’m quite an open-minded clinician. I tend to, I’m happy to try new things, as long as got a scientific rationale behind it, which obviously is caries detection dye does.

I was very open to using it and I love it. But the same thoughts that go into my mind, go into other people’s mind, but I still give it a go. I still wanna give things a go. Other people are like, well, I have my probe. I’ve been using my probe for years. I can feel the dentin. I know that this is soft and this is hard.

Why do I need some color to tell me that? Now, obviously I’ve been using it so I can answer that, but you are in a better place to answer that. What do you think?

[German]
Yeah. Okay, so, we are talking about how to be objective and subjective in this matter. Okay, so it’s perfect, that’s a good way to do the description.

If we can see what we’re treating and we can identify the substrate by different colors, we’re gonna be able to know what is there, however, let’s say you use the probe. The first point I will have is like, how can you measure every millimeter square of the surface of the cavity that you’re doing?

Good luck with that. You know, I’m not saying that you are not wrong by trusting, and I think it’s part of the clinical judgment that you’re gonna have. You have to feel what you are treating and that will be part of the guidance. But I think, it’s not completely accurate and I believe that you will get surprised.

If you finish a caries removal just with your bur and testing with a probe, eventually if you try with a drop of caries detector dye things will change and they will blow your mind somehow showing that you probably left tissues there that are not gonna provide appropriate bonding and proper seal of the surface.

And especially when we’re talking nowadays that the contemporary concepts are saying that we can leave caries behind, as long as we seal it properly to starve the bacteria and then kill it. Okay, so if you are having a leak, that’s not gonna work, and then it’s gonna bite you back eventually. I think another point is like, how subjective is hard for me.

How is, like, I think, I explained this with in a talk with Ash is a very, very simple thing. You, me, go to the gym, but I believe that I go only twice a month. But you go every day. Okay.

[Jaz]
I wish.

[German]
Okay. Yeah. Well, I’m putting just an example, but 10 kilos for you. If you’re going every day, it’s not gonna be heavy. 10 kilos for me that I go twice a month might be super heavy. So we really cannot have always, all of us the same feeling.

[Jaz]
Tactile feedback. And it’s the same as perio probing, Germán, perio probing. You’re supposed to use 25 grams, I believe of weight when you’re doing perio probing. But when you actually get the test at alga meters, whatever they use, everyone’s actually usually a bit too much. But when everyone’s different and to achieve the Optimum is difficult.

[German]
How do you screw an implant? What do you use? Torque wrench.

[Jaz]
I don’t, I use a referral pad.

[German]
Okay. Fair enough. No, but it’s a good way to think it. No, but if you think about it, when we’re doing implants, for example, if we need to know how much torque we have to give to screw, we need something to measure it. And that’s why we use a torque wrench, for example. Okay. And if we want to be even more accurate, we’re gonna use probably a digital one. Okay. So I think having, especially when the main thing that we’re doing as general dentist is remove caries every day.

We sure have a systematic or a way that we can really kind of standardize the way that we’re removing caries to achieve proper results. And I think it’s an important thing, and I don’t believe the tactile feedback, it’s not accurate. And there are papers from Fusayama that are even more important when we’re getting closer to the pulp, the closer that we’re getting.

Okay. Acute and chronic decay. There is no difference in the elasticity and the hardness of that surface. So if we are dealing with the cavities and we want to prevent pulp exposure, the best way to address it will be helping yourself with something to visualize what you’re removing and having a little bit of knowledge of the anatomy of the tooth.

[Jaz]
Well, we’ll talk about that in terms of, once you do use the caries detector, I had to interpret that data. But I think, it’s a good first point. The data is good because it turns something subjective. You know, one of the first things I learnt was the color is unreliable. You know, we used to chase everything until it was yellow.

We then know that, okay, it’s okay to leave brown and black based on amalgam staining, et cetera. And so that was fine. Yeah, I think people still struggle to believe that your probe and the softness even that can fool you because that is subjective data, and I completely agree. So, to give you my experience of using caries detection dye so far, In the last six months, I’m usually, now I’m using it. It’s validating, it’s giving me peace of mind. Okay, yeah. This is what I expected. I thought this was caries free and my caries detector dye is confirming that. However, the odd time, one in six times I’ve done it has like, oh wow, I’ve actually missed a bit there and I should go back.

And it’s just, it made me feel really good. And it also gives me a zone that I know that, okay, this zone, and we’ll talk about these zones. I can be a little bit more aggressive here. I can lead a little bit more behind here, and it gives that nice zone, which I know we’ll get into. So, I’m so far, very much converted.

I’m a big fan of it and odd timing, it has surprised me. I thought, thank goodness I’ve got this as objective data. So I totally agree that more people should use it. When should you use it? Should you use it for, do you use it for every restoration, every caries restoration, or is it only for the deep ones?

[German]
Everything. First of all, not disrespecting anyone, but if I’m replacing any restoration, I need to find out why. Okay, so let’s say there’s a recurring carries and we’re removing a fill-in. The first thing I wanna check if okay, it could be C factor, it could be something that, poor bonding protocol.

Not enough light cure. Something has happened, but the first thing I’m gonna probably try to check and this is where I respect how open-minded you are. Cause as soon as you heard that, it was like, okay, I’m gonna try it. I’m gonna give it a go. And you clearly notice the difference when I started my Biomimetics and most of my adhesive restorative dentistry, it was because things were not going well in many of my treatments.

So I had that curiosity to find out why. So I’m replacing a filling. Let’s say a patient is coming with some sort of sensitivity, there is a fill-in. The first thing I’m gonna do is an investigation. And the first step is as soon as I remove my fill-in, check with the caries detector dye and will say that in very, very, very high percentage of those cases, I’m finding effective dentin or even infected dentin in areas that shouldn’t be.

So what we are basically saying here is there are areas that are not bonding properly. So therefore, that restoration is starting to fail, causing problems to the patient.

[Jaz]
So, that is, just to make it really clear for someone who might have missed, or you said that this is, as soon as you remove the restoration, you haven’t even now started to remove any caries yet, because I guess the point you’re trying to prove is, why did it fail? And if you use it straight after removing restoration, you can see that there is still caries near the sort of external margin it was leaking.

[German]
Correct, exactly. So, it could be probably the thickness of the caries, it could be the C factor, but definitely I want to check if there is upper peak caries removal.

Okay. So because I’m taking over this treatment, so I need to sleep well, like you said, and I need to make sure that I’m gonna achieve high born strength. And therefore, longer prognosis of my restoration. Whenever I’m gonna do any caries, even if it’s like something that is a deep caries, definitely it will help me to prevent public exposure because I will have knowledge of my landmarks and I will know where I have to stop.

But more important, how to create the famous peripheral seal zone that helps to seal the bacteria. I’m preventing them from going deeper. And in those cases, what I will probably do is as soon as I remove kind of like the dirty area, we will call it like that. And I’m starting to have my cavity. So I know that I’m starting to go a little bit deep then is when I’m gonna start using my first few drops.

And I’m saying drops because it’s not one drop. Okay? Most of the people will say, oh yeah, I do one first drop clean, but they don’t check. So we will talk probably when we go into how to use it-

[Jaz]
Well, let’s just talk about that now or what is, how much did you, so I could tell you what I’ve been doing and I’m happy to say it out, you know, live on air if you like.

I might be doing it wrong and feel free to tell me is at the moment, and I didn’t read the instructions in terms of the way it’s delivered. I just, I know it’s supposed to leave it for 10 seconds and that’s what I remember and that’s what I do before I wash it away. But, I have it in a dappen spot and I’ve got maybe like 2, 3, 4 drops in there and I’m mixing my microbrush inside there, and then I’m rubbing my microbrush into the cavity. Am I doing it wrong? Am I doing it right?

[German]
No, absolutely perfect. I probably, I use maybe a couple of drops in the brush, and that’s more than you know, or in the dappen. But what I’m doing is constantly trying, constantly try and so I clean and I try, I clean and I try. I always test it. Because one thing is a staining-

[Jaz]
So you’re talking about reapplication. So you’re applying it waiting 10 seconds, you’re washing it away, then you’re reapplying it.

[German]
I clean my surface. Okay? And then I will test myself if I clean it properly. Okay. It doesn’t have enough penetration sometimes, so we really have to do reapplications in the different steps that we’re going through the removal of the caries.

[Jaz]
Got it, got it. Okay. But in terms of the actual procedure of how I’m applying with a microbrush and just rubbing it all way around, uh, yeah. Okay. Right. Yeah. Leave it for 10 seconds. Wash it away. Perfect. Fine. So before we talk about how to interpret that data, which I think is so key, and we’ll talk about the peripheral zone and using your landmarks, what does the evidence say?

Is there much evidence in terms of how reliable the data is that you, this objective data that you’re getting from the color, from the caries detector dye, how reliable is it?

[German]
This has been studied since 70’s, 80’s. Okay. And the most important thing, and especially I think, this is something that for me, it clicks a lot in a way of we’re measuring infected affected dentin so we know the bacteria’s going through, there is acid attack, and that’s producing denaturalization of the collagen, which is what create the good and the bad bond on the surface of the tooth.

And studies are from late 70’s, 80’s, and actually showing that even without complete removal, so leaving infected areas, we’re getting high bond strength. Well, high bond strength, if we’re talking about infected dentin, we’re getting around 10, 15.

But if we’re leaving affected dentin, we’re around 20’s. Okay, so 25. If we think about bonding to enamel, we’re getting 31. Okay. So even not complete removal is showing us that it’s high bond strength. Okay. And then if we are actually have sound dentin, we’re achieving up to fifties, how do you achieve it is a different thing.

And I think it’s what you spoke with my previous colleague about how to bond to dentin and more the principle of Biomimetics. And it’s all about a matter of time allowing the bond to mature properly in order to achieve high bond strength. Okay, so obviously there is several papers that are shown that we’re able to bond to caries.

And how effective is the fact that we can visualize what we’re bonding. How do you describe infected or affecting denting without having anything that is showing you? You know, it doesn’t go into my mind. It’s like infected dentin. We know that by discoloration we cannot differentiate the difference surfaces. So it has to be something. And in this case, it’s a caries detector what helps you.

[Jaz]
When you seeing the different colors. Now, let’s say you’ve got an large cavity. You removed the caries to the what you think should be removed. So, you know, you’ve gone by your usual subjective data and now you’re gonna rub in the caries detector dye.

Then you wash it away after 10 seconds and you see what’s left behind. Does the color gradient, does the pink versus red tell you something? Assuming using a red one I’ve used you use a green one is different, but let’s go with the red cause that’s the one I have.

[German]
So yeah, the have a look to the first papers that are coming around the 80’s. What they’re saying is that the infected dentin stains, whereas the uninfected dentin or affected dentin, doesn’t sustain. Okay. The acid attack on the affected dentin has been more aggressive. Okay, so everything has collapsed and it allows the dye to penetrate. That’s why it will get darker. It’s not that-

[Jaz]
Wait, on the infected dentin. It’s been more attacked, right?

[German]
Exactly. Whereas the affected, the demineralisation is not so aggressive. So let’s think about the progression of the decay. There is acid at the front. Yeah. That acid attack hasn’t been so strong. Okay. That dentin still has the ability to remineralize, which is the important thing, why we can’t preserve it, and why we have a higher bond strength.

Okay. If we are trying to penetrate with the Caries detector, it’s not gonna be so easy. So that is when you’re gonna get a lighter pink. Okay. So the red will be the affected dentin. Completely unmineralized, okay.

[Jaz]
The red is the infected.

[German]
Infected and the pink is affected.

[Jaz]
So the pink is affected. And then obviously if you get no staining at all, that’s obviously completely healthy. And, and that’s fine. Well, give us some guidelines now in terms of, if you have some pink, when is it okay to leave the pink? And what position in the cavity? Is it okay to leave the pink? I think that’s important as well.

So we’ll come to the red in terms of when you’re getting near the pulp and stuff, but, let’s start with the pink. If I see some pink, which is the affected dentin, but it’s near the ADJ. It’s near the DEJ, then that’s affected dentin. Now we can bond to affected dentin better than infected dentin. But is it safe to leave it at the ADJ?

[German]
So that will be basically losing a 30 to 50% bond strength. Yes. Because we said we’re gonna go around 20’s, 25, 30. Okay. If I am not gonna expose pulp why will I leave it? I want to increase my bond strength for a more successful restoration. So therefore it’s basically, the idea will be to lift it around two millimeters inside of the DEJ of sound dentin, okay. So there shouldn’t be any pink haze near the DEJ.

[Jaz]
Perfect. And then when we get closer to the pulp, at what point can you leave red?

[German]
Okay. So the red, this is a bit of, If we go to that paper, the Pascal and David Alleman released in 2012, there are some landmarks that is letting us, I will share you the little pictures with the probe.

I think, having a perio probe is quite important to prevent pulp exposure. Okay, so what is telling us is to avoid pulp exposure, we have to measure five millimeters from the cusp tip and three millimeters from that adjacent marginal ridge to create that peripheral seal zone, okay? So if you see that picture, we will have like a tooth. So from the cusp, we’re gonna measure five millimeters from the tip, and then three millimeters for the marginal ridge of the adjacent teeth, okay?

[Jaz]
Mm-hmm.

[German]
If we are not having adjacent tooth, which can happen, we have to think about the curvature of the tooth. So obviously if we are high up, those three millimeters that you’re measuring, predicting that there is a tooth next door, it will be different because the amount of dentin will dry.

What I will have is those two millimeters of clear dentin. But we have to use the clinical judgment. Okay. We have to look at the x-rays. An older patient will have more retracted pulps, so we will be able to be a little bit more aggressive. Okay? So these are standard measures that we’re gonna, we’re gonna use, but we also have to use x-rays.

Otherwise, and that’s the important part. You’re gonna leave a lot of red, that, again, doesn’t bond properly. So the reason why bonds is because it managed to get into the affected dentin, but in the middle, you’re not gonna get such a underloading teeth will have an impact or even fail and allowed the progression of the caries again.

[Jaz]
So in order not to expose the pulp, we wanna make sure that we have no color, no pink, no red in the peripheral zone of at least two millimeters all day round. But if you’ve got a particularly deep cavity and you’re worried about pulp exposure and you get your measurements, five millimeters from the cusp tip three millimeters from the proximal marginal ridge, and it is more acceptable to leave your pink and red in that zone. Is that a fair summary?

[German]
Exactly. And then obviously, this is just something, what half is my air abrasion unit so we know to increase bond strength. It’s a great tool. Okay, so paper shows that-

[Jaz]
Well, the literature is, quite mixed, right? There’s some maybe literature that says that abrasion doesn’t increase the bond strength. Some that says it does some that says it does it. Maybe it’s because of the plaque biofilm removal effect. what’s your stance? You are more well read up on this than I am.

[German]
At the moment, most of the things that I read are going towards using air abrasion to increase the bond strength, and that’s how you achieve a 50 mega Pascals on bond strength in sound dentin. Okay, so if you repeat-

[Jaz]
I mean, I swear by, are you anal about, like some dentists is like, it has to be 27 microns on the dentin and 50 microns on when you’re doing indirect work. Like it’s not practical sometimes. So is it a sin to use 50 microns on dentin?

[German]
So that’s dentistry. And there’s so many papers and everybody tests differently and that’s the problem we’re having, we’re all testing differently. So, in terms of, for me, if it’s something outside the mouth and I’m talking to zirconia, which I barely use it, it’s not a material that it’s a common thing that I use because of the low bond strength, I will use 50 microns outside the mouth. In terms of the mouth, I’ll stick to 25.

And the reason is because it really doesn’t show any significant difference between one and the other. And what I will say, if you go quite handy, quite heavy on your hands, on a 50 microns, you’re probably gonna remove much more than what you want. And this is exactly what I was going to try to say.

Sometimes when I get to my last stage, I’ve done my measurements and I do a nice thorough air abrasion to remove that kind of red that is there. And if pops quite a big amount and I end up with a pulp exposure, it’s very likely that my bacteria was already in in the pulp. Therefore, that pulp exposure. I will take it as like it was going to be needed.

I was going to end up, or either doing pulp capping or it was going to end up doing a root canal treatment because the pulp was affected by bacteria. Bacteria was inside of the pulp. Okay. So I will go with 27 microns on that last part area gently, but enough to just like clean and see all that part of like soft decay coming out, if we can call it soft, if that makes sense that red area.

[Jaz]
Well, for those who listen to the Pulpotomy episode by Suza, they’ll be saying Pulpotomy, Pulpotomy, Pulpotomy. But, that’s a different episode. You guys should listen to that one. That was a really good one. Here’s an interesting one. Not interesting. It’s just something that’s annoyed me and I was really looking forward to this chat to speak to you about this is when I use the caries detector dye and obviously the pink and the red that’s in the middle, is it okay just to leave it? Because now that I’ve done my washing, I’ve done my air abrasion, there’s still a little bit of pink and red there, and I was thinking for the longest time, like, oh my God, how do I get rid of this stuff? Is it okay that it’s there? Please tell me you can bond to it.

[German]
Oh, of course. That’s what I said to you and if you see the articles, I’ll send you those two. Yoshiyama and Nakajima, that’s the name of them. They do the studies, bonding to caries infected and caries infected dentin using caries detector dye, and they’re getting those numbers of 25, 30.

Will it decrease? Maybe, maybe not. We don’t know. But how do we know if we are testing that or not? And it’s still getting a 25 or a 30, on anomalous 30, so we’re getting on that pink haze a good number. If by that 10, 15 that I’m getting in caries infected, basically avoiding pulp exposure, I’m winning.

I’m already winning. I’m preventing a root canal treatment. And what’s important, you now have the ability because the pulp is still alive to heal. So if there is an inflammation slightly to heal. But obviously we’re all different. We’re all different.

[Jaz]
Yeah.

[German]
Not everybody has the same immune system.

[Jaz]
Of course. So, but just to clarify, you’re not using anything to actually remove the pink or the red, once you-

[German]
No.

[Jaz]
Which is, yeah. I was just thinking about that. Was I supposed to do?

[German]
Remember what I said, the last thing I do, I test myself by another application, another drop of caries detector die, and then I rinse it and then I check if I have a proper peripheral seal zone.

[Jaz]
Okay.

[German]
Because it’s very often done that they clean, clean, clean, and on the last clean, they don’t check it, so they just go to proceed. But if you check that sometimes you might get surprised that you are actually left affected or infected caries in areas that are not affected dentin in areas that shouldn’t be.

[Jaz]
Sure. I’m using the Kuraray caries detector dye at the moment. The red one. I like it. I think next time when I finish this bottle, I’m gonna go for green because in case there is a pulp exposure in the future, I worry that if I’ve got something pinkish red and I might not notice.

[German]
Do not, when you see the pulp exposure is evident how the little bit of blood comes out. Many times I’m able to see how come the pulp horns are starting to show off. So that is actually, remember what said clinical judgment. It’s not only about my caries detector eye. It’s a few things that are coming together to find that caries removal endpoint. Okay?

[Jaz]
Mm-hmm.

[German]
So you will see that red coming out. It’s not often that I find a patient, oh, it’s hurting and I do everything, and someone just did a pulp exposure. 10 years ago, you can see the hole and it’s all dry. Okay?

[Jaz]
Mm-hmm.

[German]
So you can see the pulp horn was exposed, and that is visible and green or red. Most important thing that you have to have is the content of glycol. Okay? The glycol content is the only thing, because it’s what it helps you to penetrate. And I didn’t know exactly the brand. Basically Kuraray will have around a 90%, but there is one of the brands I can’t remember. I’ll try to send it to you. Basically the percentage is around a 45%.

Is it actually penetrating? No. So it will tell you that you probably clean, but you haven’t. So as long as you have a high percentage of glycol to allow the fuschin to penetrate properly to allow the dye to go through.

[Jaz]
Awesome. I’m a huge, Panavia fan, so when I saw that Kuraray did that caries detector dye, I was like, yeah, I trust Kuraray. So, I gave my money to them. But yeah, if you find out the name of this Mickey Mouse caries detector dye, you let me know and I’ll make sure that no one ever buys that.

[German]
I’ll find it. I think it’s half a path or something like that. I think, Ultradent is also good content of glycol is another option that you can have, and I think that one is green if you want, but I haven’t seen it.

I only have used Kuraray since I started, and one bottle of them will last me very long time. It’s a lot of caries detector dye, so.

[Jaz]
Yeah. For someone like you who’s using it very, very heavily. Yeah. I mean, it does last a long time, so, I mean, you answered all the questions, I had Germán tell us now.

Anything that you think we’ve missed that you think is important to know before someone, for the naysayers, for the haters, for those who are still not convinced that, you know what, this is just BS and I’m still gonna rely on my probe cause I’m old school or whatever. Anything you wanna say to those guys or anything you wanna say to those who want to, who are gonna now maybe try using caries detector dye and they’re interpreting the data for the first time? Anything that you think we haven’t covered yet?

[German]
Yeah. I think the most important thing is that, and I have chat this with you so many times we’ll have to do what we do know best. Okay? So introducing new things, they will have a learning curve. They take time, and the best thing that you can really do is learning and have someone that can mentor you or help you and on the process, okay?

Using caries detector dye or not, it’s a personal choice. I’m not gonna force anyone to do it. We don’t have to force people to do protocols that they don’t feel comfortable because the only thing that you’re gonna create is hate and dentistry is science not a dogma. Okay? So that’s the important thing.

Important, important, important really is to share those cases with people that are probably knowledgeable in the matter, either I know Instagram can be a hit or miss, but there are lots of great gurus. That’s how I met you. That’s how I got in contact with you. And I learned a lot of TMJ thanks to you.

So obviously we have to have a little bit of discretion on the matter, but, absolutely share those cases. Ask question, be active, you will not learn. And second thing, you will notice that when you’re using caries detector dye, you will be a little bit more aggressive than if you were not using it.

So many times what I find with the students is that because they are not cleaning it properly or they’re not removing enough, they’re really leaving some substrate that is not bonding as good as they Cool bond just because they’re scared of having a pulp exposure. And this is where sharing those cases with our people will help you and will basically make you improve in using this caries detector dye.

And there is an important article that talks about caries detector dye is too aggressive. And what they were testing actually was that they were leaving pink haze close to the DEJ, but they weren’t finding bacteria. Are we testing bacteria? No.

[Jaz]
No. Because you said it’s, it is not a plaque indicator.

[German]
Exactly. So it will become a little bit aggressive. And that’s the myth. And there is a big myth in caries detector dye being aggressive. And there is a restorative book that was used very, very frequently that was saying the caries detector dye was not good because it was too aggressive.

I was removing too much tissue. But it was because the test, once again was done based on a different data or something that we should then be testing. So it was a mistake. And that person didn’t understood what we are tested with caries detector die and they tried to find bacteria and they didn’t find it. But we are trying to achieve high bond strength by having good dentin or-

[Jaz]
To get the best substrate possible. Yeah. It reminds me, Germán of something. My mom says, and she says it in Punjabis, a Punjabi saying, but it basically translates to, ‘The truth is always bitter.’ So sometimes when you use the caries detector dye, the truth is revealed.

There’s no hiding from it. And what you see is that, oops, I have been leaving a bit of caries affected dentin in that peripheral zone where I should have been removing it all this time to get the best bond strengths at that, you know, first couple of millimeters of dentin. So, super important.

So, Germán, thanks for covering this episode. You’ve got some exciting stuff coming with the Alleman’s coming and it out the cricket ground. I’m so gutted I couldn’t come because I’m on another course. Typical, tell us about that, my friend. That’s super exciting.

[German]
So we are, 3rd and 4th of March. David Alleman, we’re gonna spend either two or three days. It depends on what’s gonna be plan is, David and Davey Alleman both come in with Sami and me helping. So we’re gonna be at Lord’s Cricket G round, London. So we’re gonna review all Biomimetic restorative dentistry and the six lesson approach.

And if we are doing the third day, it will be how to treat endodontically, how to restore endodontically treated tooth. It’s a very interesting heavy HandsOn lot of theory, which is what I find with David Alleman. If there is something that I have to really praise and really appreciate from him is that he make me read

not just have someone that comes, and this is good. You know, like, this is good. This is good. I show you my keynote about this presentation. And it is heavily, heavily based on articles that are showing different things. And all of them will have a point why this, why not this? And why do I think, and why do I have this opinion?

And I think this is one of the best things that you can have from Dr. Alleman. And from Davey cuz Sami as well is for me, one of the most amazing person, I would like you to have a conversation about whatever you want, because if you-

[Jaz]
Yeah, he’s been invited. He’s just gotta click on the link and then book in, my friend. He’s more welcome to join us to geek out on Biomimetic Dentistry. It’s a topic that I think is really exciting nowadays. It’s been around for a long time. We’ve known about it. For me, it’s a decent dentistry on steroids, right. It’s like that.

[German]
I do love Biomimetic, and I know word that, but I’m more, I like more my DC from restorative dentistry with a lot of background on Biomimetics. You know, I think it’s just I understand what you’re saying exactly is a perfect, perfect word. It’s a big intense thing. But I think what really kind of like enlightens it is the amount of literature that really provides student dentistry and for clinicians to learn.

[Jaz]
And I think what is provided based on speaking to my Biomimetic colleagues is guidelines and protocols decision making skills, based on sound literature that’s what I thought I’ve interpreted so far, basically. So, I think that’s great. I want you to tell the website and also how we can follow you on Instagram.

[German]
So my Instagram it’s a funny one, is a German T-E-K-I-L-L-A. So, it is @germantekilla. It’s nothing to do with tequila, even if people think that it is something to die. It’s just a funny thing that came from university mantequilla in Spanish means butter. So, I play with my name just like to do that when I was a university.

So, it stays. So, it’s German, T-E-K-I-L-L-A. And then we can have a look at getbondedstaybonded.co.uk and you will find all the information about that course in the UK. If you wanna level up a little bit more and have a one year program, I will recommend you to have a look to Mimétika. It’s another great program that I recommend.

Have a look to Raphael Wymann, Hugh Byrne, and Filip Keulemans , amazing clinicians, researchers that are also I’m collaborating with them and I’m gonna be in May. I’m gonna be lucky to be with, Junji Tagami. I’m gonna be lucky to be, with Ali Sadr these people teaching all of our is an amazing program, David Gerdolle which I think-

[Jaz]
Legend.

[German]You’ve met before. Another great clinician. So if you are interested in doing something a little bit more a long year course, it’s another great option. And if you also wanna have a look, check, emulate is another restorative course based on Biomimetics and in incredible HandsOn with two amazing people like Fran and Stew, Fran Brelsford and Stewart Beggs. Incredible hands, incredible talent.

[Jaz]
And we have to shout out to, Taylor Paton again, the hybrid layer as a good resource to read up and introduction to Biomimetic Dentistry. I love what he’s done there. So there’s plenty of learning to be done there. Yeah. Thanks so much my friend, for giving your time.

[German]
Thank you. Thank you. Can’t thank you enough, honestly.

Jaz’s Outro:
Thank you, buddy. Well, there we have it guys. Thank you so much for listening and watching all the way to the end. Hope you enjoyed learning about caries detector Dye, and maybe you may start implementing this in your practice and you’ll be able to use it properly from the get-go and interpret the data so you can get the best bond strengths possible.

Now that you’ve listened all the way to the end, do answer a few questions, get that CPD that you well and truly deserve by the end of the year, all those hours will rack up. And if you want to refer to some of the notes, you can always download that as a PDF as well by scrolling on the app. And of course, if you enjoy this episode, do consider leaving a review or a rating depending on which platform you’re listen and watching on. It really helps a lot. Thank you so much and I’ll catch you in the next one.

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Hygienists working without nurses and feeling like scaling machines – it’s about time we covered this elephant in the dental surgery. I brought on my dear friends and exceptional hygienists Morgan Williams and Louise Brake – they have faced career struggles in the past in the quest to finding the right environment and have so much to share with us.

The biggest takeaway of this episode will be to consider ‘leading from the bottom’ – if you are feeling stuck and don’t just wait around for good luck (I’m such a poet!) – take action. You’ll be inspired by some of the ideas from our discussion!

https://youtu.be/X7GBKUawq4ACheck out the full episode hereNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

04:32 Morgan and Lou’s Dental Hygiene Background
07:25 The Importance of Settings Goals and Expectation
10:42 Hygienist as ‘Scaling Machines’
14:09 The Best Advice to be a Better Hygienist
17:40 Good Communication to Improve your Practice
21:26 Nurses for Hygienists
27:20 Business Models for Hygiene
29:54 Preventive Focus in Dental Hygiene
34:11 How Hygienist Treat Perio
35:52 Optimised, Personalised OHI
40:07 Number One Trait to Look for in a Practice

Check out Morgan and Lou’s Instagram, Dynamic Dental Duo!

If you enjoyed this episode, you may also like another episode with Laura Bailey: Why You Need to Take Massive Action for Success in Dentistry

Click below for full episode transcript:Jaz's Introduction: What's the best way that hygienists and dentists can work together? Well, when I was in Singapore, I didn't know a single hygienist. It wasn't really a model at the time that was used there.Jaz’s introduction:
Whereas in the UK, we depend so much on our hygienists. I feel like we work together well with hygienists. However, I sometimes worry and hygienists I speak to worry that all they become is a SCALING MACHINE.

And so, I talked about that today with Morgan and Lou. Two lovely hygienists I use to work with in Oxford and they share their struggles, how they had to work in quite a few practices where the environment just WASN’T RIGHT FOR THEM to thrive in as part of prevention minded hygienists. And I think what they have to say, well, if you’re a hygienist, listen to this.

Or maybe a dentist has said this episode to you, then this is gonna be a real source of inspiration from two lovely ladies who’ve been in the game for a little while. They know what they want and they’re gonna tackle those difficult themes such as HYGIENISTS working WITHOUT NURSES like. Where does that stand now in 2023?

My practice now where I work as an associate, only now is it starting to really implement a nurse working with a hygienist. Whereas I’ve worked with a few practices for where there is no such thing. It’s unheard of for the hygienist to have nursing support and I know lots of young hygienists who tell me that they feel really uneasy about working alone and really, is this the best way to deliver ideal patient journey that’s safe and effective? I don’t think so. But then again, a lot of you will say, ‘But Jaz, you are not a practice owner. You are not paying the bills.’ And I totally get that. I respect that.

As an associate, it’s easy for me to say that, but I’m hoping after this episode with Morgan and Lou, though, you understand why it is so important for our profession to work together with hygienists to get the best outcomes, and I do believe that starts with a hygienist being provided a nurse. Now, what I don’t want after this episode is lots of hygienists handing their notice or dentist getting pissed off and saying, ‘Jaz, what the hell do you do? Why did you encourage my hygienist to think a little bit differently and inspire him or her a little bit too much?’

I mean, I want to inspire. I want to get the word out. I want to help these hygienists through Morgan and Lou and what they have to say in learning from their journeys. But I don’t want there to be friction between dentists and hygienists.

I want there to be synergy, and I want us to create an environment where hygienists can be happy at the workplace because a happy team breeds a culture in the practice that’s palpable and patients can detect it, and I think it’s a big part of the patient journey.

Hello, Protruserati. I’m Jaz Gulati and welcome to another episode. This is an interference cast. It’s like a nonclinical interruption. So we talk a little bit about clinical here, but it’s more about the bigger picture stuff, how we can work together with hygienist the best way possible. Let’s join the main interview now.

Main Episode:Morgan and Lou, welcome, very warm welcome to the first ever hygienist to Protrusive Dental Podcast. How are you, both?

[Lou]
Good. Actually excited for our first podcast with you Jaz.

[Jaz]
I’m just excited just to see your faces again and then just have this connection and catch up with you. So those of you who don’t know, I probably said in my intro, but we used to work together in Summertown, Oxford, and you know, Morgs because you reached out to me on Instagram, cuz I think you heard me mention about how much I loved working with you two.

Right? And then I said, listen ladies, you have to come on the show because like what I do for dentists and I’m a little bit shameful in the way that I do very much make the content for dentists, and I do sometimes feel as though I’m leaving our cousins, our brothers, our sisters, our hygienist, therapists out a little bit because some of the themes I cover are just slightly different to the themes that perhaps you guys want.

But then, what hygienists have been doing, they’ve been DMing me, saying, ‘Jaz, can you just cover this one thing for us about how we can work together better?’ And I think, who better than you two? And I’ll just start from the top. I guess. Let’s have a couple of introductions first before I give you, my introduction. So Morg, start with yourself please. Tell us a little bit about yourself, how you got into hygiene, and you are interest in that regard of working in the capacity with dentists.

[Morgan]
So, I was a dental nurse for seven years before I got into hygiene. Yeah, we were talking about this the other day about how we think it’s a really great base because you already have that background knowledge.

So yeah. Then obviously met hygienist on route and thought, hang on a minute. I think I would like to do a bit of that. And then lucky enough-

[Jaz]
Did you find that jump difficult? Because a lot of dental nurses consider that move and then something comes along and they don’t do it, they don’t commit. Did you find it a big jump? A big hurdle?

[Morgan]
I mean, I was young, I was 21, I was at university, studying hard, playing hard. So, I actually think I had it really easy. We had women on the course that had children, families back home, and they were sacrificing that time away from them and studying, and they were working way harder than I was.

That was for sure. So, I think I did it an easier time in my life, but I have real respect for people that do it later on. And you know what? Great, because I have even more experience. So, yeah, I would say if you are considering it, go for it. It’s a great flexible career.

[Jaz]
And one of the themes we’ll talk about later, is a common theme I’ve spoken about on the podcast Morgs, which is finding the right place of work and how you have to kiss lots of frogs before you find your Prince Charming. And I know we had that chapter four. I’ll talk a little bit about; we’ll talk about that. Right? We’ll talk about the state of the play and the situation and stuff. But, Lou, let’s hear from you. Tell us about your background, how you got.

[Lou]
It’s, yeah, pretty similar to Morgan’s actually. I, after leaving school, I worked as a dental nurse, for a little bit longer, about 10 years.

And I used to always pop in to see the hygienist and see how she worked and offer some help sharpen her instruments and ask if she wanted some charting and everything, because she worked without a nurse. And I really loved what she did. It really, really interested me.

And she said to me, ‘Lou, you must gone do dental hygiene. You know, you’ve obviously got an interest for it.’ And that’s what I did. I started applying. I was a little older. I was 26, so it was, no, and I’ve never looked back. It’s been the best thing ever. I always knew I wanted to go into some form of dentistry, but I never quite knew why. Or what. It’s been absolutely amazing. Never look back and I would never have a different career. I love it.

[Jaz]
Brilliant. You know, that shines through when I used to work with you two, like I could say it now, I don’t want to offend any hygienist listening at the moment, but you two are just the best hygienists ever worked with, honestly, the understanding, the culture at work, just you two, just amazing, and I want to bottle you two up and spray you around the country in terms of your, just how you work together and this is what this episode’s about, right?

Because, and before we delve deeper, I’m getting so many thoughts and questions in my head already, but Morg, you said something really important before I hit the record button, and I guess it’s kind of like a disclaimer before we talk further. Do you want to just say it, go on. Just spill it out, get it out your system.

[Morgan]
So we work in a really, really lovely practice in Norfolk, Oxford. It’s a very affluent area. We were very fortunate to be hired by an amazing dentist called Guy Duckworth who was very, very prevention savvy, forward thinking and the ethos of that was carried on through the practice.

But we are not stupid to know that it’s not a cheap practice. What we can offer and the people that come here, a lot of them can well afford what we’re offering so we can completely tailor make their treatment for them. And we do appreciate that there are practices where it would have, the way we work would have to be very adapted because affordability is definitely an issue, especially in the times we’re living in. So yeah, I didn’t really want us to come across as a couple of divas that just said, this is our way enough highway in the way that everybody should be working, but what we can offer is the best of the best because of the-

[Jaz]
And it works in your business model. Lou, is there anything you want to add to that?

[Lou]
I think that you can, I think it works. We can tell patients what they need, and they obviously take up the advice, they take up the appointments. So, we find that we have the best success rates, you know?

But I would think even if you haven’t got affordability and you have got reduced time, it’s actually about set what your goals are. Your expectations and work to them. I find a lot of the time people think that, you know, oh, you’re just going to become an, you know, it’s all about removing the calculus.

It’s all about removing, you know, the staining. But actually I think that’s very, very shortsighted, basically. That’s a short, quick fix, but actually it’s not helping anybody. It’s just actually you are stressing yourself out. Your expectations are never going to be met doing that. So actually, I think you’ve got to play the long game, you know, like I said, goals, expectations, definitely in any capacity.

You know, if you’ve got 30 minutes, then I think adapt that appointment. Two, what is the most important thing? What is the priority here going forward for that patient?

[Morgan]
I was just going to say, giving a patient value for money does not just mean scaling their teeth. So, you know the whole give a man a fish for a day, you’ll feed them for a day, but teach them how to fish and you’ll give them a lifetime’s worth of achievement.

That’s exactly the same with what we do. Us offering somebody educational on how to clean their teeth is going to mean that they’re going to get so much less issues further down the line, just scaling them. No clinical benefit.

[Jaz]
And as we explore this episode further, that’ll become clear in terms of messages we’re want to send out. But I’ll give everyone an example straight off the bat, is that the way we worked together in Oxford at the time was when patients would come to see you Morgs, there were some patients and you know, you got into heated confrontations because you’d refuse to do any calculus or plaque removal until they sought them.

So, you just spent in the least patronizing way as possible. Patients always be like, wait a minute, I’m paying you x amount, clean my teeth and you are just telling me how to clean myself and you’re doing the right thing. You’re doing it by the book. But you know, you are ready to have your purpose. You have your purpose in terms of their overall health and actually sorting them out, prevention base so that they can look after themselves rather than just being a scaling machine.

You have the holistic health in mind rather than just, let me get the scaler out and stick it in as soon as possible. So that’s the kind of what we’re talking about here. The bigger picture. So taking a step back, I know about your journeys now and you did nursing first and you got into hygiene that way.

And it’s nice to know your individual, journeys and then let’s talk about actually finding the right environment and the struggle that you found to find the right place. And it’s very much ties into what you said morgues. That the young hygienist who’s listening to this, who’s just, a couple years out, and if we didn’t say that disclaimer, first up, they would listen to this, and they might feel really disheartened that they’re just a scaling machine and they get miserable.

But what you’ve made very clear is that actually you work in a very specific practice. They’re set up for this, but the second thing they’re not hearing or seeing until now we’re going to reveal it now, is that it took you a long time or a lot of practice to find the right place. So Morg, let’s hear your journey of the frogs that you kissed along the way.

[Morgan]
There’s been many, and in one practice I did five hours in their practice, and I said, ‘This isn’t going to work.’ You either get on board with how I want to work, which looking back as a newly qualified hygienist with very big head, you either get on board with how I want to work, or I won’t be here on Monday. Guess what? I didn’t go back on Monday.

[Jaz]
Well done.

[Morgan]
I think I left 12. Yeah, I left 12 practices when I first started. This is the only practice I remained at. And I remember Louise saying to me at the beginning of my journey, there are enough good practices that you’ll be able to leave the bad ones. But I would say to the newly qualified hygienist, working as many different practices as you can.

Because eventually what will happen is you’ll get offered more days in the good ones and you’ll be able to leave the bad ones but choose to be the clinician you want to be. If you feel undervalued, if you don’t feel listened to, if you’re made to work 20 minute appointments with no nurse, move on because obviously on the forums all the time is these poor, newly qualified hygienists, they come out of university so full of enthusiasm and I can remember that feeling.

You just want to go and like spread the word about all hygiene and change the world and you feel so limited and unsupported. And when I see those conversations, I just think you are literally flogging a dead horse. You need to leave that practice and move on.

[Lou]
What I was going to say, I think what we are finding is happening is because if you are working in these practices where you are not feeling valued, where you are not being able to utilize all of your skills and make that difference, then the stress levels are high and people are actually leaving the profession.

And that’s not what we want. You know, they’ve spent a long-time training and we want them to stay. I think they do have to find the right practices and be the hygienist and dentist that you inspire to be when you actually started your journey of actually, of the education, of the training. Definitely.

[Jaz]
I mean, that applies to dentists and hygienists. And Lou, just to give us your background in terms of how many practices until you found where you are at now.

[Lou]
Wow. I qualified, 23, 24 years ago, and one of my tutors actually said to me, do not become a scaling machine.

And she’d said to me, you love the oral hygiene side of it. Find the right practice for you. locum first. And that was the best bit of advice that I had. I locum first. And even though they had permanent positions, but what I’d said was that I will lock them. So, my day, I was traveling two hours one way, two hours another, but it was worth it because then I could see whether it was a practice that I wanted to be in, whether they got me and whether I got them basically.

So yeah, I lock them first. And then even when I came to Diamond House, my interview with Guy was very, very relaxed and we just had a chat and he’d said, ‘ We’d like you to start working for us.’ And so what I’d said was actually, ‘How about we actually have a month together?’

I said, ‘Just as a locum, I will do a month for you and then we’ll have a conversation at the end of the month. If you like me and I like you and we’re working well together, we’ll then you know, we’ve got a deal we can go forward.’ And that’s actually what I did. And it was the best thing. It was the best thing ever.

But I think if I haven’t got that advice at the start by saying, ‘Be the hygienist, work the way that you want to work.’ Then I don’t think I would’ve had maybe the confidence to actually say that right from the beginning. A lot of people, a lot of my colleagues that actually started qualified at the same time.

Within months, they were stressed, burnt out, saying, I’m not going to be able to do this forever. And that’s even after a few months, you know? So, I feel very, very fortunate that I took on board the advice that I was given right from the start.

[Jaz]
So the theme already we talked about is, you know, I have to kiss a lot of frogs before you find your Prince Charming. The second theme based on that is date them before you marry them. And that was a great example.

[Lou]
Yeah.

[Jaz]
Even though you’ve got this great vibe from Guy Duckworth, you said, ‘Hang on a minute. You know, I like this, but I’m going to do a month first.’ I love that. And I think that’s great. It’s a little bit brave. But I think, it’s good to have that and the themes I’m seeing here, I don’t know if you listened to an episode I did with my good friend, Laura Bailey. She is a therapist I work with in Richmond and she’s doing a lot of bonding. And the common themes we’re seeing here is you have to take massive action. You have to put your best foot forward. And that can sometimes that map, that journey can look very uncomfortable. That’s a very squiggly line from point A to point B. It’s a lot of tough conversations to have along the way. A lot of goodbyes, a lot of upsets, a lot of new places, new environments.

A lot of commuting that you did, Lou, these are the real-world issues until we found it. What I don’t want on the back of this episode is a mass exodus of any hygienist who’s unhappy. And then this episode comes out on Monday and by Wednesday, all these principals are calling me up saying, ‘Jaz, stop podcasting! You just ruined it for everyone.’

[Lou]
And then you’re getting hate mail!

[Jaz]
Hate mail, and love mail. I’m sure what you’re saying is resonating with a lot of hygienists. So really, if a hygienist is feeling stuck, rather than taking a big risk and being out of income and out pocket and struggling to find new work.

What is the first step that you could use, but perhaps you employed but it didn’t work because maybe the principal wasn’t receptive, wasn’t open that communication, it wasn’t the right environment. Whatever. What is the first step a hygienist can do to open that conversation to improve so that’re no longer a scaling machine?

[Morgan]
I think evolve. The biggest thing that everybody has to do in practice, and that’s not just the hygienist, that’s the dentist, the practice manager, everybody, nurses, we all have to learn to evolve. So, I think, if you’ve got good communication in the practice, we definitely don’t work how we first worked when we lost each other.

Yeah. Communicate. And you need to be in a practice where you can evolve. So yeah, I mean, definitely don’t do what I did and just walk out after five hours. I think try, have communication within the practice.

[Jaz]
Give it a shot. Give it a chance.

[Morgan]
Yeah, give it a shot and try and communicate and air your views as to how you feel that things could be improved and in then at that case, if you think that things aren’t improving and you have it what you are feeling, then maybe it is time to move on.

[Lou] Mm-hmm. I think good communication. We say that we are a team, actually be a team, actually converses a team, get everybody together and actually find out what everybody’s expectations are. Set some goals. Set some action plans together. Go on some courses together. Go on some, you know, so everybody has a really good understanding because I kind of think a lot of the time we think that the other person knows all about the subject. Okay? I’ve had dentist, said to me, ‘You know what, I had six weeks perio.’

I haven’t got a clue what I’m doing kind of thing, you know, holding their hands up. You know a lot more than me. And when it comes to decay and occlusion and everything like that, I’ll say, ‘You know, that’s your skillset.’ And recognize everybody else’s skillset and actually utilize it in the team, and don’t be afraid to say, ‘I don’t really know much about this, but can you tell me about it?’

And, you know, every day’s a school day, we don’t know everything about all subjects, so actually educate each other as well. You know, maybes have regular meetings with each other, even if it’s just a 20-minute coffee and just say, ‘Can you tell us a bit about what you do? Can you tell us a bit about motivating patience? Can you tell a bit us about what you’re doing, what your successes are, what your failures are?’

[Jaz]
We used to go out for Chinese food and curry and that kind of stuff a few times that we went out as a team, back when Amme and Yiannis and whatnot. So that was good actually. So, it’s nice to have that team building, you know, team building gets into everyone, but also suggest the changes and have that open conversation. Right.

[Lou]
Absolutely, and don’t be afraid to actually say, let’s do something. It’s almost like it’s positive criticism, you know? And I think take it as a positive. This, just saying that actually I think we could improve on things, I think is monumental for every practice and for ourselves as well. Everybody wants to like you said, evolve. We need to evolve as people, but we need to evolve within our work as well.

[Jaz]
Like you don’t just go into work one day and then hope that’s a day that the principal’s going to have an epiphany and be like, you know what? We’re doing it all wrong. How about we change the model and do this? No one’s going to do that. You know, things are going to not just change miraculously overnight. You need to be suggestive. You need to plant some seeds; you need to arrange some meetings. You need to come up with, you know one of my favorite things is, don’t come to someone with problems.

Come to them with solutions. So don’t be that person. That hygienist would be like, ‘Oh, this is not working. That’s not working. I want a nurse, blah, blah, blah.’ How about you come up, if we have a nurse, so this is one awesome thing that Laura did when she approached the principal Hap, who’s very open and receptive and great leader is, she said to him, ‘I want to use EMS airflow. I know there’s a huge expense, but I’ve done a calculation that if we raise our fees to this amount, we can cover it.’ And then they had that conversation. And what a great way to approach someone rather than, ‘I want an EMS airflow.’ You know what I mean? Yeah. So, so I think that’s a great tip. Any examples of when you two might have done that?

[Morgan]
Yeah, we were told at one point that when the practice couldn’t afford to have a nurse, we couldn’t have nurses. So we took a pay cut to retain having the nurse because we feel like well, it makes our day so much easier. We hugely value the girls and we want to offer the best service, and the only way we can offer the best service and give a hundred percent of our time and attention to the patient is to have a nurse.

[Lou]
And to utilize the nurse as well. Yeah, definitely it is.

[Morgan]
It’s the best decision we ever made.

[Lou]
We accepted taking pay cuts for the better machinery and to have the nurse and we enjoy our day. We enjoy what we do. And it’s because of I think of making those changes and making the sacrifices as well of it’s less financially, but actually we have a less stressful day, and we enjoy what we do. Patients are happy and everybody’s happy and it’s a win-win.

[Morgan]
And we can justify our costs because if a patient set, they’ll even come in and say, ‘Oh, no nurse with you today.’ And you’ll say, ‘Oh yeah, they’re just processing the instruments. They’ll be with you in a moment.’ And we make them fully aware that yes, we’re not the cheapest, but it’s because we’re using the best equipment. We have support a hundred percent of the day, and our focus is solely on them.

[Lou]
It’s that patient journey. I hear that word banded around a lot these days. You know, the patient journey. But it is the patient is our business basically.

[Jaz]
Mm-hmm.

[Lou]
Isn’t it?

[Morgan]
Yeah. Yeah.

[Lou]
So to make them feel really cared for and important and that they are getting the best treatment, then everybody’s a winner.

[Morgan]
I was just going to say, the biggest litigation in dentistry is perio.

[Jaz]Mm-hmm.

[Morgan]So the only way we can do our notes fully and all of that kind of stuff is with that support. So, yeah, we love our girls.

[Jaz]And what you did, those were so selfless, like, you know, taking a pay I didn’t expect you to say that. I was like, that took me by surprise that you said that, and that’s just amazing. Like those who are listening on the podcast, who are driving on their commutes, and they didn’t see me. You might have noticed my hair’s raising, right? Because that was a like, listen, listen. I was like, wait, what?

You took a pay cut? That’s like, that’s such a selfless thing to do. It was like that is amazing. I don’t know many people who would do that. So, kudos to you. Like, you know, the reason why you two are in environment that you are happy is because you’ve made this environment, you’ve fought for this environment.

And I was, you know when I said, give me an example. What a great example. Then having that conversation like, wait, if we can’t have our nurses, then we are willing to have a pay cut. But for you to do that and show leadership from the bottom is just amazing and absolutely kudos. So, let’s cover that topic now of nurses, because that’s one of the questions I want to cover.

Where do we stand nowadays? Right. In terms of nurses, I think it’s having worked with you two. I think it’s fundamental. Cause obviously before I joined you guys, I was already used to hygienists not having nurses. So, this is a huge topic now you can see it from both aspects, right?

As a business for a principal to change their business model overnight and pay nurse, additional nurse wages. Especially with a shortage of nurses at the moment. We talked about earlier as well, before we hit record button. That’s a big thing, but in terms of a difference, it makes for your clinical longevity, clinical enjoyment, what you can do for patients to patient journey. How can we find a balance?

This episode is brought to you by Enlighten Whitening, the premium brand of teeth whitening. Not only do they have the best trays in the business, the patients really perceive it as a high quality product, and it’s really clever how the whitening gel itself is separate to the desensitizer, and I know Payman talks about the importance of that and how it’s beneficial for whitening system to have those two products separated rather than squeezed into one formulation. So, if you want to do some training online, head over to protrusive.co.uk/enlighten and check out what they have to offer as free training on teeth whitening, and you get to see what the fuss about enlighten two, back to the main episode.

[Lou]
Me personally is that without your nurse, it would be substandard treatment. Basically it’s, you know, to be able to personalize your treatment, do plaque scores, bleeding scores, have fantastic cross infection and be able, like Morgan said, to actually give the patient your time is paramount to really good oral hygiene and really good patient experience and really good outcomes basically.

I think everybody needs to know their value. Basically. Education does come at a cost. So actually you know, patients might say, oh, like you are talking, I don’t know whether I’m going off subject here, . But anyway, it’s patients might say, ‘Oh, you know, well, I’ve paid 110 pounds for this and no has taught to me.’

You know, but like I said, that was invaluable information and all of these in order to actually measure and motivate all of these indices is so important and they have to be recorded, like Morgan said, for the legal aspect of things, but also for the patient motivation. If we do plaque scores on every patient that’s measurable, we can say-

[Jaz]
But what you’re saying, Lou, is that without a nurse, it’s almost impossible to get good records. And to, you know, the reason you mentioned about the fees is because yes, if you’re going to be working in the model where about you have a nurse, You can’t expect to just for that to work in your current business model.

The entire business model needs to change. The prices need to reflect that, but that’s not necessarily, you know, I think dentists and principals are scared that if they raise their prices by 20 pounds to be able to cover the nurse, that they’re going to lose their patients. But, from any experience I have had so far whereby we’ve introduced that model and increased the hygiene fees, I haven’t noticed a mass drop, and I’ve only noticed that the team are working together better. The hygienists are so much happier, and the patients are getting better care now. That’s what I’ve noticed.

[Lou]
Definitely, I think you just have to take that leap and actually believe what you want to offer patients, how you want to deliver that and just take the chance. And it will be absolutely fine.

But like I said, it’s just taken that risk. Some people don’t want to take the risk, but I think really, really push for it because if they take the risk, a few months, years down the line, you will not regret it. You will definitely not regret it.

[Morgan]
From an education point of view as well have everybody on board as to what it is that you are offering. So when a patient rings up and they say to reception, oh gosh, that’s expensive, that you haven’t just got the receptionist saying, yeah, it is, you know, our receptionists are fully versed in knowing that they are telling a patient what is offered at this practice, which they’re not getting at other practices.

[Jaz]
Just to make that clear to a young hygienist who hasn’t worked in the kind of environment that the lovely work that you do. What are patients getting for their money in terms of, you know, you’re working in a place where both of you have an important role and have had an important role in designing the protocols of how you’re going to treat perio in the practice.

And you two are fundamental, at the top of that actually. So what is it that you offer that stands you out and is able to justify the piece of fees to the patients when they pick up the phone and call reception?

[Lou]
I think it’s definitely; it’s tailored to the individual. It’s not just come in every six months and have your teeth scaled and polished basically. It’s tailored. So, do you want to say what we do?

[Morgan]
Yeah. I think as well because we’re given free reign, we’ve never been told this is how you must work. We were trusted enough that they would say, you know, you need to go off and see Morgan or Lou, and then we would tailor make the package of the hygiene as to how the patient needed it individually.

It was never, you’re going off for a scale and polish. It was, you are going off to be educated about how to care for your mouth and in doing that they will clean your teeth. But fundamentally the long term is that we want you to keep your teeth. The more you see Morgan and Lou, hopefully the less your dental treatment you’ll need. So, you were big on that Jaz. You were big on saying, you know, I’d like you to have a better relationship with your hygienist than you do with me.

[Jaz]
If you’re seeing me too much, things are going wrong. You know, you keep seeing the ladies and they’ll sort, then they make sure you’re on the straight and narrow. Very much true. Very much true. And do you feel as though you have been well supported at the management level when you’ve suggested to have a preventive focus in the practice.

[Lou]
Absolutely. I think because when we started this practice, it was very a prevention led anyway. I think we’re really fortunate that actually what we had to do was maybe have difficult conversations with new clinicians coming in and even we were getting them to shadow us to actually say that this is how we work and equally, I’m really happy actually shadowing dentists as well to say, actually, I want to see how you work as well because obviously, you have lots of different patients, lots of different personalities.

And so, it’s quite good actually. I always find that the patient have the best relationship with people that suit them as well.

[Morgan]
I think information is key and our appointments are very information heavy. There’s not a single appointment, patient doesn’t leave with a plaque or a bleeding score and god forbid we’d forget to do that. A patient as they’re exiting, would say, oh, what are my scores today? They want to know those numbers.

[Lou]
Yeah.

[Jaz]
Do you still do your A5 card with the traffic light system and the percentage of the bleeding score, plaque score and the smiley face, et cetera? Do you still do that?

[Lou]
You know what? We don’t. Since I left. Actually, no, that actually stopped. But I tell you what we do is actually, well, I always vocalize what there, I always get the nurse to actually say, what was their bleeding score last time? And she will shout out. So obviously the patient can hear, I can hear, and then I’ll say, and what is it today?

Because, then obviously, you know, you can say which whether it’s improved, got worse or stayed the same, and that leads you into what you need to do. We need to focus on these specific areas as well. I think it’s a great motivational tool.

[Morgan]
We are making the patient realize that they need to take ownership of their disease. It is not about coming and having a quick cleanup every six months to a year. It is about them realizing that what they do at home is so much more important than what we do. And that’s the difference. I think that we have the support to push forward in this practice, which I definitely didn’t get in another practices.

It was about get them in, get them out, get the money. And the education was just really not that important, but that’s what’s kept us at this practice.

[Lou]
Yeah. I tell you what I find very, very interesting as well, is that when the clinician starts with the seed of you’ve got inflammation, starts to talk about the health of the gums with the patient and even shows them a TePe, it’s that the patient has heard something and then they came to us.

And then we get them to, obviously, we educate them to understand what was meant by that. And then they just get to know, obviously the whole picture of what’s happening. You know, plaque bleeding scores, six-point pocket charts. We found that, you know, if they’re perio patient, there definitely should be having full mouth Peri-apicals as well.

And actually, so courses are good. Keep up to date. And actually, if you haven’t got that information, if you are qualified, take the PAs yourself, tell the patient, why you are taking it. Bring them over to the computer, talk to them about their bone levels. Tell them why they have bone loss in certain areas but tell them what they need to do to actually stop that and actually to halt the disease.

If you are not qualified to take the x-rays or confident in doing so. Actually, don’t be afraid to actually go back to your clinician and say, I would like full mouth PAs, please, get the patient booked in. And I’m sure the clinician would be more than happy to do that for you. But I do think communication and actually building some bridges and working together is-

And singing from the same hymn sheet. Because like you said, the clinicians are saying it and you are enforcing it and you are saying it and we are enforcing it. So, you have to work together. And I guess that brings in the whole perio approach.

Cause I got my last two questions are how do you treat perio in your practice? And it sounds like a stupid question in a way, is that what do you mean how do you treat perio? We treat perio like we’re supposed to treat perio, but you’d be amazed ladies about, and you’ve experienced these different practices.

You know, some practices don’t talk about how we treat perio and you guys like, this is how we treat perio. We have a protocol in place. So, tell us a little bit about what that looks like in your practice.

[Morgan]
So number one, OHI, as you know, and obviously we’ve discussed a lot. We spend pretty much the first appointment with every patient, and this is whether they’re direct access or sent from the dentist.

The first appointment is spent showing somebody how to brush their teeth, and then often two weeks later, we are reviewing and seeing how they’re getting on. We’re not just sending them off and saying good luck. We want to know that everything we’ve done with them, they’ve understood. We do a lot of tell how, do lots of literature, leaflets, flip charts. We can send them videos, whatever we can do to support helping them learn about how they can care for their teeth themselves.

[Lou]
Oh, the mouse map. I found really good actually getting a mouse map and actually saying which TePes or which incidental aids suits best for that area as well, and that’s where the tailormade care comes into place as well, so they know exactly they’ve got something to take away with them.

Put it up in their bathroom so they can actually reflect and say, because obviously I think it’s being found, hasn’t it? On each appointment, isn’t it? Audio-wise? They actually retain very little knowledge of what we say. So, if you give them something as well, then that just supports and reinforces exactly what we’ve been saying to them.

[Jaz]
Perfect. We’ll talk about locum cause that’s for me is really important, but something that maybe you ladies now maybe take for granted because you are working, you’ve been working this way for so long, but just remind me if you still do this and everyone who’s listening is TePe brushes.

You are actually getting out the long handle ones. You’re actually putting it in their space, you’re showing them, and then they get to take that one as a sample to go home. And is it single tufted as well? What tell us the kind of things they walk away with.

[Morgan]
Definitely we’re big into single tufted brushes, bending single tufted brushes with a burner if you need to. So that you’re adapting it for specific areas, showing patients how to use them down the pocket. Yeah, we actually, we don’t just give the patient an electric toothbrush. We are actually showing them in their mouth how to use the electric toothbrush. Because so many times you’ll hear, oh yeah, I’ve been told to brush for longer, or brush harder or soft, whatever. That means nothing to anybody. We’re actually showing them in their mouth how to use it.

[Lou]
And I find what’s really good. I mean, the IO it’s absolutely amazing. I think that’s been a real big game changer.

[Morgan]
Yeah.

[Lou]
The technology behind that is fantastic. And actually, having all the heads show the patients what to do, basically we tell them what to do and actually getting the patient to actually brush, you know, give them a mirror, sit them up, get them to brush.

You’ll actually find the reason why they actually, that they haven’t been getting anywhere for years kind of thing, is basically because, you know, the angle of the toothbrush is not right. The technique is just completely right, but they think that they’ve been holding the electric toothbrush and moving it, but the majority of patients actually use that electric toothbrush, like a manual one, you know, and but you need to just stop them, show them, and just say, you know, how does that feel? You know, can you see-

[Jaz]
Do you ever get worried or scared that by asking them to brush in front of you that they might feel patronized? Is that something that ever crossed your mind in the early days of, of doing this protocol? And have you ever had these encounters where the patient’s personality type is like, what do you mean brush? Like you try and say, I can’t brush, tell us about some of those encounters.

[Lou]
Absolutely.

[Morgan]
Yeah.

[Lou]
Quite, quite a few.

[Morgan]
We’ve both been shouted at over the years.

[Lou]
Absolutely. Yeah, we have definitely.

[Morgan]
And I will say to a patient, especially if they’re older than me, please don’t find this patronizing. I do teach people in their nineties how to brush their teeth, but I am only here to help you. But yeah, you get pushback, and one size doesn’t fit all. I have had very rarely, but I’ve had an occasion where I’ve said, look, I think the way that we are working together doesn’t work. Why don’t you try and cover hygiene? Visit with my colleague and I’ll say to Luke, can you take one for the team as well.

[Lou]
Vice versa if I’ve had somebody where I’m just not getting anywhere, or we haven’t been looked that good rapport. But like I said, you know my way of working my way advising them things, they’re just, it hasn’t, kind of got through or it just hasn’t worked for them or for me.

You know? Then yeah, Morgan’s seen them as well and it’s amazing because even sort of, it’s such successes with some people that I haven’t, so actually be fine and just saying, you know what? I think you might be better suited to see my colleague; you know? And I think that’s absolutely fine to say as well. And I think at the end of the day, the patient, even though they might, you know, obviously yeah. Have a few grumbles at reception and things like that. I think they’d depreciate just. The honesty as well really.

[Morgan]
But you can’t please everybody. You are not going to have a hundred percent success of every single person loving your practice. But you know, as long as you retain 99%, I think you’re doing okay.

[Jaz]
Yeah. But then you attract the like-minded people, right? You attract the people that buy into the health philosophy, that buy into prevention, that understand that ‘Hey, I’m paying a little bit more. Yeah, but this is way more than what I’ve ever had before. And these two, they actually care about me and my health outcomes, and I get an objective score at the end.’ And those people who value that will say those who. Well won’t, and, and you probably are happy that way, I guess.

[Morgan]
Mm-hmm. Yeah. True.

[Jaz]
It’s self-selecting.

[Lou]
If our prices have gone up kind of thing, people have actually gone and said, you know what? I can’t afford to come here anymore. I’m gone somewhere else. I would say within a year they are back and they just said, you know what kind of thing, we’ve been to other practices and actually we can see where hygienist’s going?

[Morgan]
Yeah.

[Lou]
And what you do different. And we are back, which, which is quite nice. And sometimes you have to lose a few patients and if they come back, then that’s fantastic. You know, then patients will be the patients for life.

[Jaz]
What is the number one quality or trait that hygienists should look for in a practice or practice manager or a practice principal? Anything from the practice of the management team? What is the number one trait or quality? Is important in finding the right place.

[Morgan]
I think they need to be a human first and a dentist second. I think when it’s just solely business and with the management as well, then you don’t feel cared for, because most of us spend more time at work than we do at home.

That’s just a reality of life. So, you need to enjoy yourself. I mean, yeah, we are not scaling from nine to five. We have a lot of fun on route as well, and you need to feel looked after and we really, yeah, coming to this practice was like working for my parents. I’ve never experienced anything like it.

And it’s just carried on, hasn’t it? It’s just a lovely, happy environment. We actually have a nice time and I wish that for everybody, and when I see the forums of the unhappiness, it is heartbreaking because there are so many good practices out there. So please don’t quit the career because it is an amazing one. Yeah, seek out good practices because they are out there and you will find lovely practices and environments to be in. Don’t lose the faith.

[Lou]
And just make little changes as well. Like I said, drop the seed in and make little changes, you know, because like I said, it’ll have that snowball effect.

[Morgan]
Yeah, definitely.

[Jaz]
For me, I think a really important fact for me, if you ask me that question, I would say and you know, you say human side, which is lovely and I love that. I also think leadership, just having a good leader, okay, he or she should be a good leader. They should be a good leader because that really trickles down, leadership is how the culture is brewed.

It sets the tone of the practice. Having a present leader or the presence felt of leadership, I think is the most important thing. And sometimes, if you are not getting that from the powers above, then I’m very much a proponent that leadership can start from the bottom. And then you could start being the little mini leader in your sort of capacity to try and drive the changes from the bottom.

And that looks like a much rockier road, a lot of resistance and uphill battle, but it is one which does have a pot of gold at the end, if you like. So, I think it is worth fighting that battle. And sometimes it means you to change mountains, change course, go off piece, all the themes that we discussed at the beginning. But I think it’s worth, you know, if you are feeding the lack of leadership, then become the leader that you want to drive the changes that you need.

[Lou]
Absolutely.

[Jaz]
Yeah. No, totally agree.

[Lou]
And I kind of think be a leader. I’m willing to listen to people as well, you know? And obviously make the final decision as the leader, but I think actually being open to other people’s ideas even if you tried something and just that actually we’ll try it for six months, and if it’s not working, then we’ll think about something. You know?

[Morgan]
Yeah. Yeah.

[Lou]
I think it’s better if you tried.

[Jaz]
As a final point, you’ve got the microphone to dentist and hygienists in an episode, which may become viral. I think it’s going to become viral because it’s such a- The face he made everyone, anyone know who’s listening and not watching the face that Morg has made was not one of joy

[Morgan]
It’s like love island, we’re just these two little hygienists slip kind of thing.

[Lou]
Jaz, do we need to start organizing our merch or what? ,

[Morgan]
Water bottle.

[Jaz]
Ladies? Yeah, you can totally do this. You know, your own EMS airflow kind of thing. You can do this.

[Morgan]
Jaz, on a serious note, what I do want to mention though is refer big, big point of the perio, which we haven’t discussed is have an amazing relationship with a periodontist that you trust. You’ve seen their work and that you have open communication with. We just pick up the phone to our periodontist or ring them, whatever. But we’ve got that open communication. How do you think this is going? How do you think that’s going?

Should we refer at this point? As a hygienist, we are not the end of the road. We know that. So yeah, seek out good local periodontists. That is also a massive, definitely piece of advice.

[Lou]
Yeah, definitely. And I think as well is, you know, I think a lot of the time, because we’re in different rooms, you know, everybody works independently, but actually, you know, I think supporting each other as a team is paramount to a happy practice basically, you know, support each other, be there for each other and help each other out. Definitely.

[Morgan]
Buy your nurse lots of cake and coffee.

[Jaz]
That’s something I already do. That’s something I already do as well. So, ladies, honestly, I’ve loved seeing you both again.

I miss you both so much. I wish you all the best. Thanks for inspiring. I think a generation, because I think, you know, believe it or not, people hygienists have been messaging me on Instagram saying, because I promised this episode a while ago, and hygienist messaging me on Instagram saying, is that episode out yet?

Is that episode out yet? And they’re really what they need. I think what we need in dentistry because look, the BDA aren’t doing it right, is leadership. And I think if this is a small step to get people to start thinking about that and how we can get some sort of the change in the right direction, then so be it. And I look forward to hearing people’s feedback. How can we send you roses, flowers, chocolates, cakes? How can we reach out to you?

[Lou]
We’ve got our ins, we have got actually the Instagram page. But because we’re a bit dinosaurish of the old technology-

[Morgan]
We’re going on a course.

[Lou]
Yeah. We’ve gone on a course to actually see how to actually market ourselves and actually how to actually get the word out there. So, we’re doing this course in February?

[Morgan]
February, it’s called Thrive, and it’s the hygienist and therapists to market themselves. So, if you could just use our Instagram names on your podcast. That’d be great.

[Jaz]
I will do.

[Lou]
Instagram names. Is it the-

[Jaz]
Here’s what I’m testing you because you didn’t say it because you probably forgotten your Instagram name.

[Lou]
We only go on it once a year. It’s the diamond, the dynamic duo. Yeah. I’ll message you.

[Jaz]
Is it actually @dynamicduo?

[Morgan]
Something like that. Yeah, but honestly there’s only about three posts on it. We’re so terrible.

[Lou]
We’re not that dynamic on Instagram. But in the surgery, we are. So, we’re ready to evolve.

[Jaz] But after February you’re going to see lots of more posts and stuff. So if you wanna show your appreciation, if you want to ask some questions, if you want to engage @dynamicduo or the equivalent of where, whatever it actually is, I’ll put it in the show notes as always, ladies, thank you so much.

[Lou and Morgan]
Thank you, Jaz. We love you.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. A lot of the episodes are eligible for CPD. This one isn’t. There wasn’t enough substance, but that doesn’t mean there wasn’t enough juice, right? So, there wasn’t enough substance for questions and CPD, but I’m hoping you found that as a stimulating and inspiring episode with your hygienist.

I’m hoping you’re feeling like you can leave from the bottom, and if you’re a dentist, I hope that’s opened your eyes to the struggles of some hygienist and an opportunity for you to put yourself in a hygienists’ shoes who’s working alone day in, day out, and how they’re not able to operate at their highest level when they’re not in the right environment.

If you know anyone that will benefit from this episode, whether it’s your principal or an associate or a hygienist that you work with, please send them this. And I’ll catch you in the next episode.

View Details

You asked, we answered! Q&A with a Dental Technician – everything you wanted to ask (but never did) from our Facebook community.

A legendary Dentist once told me that an average dentist working with a good technician will do well in their career. This advice has always stuck with me ever since. I recorded this episode with one of my technicians Graham Entwistle of Trueform Dental Laboratory who has been a pleasure to work with.

From shade matching to getting the occlusion right, we made quite a geeky little episode which was well worth the 200 mile round-trip to his lab!

https://youtu.be/tMiC_18fiqcCheck out this full episode on YoutubeDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Protrusive Dental Pearl: It’s high time that you find your ideal dental technician, build a relationship and grow together. Whether you are using a big lab or small lab, try to visit and meet them and be open to getting feedback and criticism from that ONE technician that will elevate you. Don’t forget to give credit to your technician for their craftsmanship – take a photo of their work being fitted and email them – credit them on social media!

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

2:32 Protrusive Dental Pearl
7:55 Graham Entwistle’s Introduction
13:41 Q1: Analogue vs Digital?
17:11 Q2: Impressions or Scans for Veneers?
18:32 Q3: Is Digital good enough for high-end work and multiple crowns?
21:12 Q4: Are our impressions and scans good enough for you?
26:15 Q5: To break contacts or not to break contacts for veneers?
29:09 Q6: How does Graham create digital models with unbroken contacts of veneer preps?
30:35 Q7: What is the best material for masking discolored anterior teeth?
36:16 Q8: Shade matching for a Single Incisor Crown – the hardest thing in Dentistry?
42:06 Q9: How do you overcome contact point issues with digital as opposed to stone models for single crowns?
48:55 Q10: Digital Triple Tray or Full Arch Scans?
52:32 Q11: Getting the occlusion right for crowns
55:26 Tips for dentists to help the technician to get the bite right

Dr. Mahmoud Ibrahim and I are currently working on a huge project called OBAB, Occlusion Basics and Beyond – it will be the best occlusion resource in the Milky Way…and that’s our mission! We want to finally demystify Occlusion and make it Tangible!

Join the waiting list HERE!

If you enjoyed this episode, you may also like another episode with Graham Entwistle: 5 Things your Technician Wished You Knew

Click below for full episode transcript:Jaz's Introduction: An average dentist working with a good technician who will do very well in their career. This was some advice given to me by a legendary dentist called Raj Rattan.Jaz’s Introduction:
It was about nine years ago now. I remember exactly where I was, who I was with. What I was wearing is just like, really emphatic advice to me at the time. It’s just stuck with me throughout my career, and it’s not too different to the advice that Finlay Sutton gave. A few episodes ago. If you scroll down and listen to that episode about Scandinavian Design of Partial Dentures, and he said to find a technician who’s a similar age as you, who’s got a similar appetite for dentistry as you do and grow together.

Hello Protruserati. I’m Jaz Gulati, and welcome back to another episode of Protrusive Dental Podcast. This time, it was actually a rare face-to-face episode that I recorded. I drove over a hundred miles to see Graham, my technician, and the theme was to answer your questions that you’d sent on the Facebook group, everything you wanted to know from a technician.

But NEVER ASKED. We covered things like digital versus analogue. Is digital there yet? Should we be opening contacts for veneers? Heck do technicians like it when we open the contacts for veneers? Their answer might surprise you. It certainly surprise me how to match the shade for a single central incisor and a huge mammoth topic of how to get the occlusion right.

Now, we covered that in good depth in this episode, but me and Mahmoud go into in loads of depth in our upcoming occlusion course, we’re almost done. It’s being Beta tested. It’s something we’re super stoked about, but it’s covering all these scenario-based themes to make sure that it’s extremely practical and tangible occlusion tips.

I also took the opportunity while at Graham’s lab to film some content for OBAB. OBAB is Occlusion Basics and Beyond. And if you wanna join the waiting list for this course, head over to occlusion.wtf. That’s occlusion.wtf. Actually, it’s a real website on a browser you can sign up to updates for when our occlusion course is ready.

Hopefully coming in March, April time. So this is huge. It’s like in the final, final phases. This episode with Graham is eligible for CPD, so you get one hour of CPD. If you’re part of Protrusive Premium, just download the app. If you haven’t downloaded the app, what are you waiting for? If you are true Protruserati and you enjoy these episodes, that’s well worth joining the app.

And you’ll be able to download the Premium Notes. So if you’re already used to watching on YouTube, you see the notes coming up on the side. Well, those notes are neatly presented in a PDF that every premium user can download via the app, and it’s just a nice summary and it solidifies your learning.

Protrusive Dental Pearl
The Protrusive Dental Pearl for this episode is very much relevant to this theme of working with your technician. It is time, my friend, that you find your IDEAL DENTAL TECHNIQUE. Just like I said at the beginning of this episode, the average dentist working with a good technician will go very far. And it’s been critical for me. Funny story, actually, I posted a case recently that me and Graham did together. It was like a single onlay.

It was a beautiful onlay. And so I posted the step by step, what I did, what my prep looks like, and one of the photos was actually bonding the ceramic with Panavia and taking the occlusal photo. And I wrote on there, Graham did an awesome job. And remember Ahmed from Australia? Hope your hand’s feeling okay.

I know you post on social media that your hand was injured. I hope you get better, my friend. You are a true Protruserati, sending my love your way. And anyway, I made comment to saying, wow, I’m just amazed that you know your technician’s name. Now I agree with him. I think it’s pretty cool that I know my technician’s name and I get to be on a WhatsApp basis, and leave voice notes.

And that’s why I love communicating with Graham so much and any of the technicians I work with. But most of my colleagues that I speak with, they use a big lab. And it doesn’t matter if you use a big lab or a small lab, but the person on the other end who’s making that crown, making that onlay, making that veneer, making that denture, they don’t know that person’s name.

So if you don’t know their name, how are you gonna build that relationship? How are you gonna grow together? With that technician, Protruserati, how are you gonna find your Graham? This unicorn, this good technician I was referring to. Well, the guess what today is Graham Entwistle. He’s a brilliant technician I’ve been working with for coming up to just two years, so not mega long time, but I’ve been really impressed with our communication, the voice nodes, the loom videos that I sent to him and how he responds back and how receptive he is to my advice and how open I am to receiving his.

I tell him, Graham, if I send you some junk, you tell me I’ve sent you junk. And likewise, if there are any protocols, we’ve adjusted. We worked a lot on vertical preparations and getting the vertical crowns with the correct emergence. And he was really good to take my advice on board and change a few parameters.

And together we’ve got some great results with vertical. But the funny thing is that I found Graham by accident. He DMed me on Instagram. We started talking and he started listening to podcasts and I knew some really great dentists like Rustom Moopen, Elaine Mo, Kiran Bhogal. I know, I knew these guys were using Graham.

So then he had just about enough capacity to take me on as a client. And boy am I glad he did. And I think every restorative minded dentist should have a good technician that they know by first name basis that can just pick up the phone and give a call or leave a cheeky voice note. I think it’s absolutely imperative.

So Protruserati, don’t do what I did. DON’T WAIT AROUND for your dream technician to DM you on Instagram. It’s not gonna happen. That’s like a unicorn scenario. Now, Graham’s not the only technician I know. Graham, sorry, I am cheating on you with another technician, also called Graham and the Dan as well at Precision Dental Studio.

So, I use a couple of labs. Graham’s one of my main guys I use. But even though I use the second lab, which is my local lab, I still visit them now and again, they know me by my face. I know them by their face. I know what their voice sounds like. I leave voice notes. They leave voice notes back. We have REALLY GOOD COMMUNICATION.

The tip I can give to any dentist who’s working with a bigger lab, maybe a chain of labs or just a lab with lots of technicians, and you don’t know who’s making your crown, it’s just go in one day, meet them, try and get the same, try and ask for the same person to send back your crowns and then grow together.

Be open to getting feedback and criticism from that technician. That is scary, but it will really, really elevate you. In fact, I urge you to make it your mission to visit your lab. Perhaps you’ve never visited your lab before. Show your face, shake some hands and agree to who is gonna be your dedicated technician and just watch the magic happen.

The best time to find the ideal technician was once you qualified. The second best time is right now. And one last thing with your technician, because they do all the hard work and sometimes we get the glory. Once you’ve delivered a case, it’s nice to sometimes take a photo and email it to your technician, say, ‘Hey, we nailed this together and your craftsmanship was amazing.’ And it’s great for these technicians to see their work fitted. I don’t think enough of them get to see that. And I can tell you they really appreciate it. And so with that, let’s join the main episode with Graham Entwistle.

Main Episode:
Graham Entwistle. Welcome back again to the Protrusive Dental Podcast. How are you my friend?

[Graham]
I’m actually quite good.

[Jaz]
It’s nice to see you. Nice to meet you in the flesh. So, just to set the scene guys. I’m at Graham’s lab. Where are we? Romney Marsh. Where the hell is this place?

[Graham]
It is literally the middle of nowhere, but it’s Romney Marsh, Kent, East Sussex border. Pretty much.

[Jaz]
Well, I was like trying to find my way here. I was like, where on earth is this? So I’m glad to have discovered a new place. It has been amazing to work with you in the last couple of years. I’ve learned a lot from you. Communication, like is exactly what I wanted. Like I think as a restorative dentist, one of the tips I wanna give to everyone is find a tech who you get along with, who you like preferably, who you can just exchange on a daily basis. I pick up the phone, I can call you. I feel at ease about picking up the phone calling you. Although our favorite mode of communication is WhatsApp voice message, which is much more real. Well because you know, you might be busy doing something and just get back to it. There’s no pressure.

So we do lots of, you see our WhatsApp trail images. I do lots of loom videos, which I’ll ask your opinion how you find those, cuz it might be hit and miss. You might hate those and you know, might be tolerating them. I’ll ask you that in a moment. If you guys haven’t listened to episode 74 already, that was Graham with five things your technician wished you knew.

So that was helping us dentist. Today I’ve been asking on the Protrusive Dental community Facebook group about what is it that you guys want to know when it comes to anything you wanna know from a technician working better with our technician. So, Graham, just for those who perhaps didn’t listen to episode 74 yet, a little bit about yourself in terms of what drives you, why you became tech, how is it that you’re able to run this lovely facility with five kids, work-life balance.

[Graham]
Blindly. I dunno where to start. So what was the first question?

[Jaz]
First question my friend Is a little bit about your background. Like what got you into being a lab tech basically?

[Graham]
So first of all, never really been the type of person to get an office job sitting there in front of a computer, day in, day out, doing the same thing.

It’s monotonous, I’m autistic and yeah, it just doesn’t suit me. So found a job, King’s Collage Hospital and went for the interview. They got me to carve a whistle out of chalk and do a few other bits and got the job and I loved and hated the job throughout the time. And I went into cosmetic dentistry after I left.

And I was only doing that for about a year. Then I run bars and nightclubs for about four, four years.

[Jaz]
You left for being a cosmetic lab tech?

[Graham]
Yeah.

[Jaz]
Right, for bars and nightclubs. So tell us a little, tell us about that. What happened there?

[Graham]

So I was working in Basildon in at the time for a well-known technician and I’m reliable. I didn’t drive, I was relying on ferries, I was cycling and it just got a bit much. So we kind of parted ways amicably, and I just found a bar job to make ends meet while I was looking. Within four or five months I had a bar manager’s job. Four months after that I was an area manager and four years later I was like, let’s get out of this. Go back to what I’m good at. So, yeah.

[Jaz]
So do you not miss being a lab tech or perhaps you were still early in your career at that stage, and perhaps you didn’t quite know exactly what kind of a tech you wanted to be. I mean, tell us a bit about that.

[Graham]
I didn’t really know what I wanted to do, so I had to go out and taste the world for myself.

And I think being in the bar industry enabled me to do that and learn a little bit about myself, but it came with its own problems.

[Jaz]
Mm-hmm.

[Graham]
So, yeah, I got back out of the industry and I struggled to get back into dental technology actually, because nowhere wanted to pay any decent money for a technician is, we still find that these days that, you know, we kind of price ourselves down in the market because everyone wants cheap.

[Jaz]
You wanna compete in dentist world.

[Graham]
As a result of that trying to attract technicians if you’re not charging a decent price is very difficult. So the price is then driven up again. So yeah. You either find unskilled workers doing your work for cheap, or you to find skilled workers is now very difficult. Cause we haven’t trained our own for a long time.

[Jaz]
But what I, what I found is on the main dentist Facebook groups, I found that a lot of the comments and threads are like, where is the best price or where is the cheapest to get X, Y, and Z for lab work? That’s the kind of conversation that’s happening.

[Graham]
Yeah.

[Jaz]
I also see where is the best. So I see two different polar opposites. I see where is the best price is not an issue, price, tell me where’s the best. And the other half is like, I need the cheapest, but still good. I want cheap but good.

[Graham]
It all depends on your business model. At the end of the day, I think, you know, it’s not down to what it is you want from this, that, or the other. It’s your business model that counts the most, I think, when you’re selecting anything and then you adapt to that and you try and find the best you can for that budget. So yeah.

[Jaz]
When you were working in a bar and in the nights industry and you were working with people, you were seeing people all the time, people in your face, and now I look at your lovely little laugh.

It’s as little are you watch a chocolate in the corner there and just you and your phone do WhatsApp, voice messages and waxing up and stuff.

[Graham]
Yeah.

[Jaz]
Is that like a big shift in change in terms of your working life?

[Graham]
It is a big change, but I’ve gone through a lot of big changes. Like since having my first child, I had struggled with addiction for a while at points in time, a little bit about myself.

[Jaz]
Mm-hmm.

[Graham]
And I’ve managed to overcome that and this has been part of my journey and I now enjoy my own company. So yeah, without the bar industry, I wouldn’t be who I am today. I learned how to run business. I learned a lot about people, I learned a lot about communication, how to be a host, and kind of got a bigger picture of who people are.

I try not to take away the humanity from the business side of things as well. So yeah, it’s kind of a difficult balance.

[Jaz]
What I love about you, Graham, is I said it already, the communication side. I think, I just think I would really urge all dentists who care about their restorative dentistry, who are really aspiring to be the best they can be.

You won’t get nowhere unless you’ve got good lab tech on your side. I genuinely believe that, that some advice that was given to me when I was one year qualified by Raj Rattan is an average dentist with a good lab tech will really do well.

[Graham]
Oh yeah, for sure.

[Jaz]
And it makes a huge difference. So I think I’m grateful to have you in my sphere and grateful to be able to work with you as well as some of the other labs I’ll work with.

Like shout out to Precision Dental Studio and Alan and the team there. I use you guys for different things. I know where me and you get along well, like your vertical preparations. We’ve talked a lot about that on calls and WhatsApp stuff, so you’re my go-to guy for that. A lot of my splint work that I do will go to another Graham, so if you are a technician wants to work with me, your name has to be Graham. Fun fact.

[Graham]
Alan.

[Jaz]
Yeah, Graham, that’s true. That’s true. So, look, we’re gonna, firstly thank you for sharing some admissions there. You know, I really appreciate the human side of that and that’s really good of you to do that. I think it really makes, humanizes us and I think we need that in life and work and stuff.

So I think that’s really great. Another feature about you, I’m gonna go and just find those questions that were on the group that the Protruserati already had for you. Some of these are like my own little questions and some of these are from everyone. So, let’s start with some of the things that I was talking to you about as we were coming up the steps, which was, you took me to the plaster room and you said that’s hardly being used nowadays because a lot of your work is now gone digital.

So I said to you, well, you know, I’m very digital, but when I get like a bigger case, multiple units, I still pick up the polyether. I still like to do that. And you are like, well, you know, it depends. So where do you lie on this? The benefits or the advances of analog or do you really think that actually the advantages aren’t really there of analog anymore. So it’s that you read can do everything digitally. Where are you on that scale?

[Graham]
It just entirely depends on what your technique is with both. So analog impressions, I dunno if you’ve noticed, but if you’ve ever had an analog models for myself, I do not split models.

So it’s always a solid model single dies. So single dies come out the first pour cuz that’s the most accurate pour. And then the solid model, master model goes into that. And what I find with that is you’re not stripping away the gingiva off of your model so you know where the gingiva actually sits and you’re not, you’ve got more an idea of emergence profiles.

So we’ve got that and then we are not spliting the model. So we’ve got no expansion contractions, sort of like differentials there because you’ve actually just kept it as a one piece. So you can wax everything, wax up little copings on your single dies, transfer them over to the master model, finish your wax in, transfer them back, seal the margins, reseal the margins, then take it off, invest, press, get them back, and hopefully crossover. Everything’s great.

[Jaz]
Did you like find it?

[Graham]
I find the same with digital. Okay. So if I’ve got a large case, sometimes I might design the models twice. So I’ll design the first one as a solid model and then I’ll design the second lot, get removable dies and I’ll print them separately.

[Jaz]
Or let’s just explain what this is, because there might be some like young dentists who just, this is all in a different language that for you, you know, being lab tech.

[Graham]
Yes.

[Jaz]
A lot of people probably don’t know what a solid die means. So let’s just break it down. Okay. What do you mean by a solid die? And then what do you mean by split? Just, just really dumb it down for us.

[Graham]
So a die is basically the prep. So you’ve got prep that you can remove from the model that is a die. So all of those removable parts of dies. When you’ve got a solid model, it’s an unsplit. No saw cuts, no saw lines or anything that’s moving within the market.

[Jaz]
So you like to work with that unsplit model where the full model without the splits without the dies, right, with individual dies, yeah. And do you think that if someone’s working with the technicians are using, sending back everything on a die, so everything’s split, is there a disadvantage though?

[Graham]
Well, yeah, cuz when you put a saw cap through your models, you then got expansion, contraction.

And as much as people say, oh, I put retention slots and this, that and the other, when you take a model out and put it back in, dust on the undersides of things and little bits of wax gets stuck and it doesn’t always go back where it should exactly. Because obviously things have expanded contracted, so you get little discrepancies between your contacts and sometimes even occlusion. Whereas if you’ve done it on something that doesn’t move, then it hasn’t moved.

[Jaz]
It’s just more moveable bits and I can completely get that now. That leads us very nicely to it. Another question, which was on the group, one of the questions that we had was veneers, like we mentioned while we were walking up the stairs about, we actually mentioned, squeeze a lot of conversation, geeky conversation and just in that one small stairs, but veneers, a lot of people have a bias towards impressing towards analog because they believe that to get the highest quality of veneer work back from the lab tech, it has to be analog. What do you think about that?

[Graham]
It depends on what type of veneers you’re looking for really. So feldspathic, obviously you can need to produce an analog impression because you need refractory dies. I don’t offer that service here, unfortunately.

[Jaz]
What is a refractory die?

[Graham]
A refractory die is a die that you can stick in your furnace basically. So it’s a heat resistant material that you can layer your ceramic on, putting the furnace with it.

[Jaz]
And so you don’t do that because you don’t work with that anymore?

[Graham]
I just don’t work with that type of process. My prices don’t reflect that type of work. So, I like to consider myself quality laboratory, but I’m not really a top end laboratory. And I don’t cater services towards that. That type of restoration.

[Jaz]
But you do veneers, but you do mostly like, lithium disilicate. Pressed?

[Graham]
And pressed and layered

[Jaz]
Okay, now we’ll do a little deviation from that. So, we established that, okay, if you want to do a feldspathic, then you need to really go analog, right?

[Graham]
Yes.

[Jaz]
But if you are doing a big case, lots of crown preps, traditional chamfer, shoulders, vertical margins, et cetera, do you feel there’s a difference in terms of the quality that you can produce or the quality, the end result, the end product between analog and digital? What I’m really trying to say to, you know, is digital there yet?

[Graham]
Digital is there. I do believe printers these days have made massive advances, but it also depends on what printer the lab’s using, what settings you using, you know, and if you are outsourcing your models, are you really getting back what it is that you want? You know, are the dies you know, retentive enough as they go in? But the more times the dies come in and out of the models. The more loose they become, the more give they’ve got, the more inaccurate they become.

[Jaz]
But you just said, and I know the answer, but I’m just saying everyone else. But you said that you don’t like to work with individual dies because you like the whole model to be together.

Therefore, it’s a Geller type setup, right? Is that the right term for it? Is that the right term? When you can actually take the prep out, but the model itself is still the same? Is that what you’re referring to?

[Graham]
It’s just a scale model.

[Jaz]
Yeah.

[Graham]
Yeah. You’ve still got removable parts.

[Jaz]
Yes. So, in case someone got confused about you take something in and out. When Graham sends my work back to me, if there’s multiple units, for example, or even single unit, the model is a whole, there’s no splits, but you can take the preps out.

[Graham]
Yes.

[Jaz]
And that’s unique to digital, right. In that way.

[Graham]
No.

[Jaz]
It’s easier?

[Graham]
You can set that with analog as well.

[Jaz]
Is it a lot more harder to do that?

[Graham]
It takes a bit of tweaking to get your parameters right and every single sort of type of tooth. So my settings for getting a molar in and out of a model will be different to an anterior tooth coming in and out of the model because of just like the surface area that comes in and out of the model and the friction that’s caused there.

So yeah, there’s a lot to think about. It’s a minefield and obviously if you do choose to use that type of model system, then the more you take the die in and out, the less friction that’s there. The more give that’s in the model and the less accurate it becomes. So like I said, sometimes I print two dies to go into one model. One can come in and out, one just sits in there.

[Jaz]
And that’s like the master where you check everything. .

[Graham]
Yeah. Master.

[Jaz]
Yeah. Okay. Very good. So the whole debate to summarize, you do feel that digital is there for like feldspathic kind of veneer work? Maybe? Yeah. We still need analog, but for most other work, for even for my rehab kind of stuff, you’ve got clients sending you all digital scans?

[Graham]
Yes. So I’m getting all digital scans and had good success so far.

[Jaz]
Because, I haven’t made that leap to full digital. I’ve got like more than maybe eight units. Okay. Not that I’m doing, I’m not prosthodontist, I’m a general dentist, but when the more units I have, the more reason I’m gonna go for analog.

But that might be changing and I think, you make a good point that nowadays digital is really great. So yeah, it was actually, Cheng was your question. What percentage and one of the things that you mentioned, what percentage of analog impressions are excellent?

What percentage are acceptable and what percentage are unusable? Now obviously you’re more digital now, but based back on your time at Kings and your previous sort of reincarnation, what kind of quality of impressions are we getting?

[Graham]
Okay, so let’s take it back to when I came back into dentistry.

I worked at a predominantly NHS kind of driven laboratory out in Canterbury. The boss was a really nice guy, but the work that we were getting from dentist was kind of slap dash, you know, that you couldn’t really see margins. No one was using cords. And sometimes you’d go back to the clinicians say, look, this isn’t really good enough.

They’re like, do your best. You know, and it’s just like, okay, well, okay, I’ll do my best. You know? So, and then even when you do your best, sometimes it’s not good enough, it comes back. It’s like, well, I did say. So I’d say the percentage of success with impressions and digital is again, based on a business model.

So if your business model is high end, sort of like top quality restorative work and you’ve spent a lot of time as a clinician on your work, refining what you are doing and taking nice impressions or nice scans

[Jaz]
And long appointments using they’re not short appointments

[Graham]
Using cords, then your success rate is much higher. Whereas if you are cutting corners doing knife edge margins that are not readable and you know, just doing a quick scan without checking and there’s a lot of people who still don’t check their scans even with top, top end work, you know, find that people aren’t quite checking their scans thoroughly enough and you know, there’s a bit of moisture somewhere and it’s caused a bit of a defect in the scan data and I can’t then extract the die with the margin intact in areas.

[Jaz]
And you’ve sent me a WhatsApp image when I’ve done that before.

[Graham]
Yeah.

[Jaz]
When in one distal corner. And it is good. It’s great to be able to work with the technician who will send you your little minor clock ups. Right. It’s great to have that and I think, I really appreciate that. I think more technicians should not be afraid to message that dentist like, oh look. And, the screenshots you send, the photos you send, I think that is wonderful to help improve us.

[Graham]
So look, a word of advice is always check your impressions. Always check your scan it, you know, an extra 20 seconds could actually save you an appointment.

[Jaz]
So the advice I would also give to dentist is if you’re new to digital, a lot of people who’ve been in the digital game for long enough, you guys know this already, but if you’re new to digital, remember that for digital actually you need a slightly more aggressive retraction compared to analog. Cause with analog impressions can seep into the nooks and crannies, right?

The wash impression can seep in. Whereas if the light can’t get somewhere, it can’t record that. So I’ve found that I need more aggressive retraction when it comes to digital to get an acceptable model.

[Graham]
Yeah.

[Jaz]
I dunno what you found with that. Do you feel as though when you see some digital models come back and you feel as though, okay, this really needed more retraction. Do you often say that to yourself?

[Graham]
Sometimes, yeah, sometimes I don’t. And sometimes you’ve already told the person three or four times and by the fifth time, you know they’re not really gonna change. So, you know, you start letting things slide as a technician, because you touch your time, do your best, you do your best.

You know, there’s only so much advice you can give somebody before it then becomes just an everyday practice that’s how it’s kind of gonna be. And then you put up with it for a little while and then you’re sort of like, after a few months you might just drop that little nugget again, just hopefully plant a little seed in their brain.

Like, do you remember talking about this? And it’s like, oh yeah, yeah, yeah. I think you’ve gone away from doing that. You know?

[Jaz]
But it’s good that you do that. Technicians are your colleagues might be afraid to say that-

[Graham]
Badgering people is bad. But if you can kind of just drop little seeds every now and then, hopefully people will start to realize, actually, I could be doing this better.

[Jaz]
I think one thing that dentist can do right now, not even tomorrow, right now, pause this episode and do this. If you don’t have your technician on WhatsApp, get your technician on WhatsApp, firstly. Secondly, WhatsApp from the following VO voice note saying, ‘Graham, if you find that I am slipping in my standards, or if there’s something I can improve, please tell me. I’d love to know. I welcome any feedback. I take criticism very well. I really appreciate to grow as a clinician with you as a technician.’ If you say that to a technician, wouldn’t they feel like much more at ease to give you more feedback? Right?

[Graham]
Yeah. Yeah, for sure. And I ask the same with my clients. If they find that my work is slipping or it’s not right in some sort of way, and it’s like more than one occasion, please tell me and I can do something about that.

Or we can take a look at what we are doing as a whole. Because sometimes it might be the fact that you’ve changed a material that you are using or you’ve changed the way that you are temping or it could be anything. Just get down some nitty gritty, get to the bottom of it straight away, nip it in the bad, and then hopefully we’ve got no problems.

[Jaz]
Awesome. So firstly, Zane, Risby, sends his love. Okay.

[Graham]
Hi, Zane.

[Jaz]
Bikram nice to CMS from you, buddy. Bik’s, fantastic dentist. I’ve seen a lot of his works. Brilliant. To break contacts or not to, for veneers, like to me, that’s more of a clinical decision making, I think. But in terms of, for you, like if every veneer prep came back with a broken contact, perhaps it’d be an easier thing for you. I don’t know. Where do you stand on this?

[Graham]
As far as I’m concerned, getting contacts, right with veneers is a nightmare. They are fiddly, they moved, they pop off the models every time you’re trying to adjust the contact. So for me, breaking contacts is a bit of a pain, so I prefer it if you didn’t as a technician.

[Jaz]
Really? Okay.

[Graham]
For ease of doing a restoration. But I would say it depends clinically on where the contacts are actually are in your patient’s mouth. If we’re looking to realign things and how it’s gonna be realigned, obviously also, are we gonna have enough room for the restorative work that’s needed or the quality of restorative work that’s needed?

Because if you are doing a lithium disilicate, for instance, if you’ve got a full contour, then you know you’ve got a certain amount of emax that’s minimal. But then if you’ve got a dark core, you need more space. And then if you’re gonna layer it, then of course you need even more space. So it just completely depends on the case by case.

[Jaz]
That surprised me a little bit because I thought, in my mind, I thought you might have said, I prefer broken contact cuz then give us the freedom to recreate everything. But actually you made raise a good point that actually it’s so fiddly to actually recreate the contacts that if the contacts of that-

[Graham]
For ease of use. It would be great if I’ve never had to touch a contact.

[Jaz]
Yeah.

[Graham]
My job is to do that. But if you’re not gonna break contacts, then the shape of the veneer prep is obviously, and the margin is kind of paramount. So you kind of need to come round the contact and go underneath into the cervical and kind of break that area down.

And that allows the technician to gain that nice emergence profile. Especially if you wanna try and close any black triangles whilst having that contact stay. If you can understand what I mean.

[Jaz]
Just rephrase it in a different way. Cause I’m trying to envisage what you’re saying as well. Do you wanna draw something? I can show it and I can describe it. Okay. So Graham’s now, for those listening, right now he’s pointing and he’s pointing to the mesial of an upper left central incisor. And what I would refer that to is the interproximal elbow, isn’t it?

[Graham]
Yes. That’s correct. You need to go into the interproximal elbow. In order to not break the contact. And literally it is just the contact you’re leaving.

[Jaz]
Yeah, you’re leaving just the contact area only. But even then, you know, contact areas aren’t huge often they’re just minimal there. But it’s important to prep that bit to allow you to cover that bit because if you don’t, you have that scenario where someone looks at the veneer, the side, they still see the prep and then they still like a discover-

And you get a discoloration over time from your bonding.

Yes. And you wanna hide that, that margin as best possible cuz yeah, margins do stain over time. So, yes. So great point well made about that. Now here’s just a technical question is if a dentist sent you some veneer preps and they haven’t broken the contacts and let’s say they’ve scanned it, then how do you create the digital dying models whereby they’re sort of you could take the prep on and off cuz don’t you have to then digitally make a split or something, right? And compared to when you used to this analog or is that also a nightmare to do it?

[Graham]
Yes, it’s a nightmare both ways. And it’s another reason why I’ve always chosen my method of doing things because with the analog, you’ve gotta stick your saw blade through, and by the time you’ve stuck your saw blade through, you’ve already taken off 10 microns of that margin.

So what I would do in this scenario is I’ll pour up two sets of die models and then I’ll just take every other and trim them out.

[Jaz]
Yep, yep.

[Graham]
It’s a bit of a prolonged process for me, but I know it’s right.

[Jaz]
But digitally it’s the click of a button. You just set your line and then it will just print it in that way.

[Graham]
It’s still difficult sometimes because if the margins are that close together, you’ve still got discrepancy there. But at that point, that’s when I’d switch to the solid model, single die thing and I would then do three designs of the models on exocad.

[Jaz]
Okay, cool, cool. Maybe if you’ve got some the show later, I can use my Sony camera and go around and make a extra feature to add to that.

But that’s a really good question. Thank you Bikram, best material for masking discolored teeth anterior. So your clients that send you photos of discolored teeth over the last few years, what material are you finding has given you good result? Like recently I sent you a case whereby we use MO or HO? Did we use HO or MO in the end for these crowns and veneers?

[Graham]
I do try not to use HO.

[Jaz]
Yeah, can you, I think you can use MO. What is HO for those dentist, dunno what is HO?

[Graham]
It’s high opacity. So basically-

[Jaz]
Lithium disilicate.

[Graham]
Yes. So it’s an ingot, high opacity ingot, Lithium disilicate. So basically it’s just masks things with very, very minimal thickness, but it kind of has a tinge in color that isn’t very nice to work with.

So the background itself. Should I say is not very aesthetic. So if you haven’t left enough room for some nice layering on top and the patient wants it to be in line with all of their teeth, then you’re not leaving yourself much of a chance to get-

[Jaz]
A set of compromise.

[Graham]
Yeah, it’s aesthetic compromise. So depending on how dark the actual tooth is, so unless it’s actually black or gray, then I tend to try and use the medium opacities and they can block out about 0.5, 0.6 mil. And then I’ll try to layer on top of that. It just allows me more scope. It’s much brighter, it’s more fluorescent and you tend to get nicer restorations using those.

So avoid HO if possible, it is the last possible resort for myself. And then also you’ve got zirconias, if you’ve got a crown and you can use the high opacity zirconia stones, which are quite old school now. They’re very hard. , but you can layer on top of them. But also now there are liquids you can use just to kind of opaque the internal surface of zirconias.

And as long as you’ve got a decent thickness, it doesn’t really affect the shade or the color of it because if it is thin still it can affect the shade because it just shines through the bright white.

[Jaz]
So the misconception that zirconia will block out everything underneath, you can still get some shine through with zirconia, right?

[Graham]
If done properly, no, but what I’m saying is you can get shine through of the O layer, so, which is quite bright. So if you are going for like an A three and you’ve put this white layer inside an opaque and block out your metal core, then that can then influence the A three and actually make it look more like an A 1.5.

Even though it looks A three on your shade tab, when you send it out, when you put it in the patient’s mouth with all the lights, reflect differently. It actually looks about a shade and a half lighter. So, it’s hard to get it right with any material, but yeah.

[Jaz]
What’s your bias? Zirconia, lithium disilicate when working with clients who send you discolored teeth in terms of you being able to deliver?

[Graham]
It depends on where it is in the mouth. Okay. So if it’s anterior, I prefer to use lithium disilicate as long as there’s not lots of space around the prep. So if the prep’s very small and there’s lots of space, I would probably say go for zirconia if possible. If there’s enough, you know, retentive sort of form there.

But obviously then you resort to emax, but then you looking at MO ingots, HO ingots in order to block out the light so that they don’t look gray.

[Jaz]
Well you mentioned emax, but I know that you’ve actually moved to LiSi.

[Graham]
I moved to LiSi a long time ago, so I used two types of lithium disilicate. I used the GC LiSi. I find it’s a bit more color stable. It’s got a bit more fluorescence in it than emax. And I also use, VITA AMBRIA

[Jaz]
okay.

[Graham]
Which is a zirconia-reinforced lithium disilicate can get finer margins using that material.

[Jaz]
But you’re no longer using emax product by Ivoclar?

[Graham]
I still use it certain occasions.

[Jaz]
Okay.

[Graham]
But yeah, it’s not my go-to.

[Jaz]
Okay.

[Graham]
So like if I’m gonna match in a restoration that’s already done in emax 10 years ago, I’ll use emax. If there’s a certain shade that somebody’s looking for, then I’ll order some emax in for it. You know, like if someone wants B4 and the patient has really high demands and they’ve chosen that color and they’re gonna want nothing but that color, then I’ll have to order that in because, otherwise I’m just setting this up for failure.

[Jaz]
Yeah. For those maybe younger dentists who, you know, the reason I mentioned this is because lithium disilicate is the material, but then you’ve got, you know, Ivoclar does eMax. GC does LiSi. I didn’t know that. Vita with Ambria. There’s lots of different brands.

[Graham]
Yeah.

[Jaz]
Even with zirconia, there’s like lava. There’s Kanata, is it? Japanese?

[Graham]
Yeah. Katana

[Jaz]
Katana. That’s it.

[Graham]
There’s vintage Press, which is a shofu

[Jaz]
so this is Shofu lithium disilicate

[Graham]
this is Shofu lithium disilicate

[Jaz]
I didn’t even know that.

[Graham]
This is Ambria

[Jaz]
That’s VitAmbriayo. Yeah.

[Graham]
This is LiSi Press.

[Jaz]
Oh, lovely.

[Graham]
And of course you’ve got your classic, original emax.

[Jaz]
Oh yes. The OG emax. Cool. All right. Love it.

[Graham]
There’s lots and lots to choose from, it’s a minefield and they’ve all got their pros and cons. Some are harder than others. Some have more fluorescence than others. Some you can fire more times than others without losing.

[Jaz]
But LiSi, I think you can fire more times without losing. I think Emax grays a bit, is that right?

[Graham]
It does gray. The microparticles are actually slightly bigger than with GC LiSi.

[Jaz]
Cool. Amazing. Okay, next question from Zhe. Zion’s got a couple of questions. So, Zik, man, I love you so much, man. I love your work that you do produce. It was great to meet you in Porter when he came to the vertical preparation course. You’re top guy. Thanks for sending this question in. So, just start with the easier one. What information, it’s kind of bigger picture. What information do you require for an upper anterior single crown?Just the basic information that you require and what other information that is desirable for you.

[Graham]
So I think at this point, photography is a must. You can’t just send me a shade unless, like, literally you take the shade and it matches exactly a shade tab. So if it matches exactly a shade tab, I will accept that A3

[Jaz]
the shade tabs are acrylic, right?

[Graham]
Yeah, but maybe not, because at the end of the day, this is where you still really need a photograph as a technician to start anything, because the enamel is always different. Where the enamel starts on the tooth is different on every patient.

So some tooth have got high chromatic content or high value content. So it’s the brightness and the contrast in the tooth of color and the light that goes through it. So the translucencies can be different. So cross polarized photograph.

[Jaz]
So this is a filter. So dentists out there, so firstly, apologies because I didn’t really make a big enough deal of this as I should have, because to match a single anterior, whether it’s upper incisor or lower incisor, is the most difficult thing in dentistry.

Right? That’s firstly, I didn’t build it up enough that this is really tough. And that’s why you know, Graham mentioned the importance of photography and cross polarizing filter is something that you can get on your camera. I’ve got one but I’ve got one by accident years ago. And it removes a specular of flash so you can see the details and so that is wonderful I think. Do you use the eLab protocol? I think I must ask you the last time.

[Graham]
I don’t use any protocols like that. I just haven’t got the business model from it.

[Jaz]
Yeah. But you see the different images that they’re saying and cross polaroid you find that helpful, so that’s good.

[Graham]
Yeah. Cross polarized is helpful. Try not to use a ring flash. Try to use a dual flash. Because you know, you get the shine back from the teeth. Especially with a ring flash. So try and use a jewel flash.

[Jaz]
Now if someone has a, done mentioning someone has got a ring flash only.

Like for me, I have my jewel flash, but it’s sometimes annoying to change. Might even get a second camera just for that reason. But, one thing you can do is you can detach your ring flash and just take a photo with the flash from the side. It gives a technician a different perspective.

[Graham]
Great tip. Yeah.

[Jaz]
It’s a really good thing. And a couple different sides from the bottom. From the side. Takes you a few seconds to do. We’re still using your ring flash.

[Graham]
Yeah. And it also helps establish surface textures.

[Jaz]
Absolutely.

[Graham]
And so, yeah, photography and the patient smiling, just how that tooth is looking in the mouth, how they smile is also a key, you know, where that tooth’s gonna sit on the lip line.

[Jaz]
Yeah. And to get the bigger macro features of the smile to get your hub, to get your anatomy right. So obviously the primary, secondary tertiary anatomy, so to copy everything in the adjacent teeth. But in terms of getting, cuz the real difficult thing here is the shape you can copy. Right?

It’s getting that shaded recipe correct, right? It is the trickiest bit. And, very often when we’re doing cases like these, tip to dentists is charge more. You just have to charge more for an upper anterior single unit crown. You must, must, must charge more. And I would imagine Graham, that you are charging more for that as well.

[Graham]
Well if I’m layering it, yes. Yeah, for sure.

[Jaz]
Yeah. And then the reason we need charge more is because we don’t do this as a one, you know, prep and fit you actually build into the, you know, call it business models. The term you used a few times now is you tell the patient there’ll be a first try and maybe even a second try and need to build that into the fee.

That’s why it takes a long time. Now, if it’s perfect that try and visit then fit it, great. But you know, I know that these can take 2, 3, 4 sometimes, depending on how demanding your patient is, it can take a lot of goes at it. So good photography, micro aesthetics and macro aesthetics, different flash settings, cross polarized photos.

[Graham]
Yes.

[Jaz]
Is that everything or is there anything else that you wanna pass on as advice a dentist who nail single anterior unit?

[Graham]
So your actual shade tabs. So your position of your shade tabs in the mouth, they must be in the light and you must be able to see the shade tab clearly against the adjacent to the one that you are gonna match is the one that you’re actually shade taking to.

So it needs to be close to that and not just one shade. Show me the closest two shades, which you think that match closest to the tooth. Now, so for some of my clients, I do actually provide a set of shade tabs that match my materials for high aesthetic work. And I ask them to kind of pick out what they see all of the colors that they see, send me the photographs and then I’ve got the basis for what I’m actually putting into them.

[Jaz]
It’s calibrated because you’ve got the same exact shade guide. So I like the idea of calibrating your shade tabs with your technician. I think that’s wonderful. I think we spoke about it last time as well actually, but it’s such an important topic. And, just to add onto that, if you’re using a shade tab photo, if you have the shade tab, two or three millimeters in front of the incised ledge like labial.

Right. And you’re taking a photo, the light reflects differently. So I make an effort to, whether it’s whitening photos or shade photos in general to make sure that my shade tab is at the same level as the tooth I’m taking photo of, so that the lighting is gonna have more chance of being similar on that tooth.

[Graham]
Mm-hmm.

[Jaz]
Just a little clinical point to make. Anything else on shade matching before we move on to the next question.

[Graham]
It’s a minefield.

[Jaz]
It’s tough isn’t?

[Graham]
Getting everything right all the time is impossible.

[Jaz]
Yeah.

[Graham]
It doesn’t matter who you are, how good you’re-

[Jaz]
Manage expectations.

[Graham]
Manage your patient’s expectations, you know, actually try and sell it as we might not get exactly right. You know, try and manage-

[Jaz]
I say, we’ll not get it perfect. There’s no such thing as a perfect, I’ve never done-

[Graham]
Make their expectations low. And then, if you perform highly, then they’re gonna be very happy.

[Jaz]
Yeah. Top tip there, Zahid’s asked another question, and this is because there’s a string between little discussion on the Facebook group between Cheng and Zahid about getting contact points, contact areas on like single crown. So he says, how do you overcome contact point issues with digital as opposed to stone, stone models for single crowns? And then Cheng was like, well, what issues are you having? And, Zahid was like, well, my lab having issues with sectioned printed model being a little bit more flexible than a rigid stone model.

[Graham]
Yeah. We covered this earlier.

[Jaz]
We covered that already. And then what he’s having is that when he’s getting things back. The contacts are too tight and he’s having to adjust the contacts a lot of times. Now, I’m not shy, I do a check with the floss and if it’s proud, if the floss not going through, and sometimes, I don’t tell you this, but a few times comes back and I do an adjustment.

I’m totally cool with that. I expect to do that because you are never gonna nail it every single time. A lot of time your work occlusion is brilliant and contact’s very, very good. So a lot of time I have to touch your work, but I think the worst thing for a dental student, especially young dentists, many years ago, you put it in and it’s not fully seating where you haven’t detected it because you haven’t checked with floss.

So these little basic checks are really important. But I guess the question I wanna pitch to you is any advice you have to other technicians or dentists in terms of getting the right contact points? Or what you do cause you do a good job, what are you doing differently that, you know, why are other tensions struggling maybe?

So basically you’ve gotta set yourself up for success from the start. So your models are the basis of everything that you do, get your models correct, print out a second set of dies, ones that aren’t gonna start wobbling. So have some that are fixed in the model and work on a master for margination and anything that you’re gonna do off of the model.

[Graham]
So I know some technicians, they like to take the die out and they work around the die and they twist, you know, if they’re doing any layering or marginal work or anything like that, they like to take it in and out. They like to have that freedom and I used to like to have that freedom as a technician until I worked at it was Lab 39 in Harley Street.

And I started learning a lot about the model systems and they still work with split models themselves. But when I set up true form dental with a guy called Lee Stringer, it was mainly Lee at the time, but we set up on Harley Street and he taught me the way that I now use. And I just happened to agree with everything that he had to say about it.

And I was just like, do you know what? I’m gonna incorporate this. It saves me time, you know, throughout the whole procedure. So set yourself up for six success with the model system. And then once you’ve got your contacts right, polish your contact, getting them right and then don’t touch them.

[Jaz]
How do you check-

[Graham]
Every time you fired them, I don’t touch them. When you glaze things, glaze around it. Don’t touch those contacts.

[Jaz]
Once you’ve got the contact how you want, don’t touch it. Make sense. What are you doing to check that this is the level of contact? Because to floss through a stone model is different to flossing in the mouth. What kind of checks are you doing to see if you’re happy with your contact?

[Graham]
So I use shim stock.

[Jaz]
Mm-hmm.

[Graham]
I actually use a 32 micron shim stock.

[Jaz]
Okay. So what are you hoping to see when you put your 32 micron shim stock in? You put the crown on and they’re pulling, what do you wanna see?

[Graham]
So I want to see it, I want to feel a slight pole.

[Jaz]
Mm-hmm.

[Graham]
Just a very slight pole.

[Jaz]
Like a drag?

[Graham]
Yeah. Slight drag. Nothing too-

[Jaz]
It’s not too loose.

[Graham]
Not too loose. But not too tight either.

[Jaz]
Yeah.

[Graham]
It’s hard to gauge. But once you get some feedback from your client, that was nice, you’ll know exactly what it is you’re looking for.

[Jaz]
And I guess feedback, feedback, feedback, until you refine your protocols.

[Graham]
So find a couple of dentists who are willing to give you the feed for every single case for a few months. And then hopefully by the time you’ve finished that feedback, you’ve tweaked everything and everybody’s happy.

[Jaz]
Mm-hmm. Now, clinically, I’ll just talk for a minute. Clinically what I’m doing to check the contacts is firstly when I try the crown, is the margin seating all the way, the margin seating all the way. That, okay. The contact will not be a potential reason to stop your margin seating.

So if the margin’s meeting all the way, I know that, okay, it, it’s not necessarily that the contacts are so tight that it’s not allowing you to even seat the crown. So that is the first thing. Then I’m checking the floss. Can I get floss through? If the floss is too loose, which never happens. This rarely happens.

So usually with technicians I work with are not having this open contact issue, which is thank goodness for that. Am I able to take the floss through now? Sometimes so tight, I can’t get floss through. I know I’m too tight. Now what I used to do is I used to take off the crown. This is the way my consultant taught me at a hospital is I used to put I think it was like 40 micron arcticulator paper in red arcticulator paper, put the crown in and then pull just like you are on the model.

And then the problem with that is get gets really fiddly, you know, one hand in the mouth. Okay? And, you know, the first time the consultant showed me, the crown fell out into the patient’s mountain. And so my little joke I make with every patient is, if I drop it, don’t swallow it and they have a little nervous laughter, but I mean it to them.

[Graham]
Okay. Yeah, for sure.

[Jaz]
It doesn’t happen very often, but, you know, they need to know that. So, I switch from that to something else, which is what I created. A doctor, Ricky Bophal crosses on his top guy, and essentially, instead of now putting the articulating paper in and then seating the crown, the mouth and pulling, I’m actually coloring the red arctic paper on the floss.

And now I’m forcing the floss through. And wherever it’s too tight, the contact, the red articulating paper is rubbing off on the contact area. Bullseye. That’s where I’ve gotta adjust. So then I will usually get like a yellow stone or something, just polish a bit. I’ve got my ceramic polishing burs and whatnot as well. And I’m just checking. It usually takes minute and minute half to get it perfect.

[Graham]
Yeah.

[Jaz]
And then I move on. So just a little clinical tip for those dentist who may be struggling to find a way to check their contacts.

[Graham]
But obviously like from a clinical point of view, it could be coming from what you are doing as well, the way you temp things paramount. What material are you using? Has it got an expansion to it? Are you actually gonna be pushing those adjacent teeth further out so that when that comes off actually they spring

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Which type of sedation is best for my patient? Are Temazepam tablets good enough? Is that even allowed? How can I safely provide Sedation in my practice? We are joined by the calming tones of Dr. Roy Bennett who busts some myths and guides us clinicians on Sedation in Clinical Practice.

https://youtu.be/F6tf6HqqxD8Check out this full episode on YoutubeDownload Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Protrusive Dental Pearl: Communicating Risks to your Patient: Be calm and SLOW your pace down when communicating with your patients to EMPHASISE certain words. Becoming a visual educator to the patients is also a really good way to communicate risks – intra-oral camera is the best investment you will ever make.

FocusDent MD740 Dental Intraoral CameraNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

1:07 Protrusive Dental Pearl – Communication
4:27 Dr. Roy Bennett’s Introduction
5:40 Pre-medication – is Temazepam any good?
9:27 GDPs entering the world of Sedation
13:48 Which Type of Sedation, When?
15:12 Level of training required to provide sedation in practice
17:32 Sedation and Clinical Dentistry at the same time?
19:09 Learning Sedation
21:48 How long can we Sedate a patient for? Is it just 1 Hour Max?
23:41 Offering sedation in YOUR practice
25:41 Ideal personality traits of operator-sedationist
28:15 Thing to know about implementing sedation
32:21 Two good qualities that an operator-sedationist should have:
34:24 The “New Drug” – Remimazolam

Check out Dr. Roy’s training site:

Web: mellowdental.co.uk
As a senior clinical advisor – Webinar and Presentations: uksedation.com

UK Sedation will be presenting at the Royal Society of Medicine on the 15th of February on the new drug

If you enjoyed this episode, you may also like another sedation episode: What Every Dentist Should Know About Managing Dental Anxiety with Dr. Mike Gow

Click below for full episode transcript:Jaz's Introduction: What's the deal with prescribing Temazepam as part of oral sedation or pre sedation? Are there any concerns about giving this to your patients or maybe sometimes the doctor, the general practitioner has given this to your patients? Jaz’s Introduction:
And what about deciding whether inhalation station, AKA gas and air versus intravenous sedation is best for your patient, and what is the correct path you have to take to be able to safely provide sedation in practice? These are all the questions we’ll be covering in today’s episode. Hello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast.

It’s not often we do an episode on sedation. It’s quite a niche thing, but it complements some of the previous episodes we’ve done such as the one about hypnosis with Mike Gow. You have to listen to that one. And Mike and Roy, today’s guests are actually really good friends, and it makes total sense. You know, Roy was a fantastic calm communicator. I would feel very safe in his hands as a patient. And that’s what we all want. We all want our patients to feel safe around us, and that come from how we communicate to our patients. So, before we start on this episode about sedation, all those things that I just discussed, let’s get to the Protrusive Dental Pearl.

Protrusive Dental Pearl:So, if you’re new to the podcast, every main episode, every PDP episode, I will share a Protrusive Dental Pearl. One tip that you can apply straight away. And this one is about communication. I very often like to do well communication one and this is not because I am some sort of master of communication.

This is far from it. This is just something that I’ve been very much in tune with myself. I try to reflect on my communication skills and try to improve, and I try to look at other clinicians when I shadow them or when I see them in practice. What can I learn from them? So, the example I’m gonna share with you today is I had a dentist shadowing me recently, and I like to ask dentist, what did you learn today?

What did you gain from today? And she said to me, ‘Jaz, I like the way that when you were explaining risks to a patient, you just slowed down. You just really slowed the pace down and emphasized certain words.’ And through doing that, I think you are a more impactful communicator and patients will remember.

And I’m very intentional when I do this, in fact, after a deep restoration or a really nasty crack, and I take a photo with my intra or camera and after the procedure. I’ll sit the patient up and I’ll say, wow, that was really tough, Mrs. Smith, or make some sort of comment and I’ll also compliment them, ‘Well done. You stayed open really well and I appreciate how still you were.’ Or something like that, and then I’ll say, ‘I’m happy with how everything went, but you do have quite a nasty crack in there. I’m hoping that your nerve will survive, and you won’t need something called a root canal treatment, but in case you do, here are the things that you’re looking out for.

I want you to get in touch with me, if you get a severe throbbing ache, any sleep disturbance due to toothache or just sensitivity that doesn’t settle.’ And of course, I’ll show them on the big screen the photo of their crack, and now the patient has owned their problem is their crack. I’m just the communicator.

I’m just passing on this message. I’m just showing them what I’ve found in their tooth. And I know that in 99% chance that they’re not gonna have any issues. They’ll think, ‘Wow, you know, this is amazing! Jaz, a great dentist.’ I didn’t get any of that horrible pain that you described. But equally, if they do get irreversible pulpitis or get into trouble from this tooth because of the crack, they remember that part of the episode.

In fact, it takes me back to a really good episode we did, which called Consent is Like An Onion, with Shaun Sellars and Zak Kara, do listen to that because Shaun summarized something called the Peak End Rule. What parts of the consultation do patients remember? What parts of an appointment do patients remember and they remember the peak?

The most significant thing of that appointment and the end. So, if you end on a high, and if you’re nice and calm in your approach and you slow down and emphasize and be a visual educator to the patient, you show them the crack, for example, in this example I’m sharing with you, then I think that’s a really good way to communicate risks to your patient.

Main Episode:Now let’s join Dr. Roy Bennett. Talk about sedation for the wet fingered practitioner, Dr. Roy Bennett. Welcome to the Protrusive Dental Podcast, my friend. How are you?

[Roy]
Yeah, really good, thanks. How are you?

[Jaz]
Yeah, great. And it’s great to have a rare sedation speaker. It’s not something we’ve covered that well on the podcast or on that much depth.

So, I want to cover it in a way that’s gonna, those burning questions that we have around the world as dentistry. As I do believe, and I’m sure you’ve seen as trends, and we’ll talk about it, is that. The USE OF SEDATION is perhaps UNDERUTILIZED in various countries, and it’s only gonna go high and higher, but you are the expert in that.

For those who are unfamiliar with you, Roy, please tell us a little bit about yourself as a practicing dentist and yourself as a sedation.

[Roy]
Okay, so I’ve been in practice about 34 years now. I’ve spent about 15 years of those with special care dentistry at the university background. And then I set up my own teaching facility back in 2011 to teach a postgraduates around the country sedation.

Cause as you said, there’s an absolute need for that. And I teach IV sedation. Okay. So, I’ve actually do a little bit of oral sedation, bit of inhalation sedation. And also, I’m quite a holistic practitioner, so I do off hypnotherapy as well.

[Jaz]
Brilliant.

[Roy]
So quite a well-rounded sort of sedation if you like.

[Jaz]
You showed me some videos of someone who, I believe for some reason you couldn’t use IV sedation, but then you were using hypnotherapy and you showed me how relaxed that patient was and so that was really cool to see. So I’m sure we can, even for those practitioners who aren’t using drugs of any sort or gases of any sort to sedate, there are some things that we can perhaps share to help put their patients at ease a bit more. So I’m very excited for today’s chat and so it’s great to hear you’ve been teaching dentists about this kind of stuff. So I’m gonna start with my basic level question before we then escalate to IV and whatnot, is oral sedation. A lot of my patients in the past have obtained Temazepam like oral from their GP.

Prior to the appointment with me, and that made me feel awkward because I was a little bit uncertain about where that puts me in terms of, okay, a patient is technically under sedation, I’m not sedation trained. How could something go wrong? Okay, so I wanna know from you, medical, legally, what are the rules and the laws in terms of me being able to, A) give out Temazepam?

And then what level of training do I need or what are the requirements? And B) that goes along with that. What if the GP gives Temazepam? Am I in still some way responsible for the sedation during the dentistry? Interesting, isn’t it?

[Roy]
Okay. Okay, so let’s go back to basics. Basically, the temazepam is a benzodiazepine, right? It’s one of the family of the drugs, quite traditional in the sedation world that I work in. But you know, things like Temazepam is a premedicant, so it’s pre-medication. It just takes the edge off people that when they’re slightly anxious, okay? Now I prefer my patient to be open with me and as they’ve been with you to let you know that they’ve taken that.

But one thing you’ve gotta know about that is one thing you’ve gotta know is that your consent process then is not valid. If you wanna change a treatment plan when a patient on Temazepam, then you have to go back to when they’re not on Temazepam. So you can’t then launch into a different treatment profile once they’re slightly sedated. If we’re doing sedation on site, we wouldn’t give Temazepam, we’d use oral sedation. So to me, Temazepam, to be clear or Diazepam given by a GP or prescribed by you, would be just to take the edges of somebody. It’s just to relieve the pre-treatment anxiety.

[Jaz]
And do you think it’s a useful thing to- You’re not a fan. Okay. Just coming onto that.

[Roy]
No, I think it’s an adjunct. I think if you’ve got somebody who’s particularly anxious, sometimes they’ll double up on the dose. They may take alcohol with that, but you’re not in control. And I’m a guy in sedations likes to be in control. So when you take a pre-med, you’re sort of fixed into gear.

You can’t go through the gears, you can’t titrate the drug. The Temazepam is a one fixed dose, as it were. And then it’s also dependent on what they’ve eaten, how they’ve slept. what their demeanor is. So it’s, a lot of clinicians will use this, but I’m not a fan because you’re not in control. You’re not controlling the sedation now. So medical legally, I’m not a fan, I have to say.

[Jaz]
Okay. That’s useful to know.

[Roy]
It has its place to give the patients a reasonable night’s sleep the night before. But to be honest, when you get a very anxious, it’s not gonna hit the side that controllability is not-

[Jaz]
So it’s not enough of an anxiolytic it sounds like. And also it does mess up your consent process. So for those listening who do have a patient who didn’t know was taken Temazepam and they come to you and say, ‘I just, I was so nervous my GP gave me Temazepam and they’re kind of drugged up in your practice, then a great point made by Roy that actually you gotta be really careful about changing the course of treatment.

[Roy]
And also if you go outside the remit of what a GP does, which is usually about, you know, two to five milligrams of Diazepam, or 10 to 20 milligrams of Temazepam. You’re really straying into more high sedation levels. So pre-medication, before the procedure or going to sleep, it’s quite low doses. So really those low doses are just gonna just take the edge off people. If they’re really anxious when they come in to see you, that anxiety will still be there in some way. So you might be disappointed as a clinician that hasn’t done what you thought it would do.

[Jaz]
Okay. You’ve done a good job of pulling me off Temazepam. What is the level one, so you know, what is the next level up from that, that you think that GDPs who may be entering the world of sedation could start to do that you feel has its place a more widespread in clinical dentistry?

[Roy]
So one of the important things is to assess the patient correctly. So I use a pre-visit questionnaire, which I send out to the home address. They fill that in. I get a level of the anxiety that they have through the modified dental anxiety score. We get a score, which is more valid, and then I can work out what kind of approach that we’re going to do with that patient.

Now it might be inhalation sedation. It might be a little bit of hypnotherapy. It might be the language you use with the patient. We’re gonna put topical on. We’re gonna look after you. It’s the language that’s really important. It’s a bit like NLP language. Okay. So we don’t use the words obviously, pain, injection, excavator.

We talk about things like comfort, how comfortable you are. We’ll put cream on that will make you feel more comfortable. And then we’ll present the treatment plan and decide which route we take the patient down, whether that’s inhalation, sedation, or just sort of normalistic programming you like. Or we’ll go down the IV sedation route.

[Jaz]
Okay. So it sounds like really in terms of lowest anxiety to highest anxiety, like level one, we’re talking just really good care in terms of communication and being selective of your words and creating a nice calming environment. One level up from that, which might need a bit more investment in the practice.

We’re talking about scavenging and stuff like inhalation sedation. The level up from that would be intravenous. Are all of those that are used in general practice by general dentists or are there any others?

[Roy]
Well, you could use intranasal sedation if somebody’s quite phobic, and you could use some oral sedation, which is onsite sedation.

Not outside the practice, really take a tablet. So they come in the practice and then you would mix an elixia or a drink of benzodiazepine, Midazolam, and that would then calm the patient. Now, if you are gonna go down that route of them having a drink of oral sedation, then they do need to be cannulated.

So you’ve gotta have the know-how and the core of knowledge to be a IV Sedationist to give all sedation. Does that make sense?

[Jaz]
It does. And is it a myth that inhalation sedation is just for children?

[Roy]
Correct. Absolutely. So, I’ll do a myth bust here for you.

[Jaz]
Please.

[Roy]
So basically, I do inhalation sedation right from sort of five-year-olds right up to 95-year-olds. Okay. It’s a really, really good system. It’s a really safe system. When we do inhalation sedation, we’ve always got 30% oxygen flowing through in that background, which is even better than the 21% air that we breathe. Isn’t it? So very safe system, titrateable. So, you can go up and down. As with IV sedation, which is what I like Titrateable, we can dose it to the end point and the reaction of the patient.

So I’m going through my gears, going through the inhalation sedation of percentage of the drug, the sedative of nitrous oxide that we would give so you are safe. Underused in the UK, 50% of American GDPs use it in the states which is amazing, isn’t it? When you go, when you visit the states, you’ll notice every practice or every other practice has an insulation sedation unit.

And why is that? Because the public expect it. They expect that kind level of option or care when they need the treatment. Okay. So it’s an expectation of the American public. So inhalation sedation absolutely underused in the UK shouldn’t just be used in community care or special. So it’s a really good thing.

Sometimes I don’t want to sedate an elderly patient or they’re on certain medicines. We’ll just use a little bit of inhalation sedation to take that impression. If we’re not doing a digital scan, whatever, or they’re just little bit phobic, it’s limitations, if you like, are probably where the patient is extremely phobic or extremely anxious.

And then the inhalation sedation, the nitrous won’t be enough to get them from A to B. So we really do have to go back to what I said at the start, which is to be, let’s assess this correctly. Where does that patient lie in their anxiety score?

[Jaz]
I’m gonna ask you a tough question now, Roy. Assuming all things being equal with a patient, patient A, and patient B, that their medical health history is that they’re ASA grade 1 fit and healthy but they’re slightly different in the anxiety level in terms of MDAS, is there a magic score in terms of, okay, after 21, I consider inhalation sedation not to be effective. Is there a magic score or is it still an art form? Is it still arts and crafts?

[Roy]
Yes. Yeah, it’s a good question. Sedation is an art form. It’s bringing the science together with your personality on the demeanor and the personality of the patient as well. So absolutely, as we always said, in any kind of sphere of dentistry, whether it’s implant dentistry or whatever, there is an art form. It’s that discussion which is pre sedation discussion with the patient, which is critical.

So I’ll always book 20 minutes. I’ll sit down with the patient, not in the dental chair. We’ll sit together, we’ll go through it and we’ll find out what ticks the box for that patient. Where do they lie? Because some patients who are controlled type patients type a behavior probably might resist the sedation and it might be a bit of a sedation failure for you.

So we have to see that patient has to trust you and they have to be on board with the sedation, we’re not gonna do the sedation of the patient because we’re ticking an MDAS score. We need the patient to follow us on that journey as well.

[Jaz]
Got it. So there’s no, yeah, I mean I expected that to honest. I know there’s no magic answer. Magic number.

[Roy]
Yeah.

[Jaz]
In terms of the level of training medical legally required, and if you know about the US and Australia, cuz got lot of listeners from US, Australia, and New Zealand around the world, but obviously I’m sure you know about the UK, but if you know about the world as well, it’d be great to know from you what is the level of training that you need to be able to provide inhalation sedation in practice?

[Roy]
Okay. So, you need to basically do a core of knowledge over one or two days, like the 12 hour CPD, which is didactic teaching, and then you’ve got to be supervised through your 10 cases of mixed variety inhalation sedation. If you are gonna do that, then you would do some assessments as well, just so you’ll have a supervised colleague standing next to you, and then they’ll go through the 10 cases.

So you might take one or two or three days to do that if you’ve got all your cases together or over a matter of weeks or month, and then you will revisit those cases and discuss that with your supervisor. So IV sedation a little bit more in depth. Again, a two day beginner course, core knowledge. And then we need to do 20 courses-

[Jaz]
20 cases, yeah.

[Roy]
20 cases of mixed ability. Again, so from extractions, fillings, or whatever. Okay, so you do need that 20 cases. Now, that just gives you a basic sort of understanding in my view. Then you really start learning as all things in dentistry. You start, you have some failures, you have to accept that, you have to revisit that.

So, but basically, the ISCD, the Intercollegiate Advisory Committee of Sedation in Dentistry 2015, revised 2020. The standards, and that’s what we follow and what the lawyers follow is 20 cases, logged cases.

[Jaz]
Mm-hmm.

[Roy]
Now, when you carry on as Sedationist, you must keep your log cases, the log book in case the CQC ever decide to walk in and say, ‘Oh, tell me about your sedation cases.’

[Jaz]
Oh, that just makes sense. Fine. That’s the lovely, nice, clear guidelines to follow in terms of being able to implement this. I remember doing some restorative cases and then I essentially, I hired a sedation to come to just manage the sedation cuz I had so much on my plate.

I was raising the vertical dimension. It was my early days. I was still, very much engross in my restorative density. There’s no way I could expect to do anything beyond what I was doing in the mouth. Now I’m at a point where I’m a lot more comfortable with my restorative dentistry could I, is it naughty if I’m doing the restorative entry and the sedation at the same time? Or should there be someone else doing the sedation always? How does that work?

[Roy]
Okay. So, my philosophy is if it’s a straightforward thing that you’re doing in dentistry, if it’s a simple thing, if it’s a straightforward extraction, if it’s straightforward restorative, if your head space is not too overused as it were, then go ahead and be the operator sedationist, and that’s the term that you were mentioning there, operator sedationist. Now, if it’s not simple and it’s not straightforward, or the patient is challenging or the patient has some medical comorbidities, or the general situation is a bit more stressful for you as the operator, then I’d always get a dedicated sedationist.

[Jaz]
Got it.

[Roy]
Okay. And that’s what the standards say actually, if things are a bit more challenging, step back, take two steps back. Well, I’m gonna concentrate on my occlusion today. On the restorative, I’ll be placing the implants. My head’s gonna be pretty full. And this patient’s a bit challenging actually. So do you know what?

I’m gonna have a good team member with me. I’m gonna have a dedicated sedationist in who’s gonna take that pressure off. And also that’s best care for the patient as well because we need a dedicated sedationist at the other end of the chair who’s just gonna monitor the patient, look after the patient while you, you can do your excellent dentistry.

[Jaz]
Brilliant. Now, if we dentists start thinking about sedation training, and let’s say they get some cases under their belt, they build their portfolio, they get their 20 cases, and we’ll talk about the end, about how to go about doing that. I’m sure you have a great help that you can give us all. When dentist, maybe your delegates or a dentist that you’ve trained run in trouble, cuz everything’s got some failures. Just like you said, you know, we get failures, I get restorative failures. You get sedation failures and that kind of stuff. What are the most common lessons to be learned for those starting in sedation that you could share with us?

[Roy]
Okay, so I think the first hurdle that most people sort of have to leap over, if you like, is on their first few cases when they are giving the drug. Okay, so giving the drug is via cannula, obviously in the back of the hand or in the arm, and actually cannulation skills is a big hurdle for most people.

So it’s a learned skill. Bit like when we’re trying to find a, you know, second MB canal and a molar. It’s a learn technique, okay? So cannulation. The more we do, the more we learn, the better we become. So that’s a little bit of a hurdle. Second hurdle that we come across is we administer the drug under supervision with our colleague.

But then we say to our colleague, when do you think I should start to numb the patient up? When do you think the patient’s ready? And that’s where the art form from. You’re looking at the patient and saying, ‘Right. I’m gonna say to the patient now, are you okay if we numb up now? Are you ready to proceed?’

And the patient may go, oh yeah, nod or not, and we know we’re at the right level of station. Then what we don’t want to do is jump the situation and the patient be under sedated and then start numbing the patient up and that can dissipate the good effect that we’ve achieved already. So it’s the timing.

The timing of numbing up, the timing of administration, the drug. So that takes a learning curve of sort of five to 10 cases to see that-

[Jaz]
It’s turning that knowledge into wisdom, isn’t it really, Roy?

[Roy]
Yeah, absolutely. And then keeping that patient, you’ve taken the patient to a nice level of sedation and as I say, cruising altitude. We want to keep the patient nicely, comfortable and it might be a long procedure. It might be 2, 3, 4 hours, implants, whatever. So we want to maintain that patient at a nice level of sedation, let the patient learn and become to a nice recovery and a safe discharge. So it’s like taking that patient on a sedation journey.

[Jaz]
One question I’ve got already, Roy, cuz you’ve sparked my interest now, is I had this another myth busting, let’s call it then a misconception that I had. But previously when I asked you about inhalation sedation for adults, that was a previous myth that I had that was corrected and me and Mike Gow many episodes ago discussed that and then we confirmed that. So if you guys haven’t listened to that, Mike Gow episode, it’s brilliant. Roy, you and Mike are good friends as well, so that is nice to hear. Hello Mike if you’re listening. And so another misconception I had with sedation is that, I dunno where I read this, but like the golden hour, the golden 45 minutes once you start IV sedation, you’ve gotta get everything done in 45 minutes. And I actually remember doing restorative cases being like, okay, I’ve got 45 minutes. Prep, prep, prep. Oh, so you’ve actually just busted that myth. So what is the truth there? How can we, how long can you safely go for?

[Roy]
Okay. Okay. So if we think about the drug that we are using, that can have an effect. So if we are using the basic drug that we use in the UK, which is Midazolam currently, okay? Benzodiazepine then, and we titrate to effect and we get the patient in the first sort of three or four minutes at the right level of sedation. We probably, and I agree with you, we’ve probably got a window of about 30 to 45 minutes of peak sedation.

If we want to extend that, then we need to have a bit of experience, and then we need to, I don’t like the word topping up, but we need to add some more Midazolam after about 30 minutes. Okay. So we’re topping up. We’re topping up. But what we have to understand is that patient’s gonna have a longer recovery then.

[Jaz]
Mm-hmm.

[Roy]
Because we’ve added more drug than what we started with. Okay. So now the drug profile is changing. Some of the things that we have to think about is how long can I keep the patient titrated at that level? Okay. Now some clinicians will use maybe a different drug that we can touch on, but which is appearing in the UK, which will give you that top of level continually.

Okay? So there’s different drugs out there, and there’s a anesthetist that use different drugs like propofol, and that’s the continuous infusion, which sort of gets around this problem of the drop up after 30 or 40 minutes. But that’s advanced sedation.

[Jaz]
Got it. Now we’ll talk about this new drug because I see you’re doing lots of lecturing about it, so it’s worth touching on at the end in terms of some nitty gritty details and making it tangible for the dentist.

What this podcast is all about is when dentists are starting out implementing sedation in their practice, what are the hurdles that they have to jump through? Like I’m thinking it’s such a useful thing and I’m thinking already. In my practice, we don’t have anyone that provides sedation and we always have to reach out to someone.

So I think it’ll just make business sense and also how much more we can serve our patients. If every practice had one dentist who was trained in sedation. So what are the hurdles? Like one automatic one I’m thinking of Roy, is that perhaps our nurses then also need to be sedation trained. Is that a hurdle?

[Roy]
Yeah, that’s correct. So there are two route you can go down in the practice. One is that you’ve just mentioned, you’ve touched on, which is you bring in a dedicated Sedationist and that sort of complies with all the regulations and the standards. They would be purely administering the drug and monitoring the patient.

So it’ll be nice for your team to have some core of knowledge, but it’s not absolutely required. So that dedicated Sedationist will take all of that sort of paperwork and sort of administration off you. Okay. The other route is that you actually become the operator sedationist and treat some of your patients. And yes, you would need to have a dedicated nurse who you pick out of your team who you think would be suitable to become the monitoring dedicated sedation nurse.

And she would need exactly 20 cases core of knowledge, and that’s what you’d need. So you’d need, I tend to, if I’m doing operating sedationist in my practice, I’m having me as a clinician treating, and then I’m having my sedation nurse who does all the monitoring dedicated, and then I’ll have my four handed nurse next to me. So I have a good three member team. Okay.

[Jaz]
Got it.

[Roy]
So the minimum is having an operator sedationist and a dedicated sedation nurse, but that then stresses because you haven’t got your 400 nurse as well. So I always say have three in the room if you are the operator sedationist.

[Jaz]
That’s a good rule actually. Yeah. Rule of three. I like it. It’s also same in crown lengthening. Rule of three. But that’s another time to tackle. Roy, is there a ideal personality trait or an ideal type of dentist that lends himself to being a operator sedationist or doing sedation training? Like me personally, I love the idea cuz I like getting people out of pain.

I like making ’em feel at ease. I like to learn new tips from people like you to make my dentistry calmer experience. So I love all that, but equally, I am like, when I’m doing my dentistry, I am like in seven and a half magnification. I’m so engrossed on every enamel prism and every retraction cord and I’m loving it, right? I worry about then splitting my attention to something else. So is there an ideal candidate?

[Roy]
So I think, well, let me take you back in time. The reason I got into sedation was a little bit of self-preservation room. I’m quite an empathetic guy, but in life you’ve only got such petrol in the tank and you can be so empathetic and that can, if you’re being caring individual, you need sort of systems in your practice. You need-

[Jaz]
Need drugs.

[Roy]
Well, not always drugs, but it’s useful to have, isn’t it? So, yeah, so I just needed a toolkit into my bag to sort of approach these very anxious patients that would find me to get referred from colleagues. Go and see Roy Bennett, you know, we don’t wanna do this sedation case, you know, Roy, you can use short.

[Jaz]
It’s a great practice builder.

[Roy]
Absolutely. And we became a referral hub for doing the cases that nobody really wanted to do. So I had to build a very experienced team around me. So it’s not just me, it’s my visiting anesthetist. It’s my sedation nurses that I’ve trained over the years. It’s the receptionist.

Everybody in the team is really important. It’s a holistic thing. It’s a whole team that’s important in giving that patient that journey from being very phobic to being accepting the treatment. Okay. So my mission really is to take them off the drugs. It’s not to be a sedation dentist. It might be of the first few appointments, but if I follow the standards, it’s doing the simple way, simple things for patients.

So it might be to wean a IV sedation onto inhalation sedation, and then hopefully one day just by talking to them. Okay, so that’s the mission. It’s not always about one tick. Everybody gets IV sedation. That’s not the way to do it.

[Jaz]
Well said, and I love that. That’s really good. An individualized approach. And I like, a bit like endodontists, they always tell me, oh, preventive endodontics, we want to do pulpotomies.

You wanna preserve the pulp, you guys you want to, yeah. Get them off the sedation, which is very admirable and very good. I like that very much. Before we talk about the new drug and then how we can learn more. And actually for those whose interest has been peaked by learning, wanting to learn sedation, which I think is such a great thing to offer.

Any other key points that you think GDPs, wet-fingered GDPs out there right now should know about sedation and our patient base and how either something scientific you want to share, or a top tip.

[Roy]
Okay. So, I would all say that I think any new patient that comes to me, we get a proper sort of prequestionnaire profile, a good assessment, and then decide what anxiety levels they might have.

Okay. I think the advancements in sedation will probably be on the monitoring. So for me, for the last 10 years, I’ve sort of always looked at those advances and most of sedation now we use a pulse oximetry. We check the blood, we check the blood pressure. I’ve always wanted a bit more than that. So I have a entitled carbon dioxide monitoring as well, which is five stream monitoring, which is on the nasal.

And that can assess the ventilation of a patient because in primary care you’re not in a hospital setting. And it gives you a little bit more confidence of safety. I’m all about safety in the safety aspect of sedation. If I was saying to somebody starting out in IV sedation, like, is that something you really want to do?

Cuz it’s not suitable for every practitioner. It depends on your mindset as well. And is it something cuz you will attract certain patients that will be challenging? And difficult, so I think, I’m very like Mike Gow. I look at the whole patient. Is this patient suitable for sedation? Okay.

It’s not just a tick box mentality. Okay? So it’s very important to use good language. I think hypnotherapy really helped me in my career, and that’s just using some words and relaxing the patient. And I’ve been on some courses for, just to help with that, to use the right language and speak to psychologists and hypnotherapy because as we know, dentistry is, you know, there very lots of anxious patients out there, about 50% unless of those patients that are gonna need maybe inhalation or IV or oral sedation. So, it’s finding out really going back to basics from what the patient is.

[Jaz]
What really struck a chord with me there, Roy, is be careful of what kind of patients you would attract and make it a considered thing for you. So I don’t actually advertise directly to patients that I treat TMD I quite like doing that, but if I advertise, I know that my diary would be booked up six miles. I still get people driving hundreds of miles to see me, which is great, you know, very flattering. I’m very happy to help them. I loved this field, but I still want to get rubber dam on. I still want to do my restorative density so I don’t advertise. But if you invest in a skill like sedation and you want to go in to be able to offer that to your patients, then if the word gets out and then you start seeing more challenging cases, then yeah, you have to be kind of prepared for that as well. So I think that’s a excellent point there that I can definitely relate to. Roy, yes, please.

[Roy]
So I would say, you know, a good mentor once said to me many years ago, you know, if you’re about to sedate a patient, always expect the unexpected, okay?

[Jaz]
Mm-hmm.

[Roy]
So it’s like going on stage. You never know what the audience is gonna be like to, so you’ve got to be ready and you’ve gotta have a team of people ready and what’s my plan B? What’s my plan B if the sedation is a failure or I didn’t complete the treatment, what am I gonna do? So you need to think ahead a bit and think about, okay, my plan B is, I’ve got some colleagues that can come and help me who do advanced sedation. So that’s my plan B of plan A, which is the simple plan fails.

[Jaz]
Mm-hmm.

[Roy]
So I’m just always one step ahead and I’m thinking, okay, this patient may be challenging. But I’m surprised we get through it with just basic, safe sedation. Everybody’s happy, but I can let you into a statistic. About 4% of my cases end up being sort of a dance sedation where I’m having to use different team members or different drugs or so 96% of the time, we’re following straightforward techniques in most of my career in 34 years.

[Jaz]
Excellent. I’m thinking of two. I mean, based on our chat now, I really enjoyed this, by the way, Roy, of two qualities. I think then just what I’ve interpreted, this is my artistic interpretation of what you’re saying. Two good qualities that a sedation operator or someone who wants to start doing sedation should have is, A) emotional intelligence or stroke, a good communicator, and B) is leadership skills, Roy, because you gotta be quick to think on your feet and then you’re managing and you’re leading a team and you need to instill confidence in your team when you’re doing this. Any other attributes or anything you wanna add to that?

[Roy]
So I would say, well, let me tell you a story. A practitioner rang me up a few weeks ago and said, look, I’m interested in starting it in my private practice. I’ve converted to private practice. I really don’t want to refer the patients out. I’ve thought about sedation. I’m not sure whether it’s for me or not.

Okay? So I said, okay. So what we’ll do is I will come to the practice, I’ll show you the systems, we’ll do the management, we’ll give you the leadership, but here’s the thing. Why don’t you bring in a dedicated sedationist who you’re comfortable with and you can interview them, that they fit in with your practice and that in your ethos.

But why don’t you sit in with those cases and watch the dedicated sedationist do that and then get a feel for it and see if it’s for you. Because all this guy ever had was some just experiences, an undergraduate, you know, he’s only done about 10 cases from over the last 10 years. So, and those cases might been challenging.

Why not experience that before you commit a lot of time and energy to a course that what we don’t wanna do, like in dentistry, and I’ve done myself, you’ll go down into a course, you’ll go off left center and you’ll make. I must do that and then end up maybe not using that.

[Jaz]
I hate that so much, Roy. And what this podcast has become is a constant reminder to implement and therefore be very careful about your next educational move. Do the education. It’s amazing for fulfillment from your career, but have that mindset that you’re gonna go all in.

[Roy]
Absolutely. So, you need to sort of pace it really. I would get somebody in, is this gonna work in my practice? Is this for me? It’s quite a commitment for a principal to do that.

[Jaz]
Well said. And that new drug. Before we talk about how we can learn from you, just tell us about that new drug. How new are we talking? Is this something that’s been around in other countries and now just been introduced to UK? Or tell us more about it.

[Roy]
Okay. Yeah, so, this is a benzodiazepine, very similar to Midazolam that we’ve used over 40 years, but to me it’s a bit of a game changer. So I’m quite excited about this new development. It was patented in about 2020. It’s been authorized in the UK 2021. I’m using this drug now. I’m still using Midazolam, but this drug is called Remimazolam , okay? Not to be confused with anaesthetist drug called Remifentanil. That’s a completely different drug. Okay, so this is Remimazolam. It took me a while to learn to say it.

[Jaz]
Who comes up with these names. Just pick something more catchy, you know.

[Roy]
Ah, so the trade name is by Favo, B-Y-F-A-V-O. And so, so why do I think this is useful? Why do I think this drug is useful? Okay, so this, the onset and offset of this drug.

So how quickly comes on board and how quickly it wears off much faster than Midazolam. So this enables us to have a quicker induction for the patient. The patient will sedate more quickly, so we’ll then be putting the local in much more quickly. But the thing that we have to watch is that the drug then profile is offset is much quicker.

For example, after about eight minutes, for 10 minutes of me giving the last in increment of this drug, the patient will be up and about recovered, walking safe discharge. Okay? Now why is that good? Because in my experience over the years, some cases midazolam, the patients be quite groggy. The discharge has taken a while.

We’ve had to book a full hour. To make sure that the patient recovers well. So we might have finished a straightforward extraction phase that took me 10 minutes, but we’ve had to make sure with the drug profile that the patient was safe to leave for an hour. So with this drug, I can, if it’s straightforward procedure, I can be done and I can be inducted, treated, and finished within, say, 30 minutes.

[Jaz]
Mm-hmm.

[Roy]
And as safe patients leaving the premises in a safe way. Okay. They still need an escort. Still need a chaperone. I, like I term it as a soft drug, a clean drug. Its profile to me is really exciting because compared to, say, Midazolam have the occasional patient who will have a aggressive, idiosyncratic odd reaction to Midazolam, and I’m sure people out there may have had that in their careers. We don’t tend to get that through this drug. It seems to be metabolized slightly differently. And also with obese patients who are overweight and sleep apnea, they worry me when we have to do sedation. So this will seem to get better outcomes with.

So all in all, I’m about safety, so I like the safety aspects of this drug. I like the pharmacology of this drug, so it’s gonna be in my repertoire. Definitely. Yeah.

[Jaz]
Is this the future of sedation?

[Roy]
I think it is going to be one of the mainstays. I don’t think Midazolam is going to disappear. I don’t think some of the anesthetic drugs gonna disappear like propofol. That’s all gonna be there, but isn’t it nice? For a dentist to be able to go, ah, well for this case we’re gonna choose. We’re gonna use that because we know it’s safer. We’ve got an elderly patient in, we don’t want it to be confused at the end of the sedation.

Cause that’s quite frightening for them. Whereas with this drug within eight minutes, 10 minutes, it’s like clearheaded recovery. Good discharge. So I think it certainly, I wish I’d have had it 25 years ago, I think.

[Jaz]
Well, it sounds very promising. Roy, thank you so much for this really educational episode. Please tell us, for those who, who may be interested in learning more, who are implementing sedation into their practice, you’ve been doing teaching for years, how can we learn from you, which association are you attached to? How can we find out more?

[Roy]
Okay, so I’m attached with the two associations. One is my own web training site, which is mellowdental.co.uk and you can find me on there. But I’m also a senior clinical advisor to UK Sedation and we’re doing webinars and presentations. So be on to uksedation.com, and we’ll be presenting at the Royal Society of Medicine on the 15th of February. Next on the new drug that we just talked about so you can come and learn about that and be excited about that.

[Jaz]
Please send me the links, Roy, and I can put them in the show notes so people can jump on to learn more. And guys, even if you don’t, even if you decide it’s not for you, but someone in the practice may benefit, please send them this episode. But equally, I’m sure you gained something of value in terms of maybe you had this misconception about sedation or one of those myths that we busted. So I, it certainly helped me, Roy, I love your clear, calm communication style. Thank you so much.

[Roy]
Thank you. And thank you for inviting me.

Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end because you have listened and watched. If you’re on the app, you get 45 minutes or 0.75 hours of CPD credit. So now that you’ve got this far, why not answer a few simple questions to validate your learning, to ingrain your learning, but also to get a certificate that my team will send that to you. And that’s on the app. If you haven’t already downloaded the app, it’s on iOS and Android. It’s a free app. If you wanna rinse it for all the free stuff on there, go for it.

Be my guest. But if you wanna gain CPD and get exclusive content, become a Protrusive Premium member, I would love to have you as part my community. Otherwise, you know how much I love connecting with you guys on Instagram. So if you have any ideas for episode, or you just wanna share some love? It’s @protrusivedentaland I look forward to hearing from you. I’ll catch you same time, same place next week.

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I think self development and emotional intelligence is foundational to our relationships with others. It’s how we interact with our patients, significant others, children and family members. Investing in your personal development makes you a better communicator. That’s why you should listen to Dr. Agi Keramidas in this episode!

We discussed how to begin your self-development journey and what are the important areas for dentists to focus on. We hope you’ll apply just ONE THING whether it’s a book title that we recommend or implement one tip to better yourself or your interactions.

https://www.youtube.com/watch?v=HzItyEV3x_cCheck out the Video for Free on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:

4:58 Dr. Agi Keramidas’ Introduction
10:57 Getting started with self-development
14:05 Important areas to develop for Dentists
21:04 Dr. Agi’s communication style
30:03 Roadmap to self-development
35:13 Practical tip for self-development

Check out these books recommended by Dr. Agi Keramidas

How to Win Friends & Influence People by Dale Carnegie
Rich Dad Poor Dad by Robert Kiyosaki
The Biology of Belief by Dr. Bruce Lipton
The Daily Stoic by Ryan Holiday and Stephen Hanselman

Check out Dr. Agi Keramidas’ podcast: Personal Development Mastery for more personal development episodes

Website: agikeramidas.com
Podcast: personaldevelopmentmasterypodcast.com

If you loved this episode, you will like 12 Rules for Dentistry

Click below for full episode transcript:Jaz's Introduction: One of the most common questions I get to the podcast is, WHICH SCANNER SHOULD I BUY? 'Hey, Jaz, I'm starting to make this venture into digital dentistry.' And it's overwhelming, right?Jaz’s Introduction:
There’s so much out there in terms of different types of scanners, different requirements, so which is the best scanner? Which is the most appropriate scanner for your clinic and your requirements? Well, that’s exactly what we’re covering today with Dr. Gulshan Murgai. If you haven’t listened already to IC027, it was his story that we covered and it’s titled, ‘He got Sued and he won.’ So essentially, it’s his entire legal case how it led to that. And we learned so many different medical legal lessons and it was just great to hear about his triumph. So, if you haven’t listened to that, please do listen to that. But if you’ve clicked on, because of the title of digital dentistry in which scanner to buy, there’s so much meat in here because Gulshan has tested and tried all these scanners, and now he’s gonna summarize for you which scanner he thinks is the best and why that might change depending on your needs and the needs of your practice. Now, Gulshan doesn’t keep it a secret or hide it or anything. He has got some financial interest in a digital scanning company. But I still think there’s so much of meat in terms of gaining the knowledge to know what are the differences in the different scanners and how you can choose which scanner to invest in. Let’s join Dr. Gulshan. I’ll catch you in the outro.

Main Episode:
Dr. Gulshan Murgai, after that really enlightening episode about how you triumphantly won the case and so many lessons shared. Welcome back to the Protrusive Dental Podcast. This group function today is to answer one burning question, and I’ve seen you lectured before. I know you’re super passionate about digital dentistry. For those people who haven’t listened to that episode yet, just introduce yourself again and why you are so involved with digital dentistry why you are so passionate about digital dentistry.

[Gulshan]
So, my name’s Gulshan Murgai. I’m a practitioner, general practitioner practice in Watford, Northamptonshire. So, I’m basically got exposed to digital dentistry as an undergraduate. So year 2000’s thanks to Professor Burke at University of Birmingham. He brought in the guys that were selling Cerec at the time. Sirona and I saw it as a final year undergraduate and I was blown away. I was like, oh my God, I need to have this. And he knew how it affected me so much so that in my finals, one of my finals case presentations, Prof Burke, was actually the one who was examining me, and he asked me a question, that the answer was digital dentistry. But I was so bloody nervous, I actually couldn’t get it out. And it was the difference between the highest mark and one down. But anyway, so having found that out, I thought, you know what? I’m going to carry on with this digital dentistry stuff. Imagine then I go through VT. During VT, I then see that Cerec has now become Cerec 3d. So, I was at a trade show at Excel or Birmingham, whatever, and I saw it and I was like, you know what? I need that, I want that. And that’s what I did. So, age 27, 2003. So 18, 19 months after graduatuion. I ordered my first Cerec system, and that’s what I talk about in some of my lectures.

[Jaz]
And what generation of Cerec do you have now? Before I ask you the big question, tell us about your kit. What kind of kit do you have in your practice at the moment?

[Gulshan]
Lots because what people need to know is that I am biased. Okay. I’m one of the few that actually highlights the fact that I’m biased because loads of us are, okay. Don’t forget, I’m a practitioner, so I have my clinical biases, but I’m a lab owner, so you know, I see a lot of work from a lot of people. All around the country that comes to our lab. And thirdly, I own a supply company, right? So, I sell stuff, yeah. And the difference between our supply company and others is that every single thing that we sell, we use in our other businesses, right? So as a result, so we are not what’s called a box mover. We don’t just sell something for the sake of things. We’re a specialist kind of niche company. It’s called Implant Solutions Direct. And the solutions part, that’s the important. Is that we found holes in the digital market years ago as we were kind of going through it, and I wanted to find solutions for implant dentists and solutions for restorative dentist to make things easy. So, the answer to your question’s not easy, but what I do use now is open systems that all talk nicely to each other. I n order to allow me to do my chosen workflow efficiently and profitably.

[Jaz]
Well, I guess when I get come to ask you which is your favorite system? You know, it’s the one that you’ll be using anyway, so it makes sense. And so, just to give those listening, watching a little bit about my background. I first got exposed to digital dentistry about four or five years ago. It was a TRIOS 3. I really enjoyed using it. Then when I was working in Richmond, I had the iTero and then we had the new iTero so I’ve used iTero and TRIOS. I have seen Cerec In Action, great bit of kit, the blue cam, which is the older one. Ah, I tried it. I found it really complicated to do, but again, I didn’t go any courses, so I should have you know, actually done the due diligence to learn, but I didn’t. But where I am now is we use iTero in the practice because we use Invisalign. So, when someone asks me, Gulshan, ‘Jaz, which scanner should I get?’ I’m like, I don’t know. Ask someone who knows what they’re doing, like Gulshan. But then I say, but for me, we use iTero because we use in invisalign and you can’t use other systems unless you’ve got a TRIOS 3 in the US I don’t know if you can or not, but in the UK, you may still be able to. So, we use iTero for that reason. But if you want to ask you that question now, which is the scanner, so imagine someone’s entering the world of digital dentistry because people speak very highly about the prime scan and how precise it is. People who got TRIOS very speak very fondly of that. There’s many iTero lovers. Which ones should we get? Now, by the way, I’ve seen the Medit being demoed by Neil as well and that’s a lovely bit of kit, lots of different softwares, so it’s too much choice out there. Which one should people opt for?

[Gulshan]
Yeah, so like I said, I’m biased. Okay, so big bias, I sell Medit, I’m global key opinion leader for them. So obviously I’m going to promote it. However, I’m a practitioner first and foremost, right? I make the larger majority of my income is doing clinical dentistry every week, right? So, despite what people may think, you know, that’s where my income comes from. So, my history, as I said, started with Cerec because we gotta pay tribute to the fact that they’re the guys that kicked it all off. You know, massive innovators at Sirona came up with this technology many years ago in 1985, right? So they started off, that’s where I started my history. But what have I used over the years? I’ve owned and used Carestream scanners. I had a iTero here up until recently. Obviously, I’ve got all of the range of medic scanners now, but we’ll come back to that. But apart from that, I’ve used TRIOS I’ve used some of the Chinese scanners because I’m involved in exhibitions and trade and things like that. People hand me scanners and say, here, try this. But also, at trade shows I get asked to compare. So, I’ve lost count of how many different scanners I’ve tried over probably the last three or four years, because now things are really growing. But given that exposure that I’ve had, I still choose Medit every time. It doesn’t matter tomorrow if I no longer work for them and no longer sell their products, I would still choose to purchase-

[Jaz]
But that’s why you’ve chose to work with Medit, but that’s why you’ve chose to stop Medit and work with it because, you know, you’ve done your research and whatnot and you liked that one, and that’s why you went with that. But, you know, I want firstly, extract from you what makes the Medit so stand out and what are the features of it. But then also, I mean, the other question we need to respect is, it’s a bit like buying a car. If you say, which car should I get? It depends, well, depends what you want from your car, right? And then it depends on the needs of the practitioner. So please tell us about the Medit, why you feel that is the best scanner on the market today. And then also what kind of practitioner should be getting the Medit and perhaps, someone like me who’s has an interest in Invisalign and therefore would I have to get iTero, therefore, and then give a miss on it? How does that work as well? So you can come until later please.

[Gulshan]
So, let’s deal with the Invisalign thing first, right? I am originally an Invisalign provider from 2005, so I wasn’t just in the early adopting digital implant dentistry, 2005. Okay. That’s a long time ago. Back when it was just all impressions, right. And I’m actually still pretty good at taking impressions, right? But scanners are the way forward. So I’ve got nothing against Invisalign. I’ve got a bunch of patients who still see me all of these years along who’ve got great long-lasting Invisalign results. But like people say on tv, there’s other products out there that do the same. Likewise with scanners, right? Whilst I’m promoting Medit scanners and I know it is all that anyone needs unless, they’re wanting to do Invisalign, and we’ll come back to that. You know, prime scan’s a great scanner. So is TRIOS. So is Carestream, right? At a certain level, Jaz, they all work really well. But here’s the big caveat. You already highlighted it when you said that you had trouble using the blue cap, right? That’s where I came in. So where I bought Cerec 2003. From 2006 to 2010, I was one of the primary UK trainers for all new users for Cerec, right? It was my responsibility to go around the country on behalf of Sirona, right? There were other researchers where I was working for Sirona, and I would go out there and I wouldn’t leave that practice or that practitioner until I felt that they were competent and confident in using it. Right? And they were paying for that service. And that’s what I do now as well, is that I don’t just sell products, but I don’t leave people alone until I know that they’re competent in its use. And that’s what’s different about us as a company, but also like with anything else in a practical vocation. Right. At uni, we were all tested in non-clinical, like phantom head situations before we were let lose on patients. The sad thing is that nowadays, if you’ve got the money, you can go out and buy whatever you like, but no one tests whether or not you’re competent at using that. You then say lots of negative things about it, but you don’t put in the caveat that, oh, by the way, I didn’t purchase any training and I didn’t go for any support because my ego is this big. Then you won’t have much positive things to say.

[Jaz]
It’s like buying a laser. You can buy a laser, but if no one’s ever shown you how to lose, use it, then you might think this is rubbish. And-

[Gulshan]
That’s exactly what happened to me when I bought my first laser. Actually, I didn’t use it for the first 14 months. Because the people that I bought it from didn’t have anyone to train you on it. Quite happily to take your money though. Right. And you’ll see this on social media as well, when I go up against a few other people out there and say, well actually we do things a bit differently in that I’ve been responsible for training people that are bought their hardware from other people and they’ve hadn’t had adequate training support. So that’s where I come in. That’s why Medit choose to work with me. That’s why exocad and other digital companies choose to work with me because I’ve got the clinical experience. I work in my own lab as well. So I’ve got the technical experience and that’s why they came to me and said, ‘We want you to sell our product.’ Right? And I said, ‘Uh-uh, not until I’ve tried it.’ So I tried the Medit alongside the Carestream and the Cerec for a period of time before I thought, you know what? This just does everything I need. I don’t need the others now. So that’s the first answer to your question. It does everything I need –

[Jaz]
In case anyone missed it, cuz you mentioned it there, there are other aligner systems available, so I know that spark are becoming very popular. We know SureSmile, et cetera. And those other ones I’ve mentioned, they are open source, so they will accept Medit scans and Carestream. So there’s a huge shift happening now. I think finally we have some competitors for Invisalign, it’s fair to say.

[Gulshan]
Well, exactly, you’ve hit the nail on the head. So what’s happening in the clear aligner market right now? The big boys Invisalign are starting to lose market share in the same way that, as we’ve mentioned now several times, Cerec used to have massive market share in digital dentistry as a whole. Right? And now you know their product on the market is Prime Scan. Right? And Primemill. So it is just the new name for what was Cerec. Right? And so yeah, there’s loads of systems are out there that work and really, you’ve gotta decide what works for you. Some people in this profession and others like to have their handheld, okay? They want closed systems where they know that there’s few mistakes to make, so they go down that route. Okay? Other people and I deal with a lot of dentists nationwide, worldwide. They like to be open and they like to basically do what works for them. They like to take things apart. You know how many dentists that are super nerds that’ll buy some technology, expensive technology, and when no one’s looking, they’ll try and take it apart. Right? They do that. They’ll throw that with software, they’ll do it with hardware, and I’m one of those, right. That’s why I became a Cerec trainer because I worked out how to break Cerec, right? And only you see, I had no UK based training either. I was on my own. That’s why we run this company in our education the way we do, cuz I don’t want anyone to feel the way I did at age 27, 28. I spent 62 grand on this system, right? My dad went crazy, right? Because I just bought the practice. I just bought a car, just bought a house, and then I bought Cerec, right? Imagine that’s why I was working six days a week, right? But I wouldn’t change it for the world, right? The point is, I had no one to rely on. I didn’t have someone I could pick up the phone and say, I’ve got a patient in the check. Can you help me with this? And if I could, there was a language barrier, German English, right? So I had a once a month call with them and basically it turned out after a few weeks, me telling them how I worked out how to break the system and I was teaching them about their hardware and software that’s why three years later, I was their train. So going back to Medit and new scan as a modern scanners. Now, don’t get me wrong, they all work. Like I said, first you’ve gotta choose closed system open system. Invisalign, iTero, kind of let’s say closed system, you’ve gotta follow their pathway. Other clear aligner systems are more open. You know, you don’t even need to use a branded system. What I say as a lab owner, please support your UK-based labs, right? Who can do the same thing for you. Build relationships with people in your country where you are working. And deliver that to your patients. That’s what I try to do. Right. So likewise with the scanners, I’ve chosen to work with a scanner company that’s massively innovative. The Koreans are like me in my company, Implant Solutions. They basically go to clinicians and technicians cuz they’re big in the lab site as well, and they say, feed us your problems. Tell us what you would like. And look at the support groups. Look at the medic support groups. You asked for something six, well, not even six months, three, four months later, it’s in the new software, right? So they really do listen and respond to their users. That’s one really massive thing. Openly, right? They take criticism on the chin. We’ve just spent an hour talking about risk management and saying sorry, and putting your hands up when things go wrong. Likewise, when, you know, Medit has been criticized in the past for various things in their hardware and software, you know what? They put their hands up publicly and say, ‘Sorry, our bad, let’s talk about this. Let’s work it out.’ You know, and that’s a big deal for a multinational, multi-billion dollar company to put their hands up and do that. The others don’t. Their egos are just too big. They don’t do it. So I like that because I thought that works for me cuz that’s more like me.

[Jaz]
It’s an example of a big company thinking like a small company.

[Gulshan]
Absolutely.

[Jaz]
All right. And that’s what makes it very endearing. And that’s what makes it the support network that it is.

[Gulshan]
Yeah, well, I’ve met all of the senior management, they all know me. I’ve met the CEO, and when you spend time with these people and you realize that it’s not about the bottom line all of the time, it’s actually a lot of it’s about how they make people feel and the solutions they’re providing, and that just works for me. Previously, I worked with, like I said, Sirona with Carestream. I’ve worked with the guys at iTero because of my connections through exocad and things like that. So, you know, they’re all good people. But you asked me why I chose this because emotionally, they’re brilliant support wise. There’s no one that can touch them. The hardware, they’ve got innovative technology in the hardware that nobody else has got. And then on top of that, look at what they do in terms of software, apps that are free to use, free to download.

[Jaz]
I’ve seen the software, they’ve got the Medit splint one that’s recently released and they’ve got so many others too, so what I’ve used before Gulshan is that one of my delegates on my, I teach splints and stuff and they had a patient who suggested that their bite had changed due to over eruption from wearing an NTI, SCi, et cetera. So I was able to overlay the two previous scan before the over eruption and after, and found that actually the teeth are matching up perfectly is the joint level change that’s happened. You see, so I use that actually on the software. So the crazy thing is you don’t even need to have a Medit to use that software.

[Gulshan]
Exactly.

[Jaz]
Which I thought, like, why are they giving this away for free?

[Gulshan]
Exactly.

[Jaz]
So I respect that a lot which is pretty cool. Now I’m sure a common question you get is about money, about costs. So in terms of a hierarchy I’m fairly sure that Prime Scan is like number one in terms of the most costly is that fair to say?

[Gulshan]
No, there’s some pretty expensive criteria models out there as well.

[Jaz]
Okay.

[Gulshan]
You gotta remember Jaz, that the Prime scan system right, is the replacement for Cerec. So really that system is designed to be a closed system where you have their acquisition unit and their mill, right? What they realized some years ago was, we are losing market share here. Right? So then they thought, okay, we better separate these and give people the option to just buy the scanner. Right? Which is where there’s Prime scan, right? And that’s why the name has changed. That’s why it’s no longer Cerec, right? Cerec gives you that thought that it’s a whole system. So yeah, prime scans are not exactly cheap, but remember they’re innovators. You know? There’s always gonna be people out there who think that if it’s expensive, it must be good. And that’s why, you know, Bentley Rolls Royce still sell their products, but yeah, you know, there’s some expensive criterias. If you want, I can sell you an expensive Medit, you know?

[Jaz]
And with iTero, just so, because we’re very straight talking. I think you might give a good answer here, is the whole caries detection bs or something pretty cool?

[Gulshan]
Okay, you’ve gotta understand my position here, guys. I work for exocad as well. Exocad’s parent company is a line tech, and Line Tech owns Invisalign, exocad iTero, and you know, they might even own Medit soon. So I’m not gonna publicly say anything against these. It works. I had it here. Right.

[Jaz]
Yeah.

[Gulshan]
What I can say, and I’ll say, and I’ve said it to everyone openly, is that, right there behind me on my dental chair, I’ve got a caries detection device in my camera, right? It’s this big, it’s very light. It’s on my chair. I can use it in a second. I can switch it on, right? I don’t have to have this big trolley or anything next to me, and I certainly didn’t pay a massive premium for it. Okay? What they’ve done is they’ve bundled a lot of technology into there, and that costs money, right? Because that’s, you know, they’ve created convenience. In the same way that Medit have done the same in some of their higher end scanners, there are more features in there that you’ve gotta pay for compared to some of the more budget scanners, right? It’s one of those things, Jaz, that you pay your money, take your choice. Not just in scanners, but also software. We talked about cars. It’s all so the same between Android and iPhone, right? It’s BMW and Mercedes. But just with scanners, there’s quite a few out there, just like there are with phones and cars. . So I think there’s more to it than that. You have to first beat to people and say, what do I want to achieve out of this? Right? So there’s some people in their particular point in their career where this is what they do and this is all they’re gonna do until they finish. There’s other people who say, well, like for instance, you touched on implants. If you are gonna do more implant dentistry later on, you wanna keep that channel open, right? If you are not doing clear aligners, but you want to, you know, go down there in the future, that’s an option. If you are an associate that works in four different practices and you need a system that’s mobile, right? So I need to, as a reseller, I need to listen to what you need, and then I can say, is this, or this option? And here’s the pros and cons on all of them, right? And you decide. Right.

[Jaz]
So it’s a fair summary Gulshan, if you don’t mind paraphrasing whatnot, is that all these systems are good, they’ll get you from A to B. A closed system. An example of closed system is iTero and therefore that has some limitations, but it’s a good scanner still. Nonetheless, if you want something that’s a open system and something that from you who’s tried all these softwares and scanners, you’ve really enjoyed using the Medit and that’s something that you speak very fondly of, but ultimately have that conversation with someone to find out what your needs and wants are to really match up, which is the best ideals scanner for you as an individual practitioner.

[Gulshan]
You’ve got it. Absolutely. What I will say is, this is, I mentioned the term earlier, which is called box movers. Right? Box movers are suppliers who, they don’t care what they sell as long as they sell something. I think you’ve understood me a little bit more since we’ve been talking today. I’m passionate about what I do and also what I sell. So I’m far from a box mover. I sell a particular software, particular hardware, because I’ve tried and tested it, right? I can show people how to get the best out of all of those things. Now, there are some great reps out there from great companies who might also say, but I can show you this, and this. So just be careful of people’s biases. You don’t have to buy for me or the next guy. You pay your money, you take your choice. For me, it’s about building relationships and for me, I easily build relationships with other dentists because I can relate. I’m still practicing it pretty much every day. Right? So that’s where our company’s different from others in literally I put it into practice every day. I have used iTero. It’s a good system, right? We shouldn’t say it’s closed. It’s partly closed, right? It’s a little bit-

[Jaz]
Because you can export STLs and stuff, but it’s just that-

[Gulshan]
Exactly. Okay. So, you know, there’s other systems that are more closed. So if you listen to my colleague, David Claridge, he had a word that he created some years ago is called Tropen, T-R-O-P-E-N. Truly open. And this is a thing. So, there’s tropen and then there’s fully closed, which is flosed. Okay. Which is something I came up with just to go against him. But, you know, find someone who’s passionate as you are about the kind of work that you want to do, and then sit down and talk about it. And if you do that, you’ll make the right decisions.

[Jaz]
That’s a great way to end it. And I think I just wanna add in there that from being involved as an associate, in practices where the principal was at that time, you know, making that, buying the first scanner. So I’ve been involved that, you know, two, three times where the principal was about to buy the first scanner actually three times, four times that’s happened to me. Oh my goodness! You know, whilst I haven’t been the key decision maker, they asked for my opinion, and I’ve seen what happens in the first few weeks after they buy a scanner. A lot of hand holding and support is needed. So if anything, my 2 cents is find someone who will support you. That could be a big company, that could be a small company, could be whoever. But as long as that support is guaranteed and someone who can ideally, I mean, I like the fact they’re a clinician and then, you know, if you support and then having that extra sort of nuances of you know, you did a whole lecture, on capturing sub ging ival margin and stuff. You talk about that. So yeah, so the, we should probably do another episode on that. By the way so, Gulshan, I really appreciate and now please tell us about your company cuz you’re obviously, you’re doing great things in Digital Dentistry now we can tell about your groups as well. You know, you run the exocad and stuff. So those who are interested in Digital Dentistry and learning and getting supported would love to know about that.

[Gulshan]
So our company, our supply company is called Implant Solutions Direct. Our other name is ISD Digital. Obviously, implant solutions are digital because actually our biggest customers globally, because we actually export globally are labs. Okay. Around the UK I supply around about 105, 106labs. So we’ve got a big relationship with them. We are going more and more into the clinical side with our scanners and our software, hence ISD Digital. We have our sister company, which is a full production crown and bridge lab that’s called 4D Ceramics. I’m intricately involved with that. I have staff, but also we do a lot of implant-based staff, guides, things like that. As far as where you can find information, follow me on Facebook and then you’ll get access to my pages. So I’ve got Medit worldwide, I’ve got Exocad Worldwide, and the group called Intraoral Scanners iOS, that’s also my management. I manage that group as well. So, about 10,000, 12,000 people all in across those groups.

[Jaz]
And different levels. Welcome beginners experience, that kind of stuff.

[Gulshan]
Oh, absolutely. And what I try to do Jaz, is try and get my users and other people to share their cases, right? Because of various politics involved. I don’t get to share all of my cases everywhere that I want to because people just believe that all I’m trying to do is sell something. So that’s why I said in the last podcast that we just recorded about the case, that I was pleased that it was allowed to go out on various groups because it wasn’t about me, it was about the system and how I kind of beat the system, right? It was nothing to do with me. And likewise, when I’m sharing clinical cases, I don’t just share the good ones, I share some of the bad ones too.

[Jaz]
Super important. And we should always appreciate that in education, to learn from other failures and those who are open enough to share the failures. So, amazing. It doesn’t surprise me at all, Gulshan. Thanks so much for giving your time and for both those episodes. So guys, if you know, hopefully it’s giving you a bit more ideas about scanners, what your individual requirements are and the importance of planning for support once you get it. Cuz the first few weeks are very frantic and it’s a bit like the laser. You know, sometimes what happens, You know what, I’ll just take an impression today and the scanner just sits there and I know it’s happened to my colleagues before. So, go all in. Commit and make sure you are well supported. Gulshan, thanks so much my friend.

[Gulshan]
Thank you. Great for the opportunity. Thanks Jaz!

Jaz’s Outro:
Thank you. Well, there we have it guys. Thanks for listening all the way to the end. It’s not just about the piece of machinery, it’s about the support that comes afterwards. It depends on how it sits in your practice. In terms of what will you be using it for? Personally, I have really come to embrace digital dentistry. I first started out with the TRIOS, then now iTero just cuz the circumstances of practice and my vertical preparations are scanned 99%. I very rarely use impressions just for some denture work. I’m using impressions. Otherwise, I’m pretty much digital and I think it’s great. I think this is the future. The future is here. And so, if you’re not embracing digital yet, does it really matter to me which scanner you get? No. I think for me it’s important that you actually start thinking about how to take the first steps into digital. And so, there’s lots of great people out there like Gulshan who can guide you, but it’s something that once you get into digital, you look back and you think, how did I ever not do scanning? How did I stay in analog so long? Now we know that analog has its advantage and it’s great, but now might be the time if you’re not already digital, to consider making that move. And I hope this episode gave you some information in terms of what are the different scanners out there and what are their strengths. Thank you so much for listening, and I’ll catch you same time, same place next week.

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Biomimetic Dentistry is the use of Restorative techniques and materials to mimic (and preserve) the structure and function of natural teeth. Dr. Taylor Paton will discuss his journey in Biomimetic Dentistry: how it differs from Adhesive dentistry and how it can be used to develop innovative treatment strategies for patients.

In this episode we also discussed philosophies and guidelines following the literature for optimal bond strengths, so that your clinical protocols may benefit from Biomimetic principles.

https://youtu.be/UFTwT86Urs8Check out the full VideoThe Protrusive Dental Pearl: How to block out a metal post. Use something like ‘Ivoclar Direct Opaque flowable resin’, a masking agent that is highly opaque. Paint it on the dark tooth substrate or cover metal (eg a cast post) with it. Other brands include Pink Opaque by Cosmedent Inc

Premium users on the App can download Premium Notes by PDF and PDF Transcript.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

2:52 The Protrusive Dental Pearl
7:15 Biomimetic Dentistry
13:17 Dr. Taylor’s journey to Biomimetic Dentistry
21:48 The Hybrid Layer
24:11 Improving Bond Strengths
26:58 How Decoupling with time works
31:41 Immediate dentin sealing concept
36:19 Caries Detector dye
42:58 Biomimetic Philosophy regarding crack management

Check out Dr. Pav Khaira’s Academy of Implant Excellence which would give you a comprehensive course encompassing A-Z of implantology

If you like this episode, you’ll also like Composite Veneers vs Edge Bonding – Biomimetic Dentistry with George The Dentist

Click below for full episode transcript:Jaz's Introduction: What actually is Biomimetic dentistry? I think in the last few years it's become like a buzzword in clinical dentistry. Is it the same as adhesive dentistry? What is this decoupling time or decoupling with time? And how can we follow simple steps to improve our bond strengths?Jaz’s Introduction:Because essentially, from my understanding of BIOMIMETIC DENTISTRY, it is like EXTREME BONDING. Basically, it’s extreme adhesive bonding and using a set of philosophies and guidelines following the literature to get the best bond strengths possible. Today I’ve got on Dr. Taylor Paton, and I love him because he’s a young dentist, like he’s super young, and I respect that a lot because he’s got something to share. He’s got fantastic online resource, all about his passion and his learning and his journey with Biomimetic dentistry. And sometimes what happens in education is that the grand master, the king of any discipline within dentistry, they are so far removed from the plight and the struggles of that learner that sometimes they may not be the best person anymore to introduce someone to that topic.

So, I think Taylor, what he presents today is a young Scottish dentist and I just love his energy and his knowledge. You know how much I love geeky dentists, and so therefore I’ve got him to talk about Biomimetic dentistry, answering my questions from the lens of a young dentist who’s just very well read up and very keen in this field, and that way he’s also learning and therefore, as us, we are all learning together with him. I think this episode is more impactful as an introduction to Biomimetic Dentistry than if I got on an established superstar that’s already well known. So, Taylor, keep up the good work, my friend.

Hello, Protruserati. I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. If you’re listening to this, I love you. Thank you so much. If you’re watching this, then you can see the hoodie that I’m wearing. Oh, my goodness! Dr. Nekky Jamal, the dentist who made the Third Molars Online course. The course I always rave on about as the course to learn wisdom tooth surgery wherever you are around the world, because it’s online. It really helped me start tackling cases. He has this fantastic merchandise. This hoodie has got a photo of Drake wearing a mask and wearing loops. It just looks brilliant. So, thank you Nekky, for sending it all the way from Canada I absolutely love it. In fact, I’m lecturing tonight at local BDA Kingston branch. I’m talking about HOW TO STOP YOUR COMPOSITE VENEERS FROM CHIPPING, and I’m gonna be wearing this hoodie tonight, so I’m doing something quite brave. A borderline unprofessional. Is it? I don’t know, maybe it’s just a new thing now, and we can be a little bit, I don’t know if it’s unprofessional. I think my heart’s in the right place here, but this is representing the future of education. So, if you are listening, watching, and you are wanting to learn more about WISDOM TOOTH EXTRACTIONS and see videos of surgeries to guide you in your own practice, there’s only one course in the world to checkout. That’s Nekky Jamal’s Third Molars Online. It’s on thirdmolarsonline.com, and if you use Protrusive at checkout, you guessed it, you get a 15% off. So, that’s once again that’s third molars online.com. Use Protrusive for 15% off. And trust me, you will not regret it. It is a fantastic resource for anyone who wants to do third molars in practice.

[Protrusive Dental Pearl]
The Protrusive Dental Pearl I have for you is HOW TO BLOCK OUT A METAL POST. So, imagine you take off an old crown and you find an ugly metal post inside, and now you want to place your future crown. And maybe you don’t want to use PFM, maybe you don’t want to use porcelain fused to metal maybe you want to use a ceramic for whatever reason. And therefore, sometimes to mask that metal sub-structure can be very difficult. It can have shine through. It can look very ugly. So, what you can do is you can use something like Ivoclar Direct Opaque. It’s like this flowable resin, which is a masking agent. It’s there, it’s extremely opaque. It’s like Tipp-Ex for teeth. And essentially you put your air abrasion adhesive and you paint this on. And like for those of you watching, you paint it on the tooth, you cover the post with it, or you cover the metal with it. And it can also be used for really dark cavities. Like sometimes you remove an old amalgam and it leaves a really dark base. And if you go ahead and restore with your usual body shade composite, it’ll look really gray, it’ll look really ugly.

So, if you put a base of opaque resin, it doesn’t have to be Ivoclar could be any brand, and a Cosmedent do a very popular one, pink opaque, anything too opaque to block it out, whether that’s the metal post or that’s the base of a dark cavity. Using an opaque like this can really bring your restoration to life, or it can prevent that shine through. So top tip for today is to consider, it’s one of those things that it’s good to have in your armamentarium. A syringe of a masking resin. This episode is sponsored by the Academy of Implant Excellence, and they have a flagship course by that man himself, Dr. Pav Khaira, let’s hear a few words from him.

[Pav]There’s no secret to success. There’s a system to success, and I’ve developed a three-step training program. If you want to start your implant career or if you’ve already started and you want to accelerate it. Knowledge clarity, knowledge depth and building muscle memory so it becomes second nature to you. I’ve taken all of my years of experience everything that I’ve learned from my MClinDent and all of the courses that I’ve attended and condensed it into the Academy of Implant Excellence course. If you want to know more, head to the website page. And you can learn everything that I’m going to be including in that course. I am so excited! It is going to be absolutely phenomenal, and I am ready to give you guys my knowledge.

[Jaz]That was indeed Dr. Pav Khaira from the Dental Implant Podcast. Do check it out if you haven’t already, and if that interests you, do check out his website, academyofimplantexcellence.com. That’s academyofimplantexcellence.com and of course, you can check it out in the show notes. That’s all for me and I’ll catch you in the outro. Let’s listen to Dr. Taylor Paton now.

[Main Episode]
Taylor Paton, welcome to the Protrusive Dental Podcast. How are you, my friend?

[Taylor]Oh, very good. Thanks Jaz, and thanks so much for having me. I’m saying that, it’s very, very, very surreal. So, I think you’ve been the soundtrack to my very long commute to VT this year. So it’s been, yeah, I feel like I’ve been listening to you in my ear every car journey, so it’s crazy to be actually talking to, so thanks very much for having me.

[Jaz]Absolutely. An honor to have you on, you are a Protruserati as we connected on Instagram. And then I remember, do you remember when we first like, we’re messaging on Instagram and I was really liking your page, the hybrid layer. And so I’ll be sure to put everything in the show notes for everyone to click on and find you. But then you had this like, and it’s very normal. It’s good to have this, you had this little imposter syndrome, he said, ‘Ah, but I’m only in like a DF1.’ So, guys, Taylor’s in Glasgow. He’s at the end of his DF1 but I’ve haven’t seen such beautiful commitment from someone such a young dentist before. And I said, ‘Look, you need to come to the show. We’ll talk about your journey. I also want to learn from you about Biomimetic dentistry.’ And then you probably had some imposter syndrome. And did you have that firstly?

[Taylor]Oh, definitely. Yeah. And I think you were, I was actually listening to that the other day actually. I think you were talking to that about one of your other case the other day. And I think it’s definitely, I would agree with yourself that one, it is a good thing as well. Definitely in terms of Biomimetic dentistry, because it’s definitely not the sort of thing that I know we’re obviously doing this podcast, but not the sort of thing that you listen to one podcast then you’re suddenly an expert and know what you’re doing. Even at my stage, I still feel there’s so many parts of it. I’m using some of the basic principles and that sort of thing, but there’s so much of it that I’m still not completely comfortable with, even though I’ve kind of made the website and that sort of thing. I think it is good to have a bit of that.

[Jaz]I think the main reason I wanted to do one, like to tell I could have had someone who’s got 25 years experience. But I think the beauty of now and again, having different levels of experience, so you’ve only had like one year experience in clinical practice, but from your website, from your Instagram page, your dedication, your hunger is so evident, and I want to extract that and share that. And sometimes, when you speak to someone who’s really super experienced, they forget the struggles that they had earlier on. So, you are very much in the midst of the struggles of a very young dentist. And I feel as though some of the audience will be able to connect so well with you and you’ll be able to break it down in a way that, you know, I might have forgot what it was like eight years ago to explain a certain concept.

So, I think, I’m really excited to actually speak to you, say about an area of dentistry, which is very much like modal. Like in the last 10 years, Biomimetic dentistry has become like a buzzword. It’s also come under scrutiny by some experienced lecturers. They call it bio-pathetic dentistry. They say that ‘Oh, it’s just a fad name for just a brand of restorative dentistry. So, let’s just start with that, Taylor. Okay. Before we then also, talk about your journey and how you got into it. But essentially, what is Biomimetic Dentistry?

[Taylor]Yeah, so I would agree with you that in terms of the label Biomimetic dentistry, it’s quite a vague one, and it can be quite fluffy at times when you see it. So, a lot of people, if you kind of start talking to them about it and they maybe haven’t looked into it too much, the first thing you usually tend to hear is, ‘Oh yeah, that’s just the, is that thing where you do the tabletop prep with the big smooth surface and only trying your best to stick on with your adhesive.’

And I personally think it’s quite about more than that and there’s so many of these kind of Biomimetic type dentists that there’s so much to learn from them. Just in terms of the fundamentals and the basics of just general dentistry as well, I would say, so I would kind of asking about defining it. I would say it’s obviously along the lines of a tease of dentistry, but a tease of dentistry and itself. I think you could see that as; say we’ve got Zirconia Crowns bonding that onto a tooth with a really heavy crown prep. That could be a tease of dentistry. I think Biomimetic dentistry would then be beyond that. Also, then just kind of respecting how the natural tooths build up and how the kind of natural tooth functions. So, it’s made of enamel and dentin, which are, you know, they’ve got very specific properties. And I think it can be quite-

[Jaz]Would you say Biomimetic dentistry is a philosophy?

[Taylor]I would say it would probably be just respecting that. We’re trying to build a tooth up the way that kind of nature intended. So, I suppose the word Biomimetic would be to mimic life. So, I think especially early in your career, like myself, I think it could be quite easy to maybe looking at like how to do crown preps and that sort of stuff. You’re looking at materials, what materials should I use, whether it’s eMax Zirconia, quite easy to think or which material then’s the hardest for this crown. So if you get a really hard zirconia, that’s good. That thing’s, it’s likely never going to break. But I think Biomimetic dentistry as well as probably using materials that if there is some sort of failure, then you would probably rather that your restoration were to fail rather than the likes of a really hard non-Biomimetic restoration that the patient might come in and you’re a hero because their crown’s completely intact and there’s no chips or anything on it, but the rest of their tooth’s fractured off at the gingival level. And it’s extracted and implant, that sort of thing.
Whereas Biomimetic dentistry, I would think it would be accepting that you’re not necessarily wanting to just go for the hardest materials. You’re wanting to try and actually first kind of understand the way the tooth works and function and while I was listening to someone and thought recently, actually they kind of comparing it. I think it was, Graeme Milicich, have you heard?

[Jaz]Nope. But please tell me.

[Taylor]So, I think he does a lot of research about the compression dome concept of enamel. So that’s basically where the enamel basically works. So, the compressor forces on the tooth and it’s kind of redirecting those vertical forces in the kind of cervical area of the tooth, and it’s kind of disrupting those to the dentine. And he’s kind of saying, and a lot of Biomimetic dentists are kind of saying that by doing these kinds of aggressive, heavy crown preps that we’re used to doing and taking away that kind of cervical area of the tooth, you basically don’t want to do that because it’s the strongest part of the tooth and it’s the area that’s receiving all that tension under function. So, by taking that away, you’re not really doing the tooth any favors.

And that little area, the cervical kind of two to three millimeters, if you go and then read about Biomimetic dentistry, you hear a lot of people calling that the bioderm. So, you hear a lot about kind of preserving that bioderm. And with doing that, you’re then taking a more kind of minimally invasive to an extent, but not going too far with that either. So, if there’s like a really thin cusp or that type of thing, it’s not like an extreme minimally invasive or you’re relying on, you know, ridiculous bone strengths and that sort of stuff. I think it’s more of an approach where you’re removing your carries, removing track. Trying to preserve the vitality of the pulp.

[Jaz]I think the word approach is a good one though, Taylor because from my perception, from what I’ve seen, from my speaking and also, I actually did have David Alleman on the podcast, but we had such massive connection issues. They never actually got posted. But from what I’ve seen and from speaking to lots of my colleagues, you know, Germàn. He’s very active on social media. I’ll have to put his, Germàn Tekilla is his Instagram handle, so I speak to a lot with him about Biomimetic dentistry and what I like, and why I’m open to it and why I don’t think it is a fad, as some colleagues will say it is, is because it’s an approach, it’s a set of protocols and no one else is talking about cariology, but Biomimetic dentists are.

No one else is talking about how to maximize bond strengths and actually those three words is how Dr. David Alleman described it when he had his brief little stint in my podcast, he said, Biomimetic DENTISTRY is really MAXIMIZING BOND STRENGTH. So, is it adhesive dentistry? What could he do to the tooth with your restoration to get the best outcome through the best adhesion possible? And also, it’s a way of preserving the longevity of teeth. So, all these philosophies and the protocols that Biomimetics has in place all lends itself to a favorable restorative outcome. So, for me, I see it as a philosophy and a branch of restorative density best practices. It’s another way to think about it. How did you get drawn to this? Because most couple people qualified one year maybe haven’t even heard of Biomimetic dentistry. Are you finding that you’re having to explain a lot to someone who you’ve met? Who’s like maybe at your level in terms of one year qualified or a dental student and you’re having to explain every time what Biomimetic dentistry is?

[Taylor]Yeah, so I think how I kind of fell into it was, so I graduated, so it was 2020. So, it was Glasgow I graduated from, so we were the year that kind of stopped a bit earlier because of Covid as well. So, we had that really abrupt stop. It was about March time where we were in the clinic one day, the next day. That’s it. You’re done.
So, there was a few weeks on, maybe a couple of months of waiting about to see. ‘Oh, do we still need to do this last OSCE exam?’ That sort of stuff. And then after that it just kind of fizzled out and that was it. So, at that point, lockdown was happening. I had a lot of time on my hands at that point as well. There was the big influx of all the webinars every day. Like you couldn’t keep up with so many webinars and stuff. There was one every morning, afternoon, night, you were kind of spoiled for choice really. And I think at that point, I was kind of then realizing like, wait a minute here. There’s just so much that I don’t know from dental school really, and I think we’ll come onto that a bit as well, but-

[Jaz]I still feel like that every time my friend. Don’t worry. It’s very normal to feel that way. And it’s good to recognize it. It’s the most important thing is to recognize that, whoa. Yeah. It’s so much that you don’t know that you haven’t exposed to. And then the more you learn about things, then the more you realize that actually I thought I knew crown lengthening. But then when you start learning about crown lengthening, when you do your first crown lengthening case and then you’re like, holy crap, I need to learn more about crown lengthening. So it’s never ending my friend. Embrace it. Embrace it.

[Taylor]Yeah. So, I think they started off with all the webinars, that sort of stuff. I think a similar point I probably found your podcast as well, and it’s genuinely being so helpful for like that stage in my career as well, I don’t know how much feedback you get from people at my stage and stuff, but it’s genuinely, completely changed my outlook on everything, and I’m not just saying that because you’re there.

[Jaz]Much appreciated. You can stay. We’ll keep this in running. Very good. No, thank you so much. It’s nice to get feedback. It keeps me going, you know, sometimes where, yeah, like today, I’m behind on my episode and I’ve got so much to do behind the scenes and you may not, have not seen actually, and I’ll take it for everyone’s benefit. You might have not seen this, but on YouTube now for the last couple of episodes, not only is the interview on the right side, but there’s notes now coming up on the left side, so that’s double our production time. But, so, you know, let me know what you think of that. And guys, if you’re listening, watching this, let me know, should we continue working OT and maybe delaying the episodes a little bit to have the notes on the left, as we’re speaking, or is this a function that you really don’t need? So yeah, something to get some feedback for. So, feedback, always welcome. Thank you.

[Taylor]Sounds good. No. Yeah. So, I’m one of the audio listeners who have then kind of started listening to your podcast, quite a long commute this year, like I was saying, it was about an hour later and an hour back. So, I’ve listened to all the podcasts from that, I was then just reading a lot more and following a lot of other dentists. And I think from that, it was kind of about on Instagram that I then fell into the little group of-

[Jaz]Huge community on Instagram or Biomimetic dentist are sharing lovely things, great lessons, very educational posts, I, which need to be respected, you know, whether you agree with Biomimetic approaches or not. I think there’s a beauty in sharing and presenting information on Instagram that is disseminating information and research. So, I think we have to re respect that.

[Taylor]Yeah. And at the start it was, I found there was so much information on these pages, and it was all, it wasn’t just a case of, I think it’s quite easy to think, oh, you’re reading that stuff on Instagram. Like that can’t be the way of doing it, but it’s all linked back to research articles and you know, reviewers and that sort of stuff. So, you can go away yourself and start reading through all those papers and kind of a lot of the time, I would then also form my own opinions as well. There’d be some things that people would post about, and I would think. Oh, I’m not, not too sure about that, but I think the more you kind of read about it at the start, it’s quite overwhelming. I was reading it at the start thinking, I have no clue what any of them are talking about.

And I think maybe after about five, six months or so of just continuing to read and I then kind of then went to, there was a online conference. It was quite big, roundabout Christmas time. It was a karma dentistry. Biomimetic conference. I don’t know if you’ve heard of that. That’s been on a couple of years now. So that had about, it must have been about 15 or 16 speakers and learned so much from that. It kind of got to the point, I just-

[Jaz]Just quickly, who’s your favorite speaker in Biomimetic dentistry?

[Taylor]Who? Favorite speakers? I think-

[Jaz]You had to pick one.

[Taylor]I always enjoy listening to the duo of David and Davey Alleman. They’re very, very, very entertaining. It was actually just in March this year, I actually got to meet them. It was a HandsOn course. That was-

[Jaz]Of course, Tariq Bashir probably organized that, right?

[Taylor]Yeah, that’s it.

[Jaz]That’s right. The famous Scottish dentist. Yeah.

[Taylor]That’s right. Yeah. So. Well, Tariq’s great. So, I think he’s done the Mastership program with David and Davey, so he obviously knows his stuff. And I think if someone like that’s, you know, following protocols like this, then you know, he’s sensible and you can tell he just really knows what he is talking about and I think, like you were saying as well, I don’t think it does. Even if you don’t agree with all of it, it doesn’t do any harm to have some of these concepts and approaches like in your toolkit really as well. So, I know that like, say yourself, you’re, you talk about bit like the verti preps and that sort of thing, and that wouldn’t be then saying that you don’t do things like that. It’s just another, you know, approach to how you can do things. So, it’s-

[Jaz]I’m very much against like, dogmatic approaches. So, if anyone’s like two on one side, I think there are cases where I don’t think you can solve it. And I mean this, you know, with humility, I don’t think you can solve every single case with just one approach. So, I can show you some wear cases where like, you can’t stick anything on this. You need to do crowning; you need to do vertical preparations. You may need to use zirconia in certain cases to be able to fix it. Okay. On this 75-year-old man, for example, whereas other cases, Biomimetic dentistry all the way, I mean all the onlays that I do, I very much try and follow all that I’ve consumed so far when it comes to maximizing adhesive strength. So, I think there’s a beauty in learning from all the philosophies.

[Taylor]Yeah. Completely agree with that as well. And yeah, I think sometimes people are quite quick when you’re talking about the Biomimetic type things, to think that, oh, that’s all that you then, then do. I know in my case, just now anyway, it, if anyone’s listened to it, it certainly isn’t. I sometimes feel like I’m going to work and I’m going to doing a completely different thing. So, I’m practice, I, I just. Like kind of heavily NHS type practice. So, to be fair, I’m spending most of my time going and doing extractions, dentures, that sort of stuff.

When I get the chance with composites, whether that be in every anterior composite or a posterior composite or the odd chance to get a little chance to do onlay, or that type of thing, I can then go into some of these concepts and use these things. But I would only do that if I’m absolutely sure that I’d definitely know what I’m doing because you do hear a lot with the very experienced Biomimetic dentist as well, who are really keen on it. They would rather have a traditional dentistry done very well to them than someone who’s maybe on the fence about the Biomimetic dentistry and doesn’t maybe completely know what they’re doing. So, I would think if maybe anyone’s listening and think they want to jump straight into it, I would really just, read up a lot about it. I think your best bets probably to find a mentor as well, which I’ll-

[Jaz]
Well, tell us because tell you, you’ve been through this journey. You found Tariq, obviously in Glasgow. You went to the course when Davey and David came along. So, if you are speaking, if you’ve got your microphone to young dentist all over the world and they wanted to take the next step to learning about Biomimetic industry, maybe one or two of the key lessons. Do they have to fly to the states? Do they have to buy a book? What’s the good first step?

[Taylor]So, I would say, if I can be cheeky and pluck the website for a second as well-

[Jaz]Do because I loved it.

[Taylor]Yeah, I’ve started up the little website and the website is in, it’s called the hybridlayer.com. Also, on Instagram as well @thehybridlayer where the share cases and that sort of thing. And the website, the main kind of goal of that. I got to the stage where maybe after about a year or so of reading things, I felt like I would then see people asking things and that sort of thing, and it would get to the point where I thought, yeah, I can start. And I know the answers to some of these questions. I can see that people are pretty confused as I was at the start, and the kind of goal of the website was basically just to get some of that basic info down so that it could maybe even give people the chance to have a read data, it saves you read, scrolling through thousands of Instagram posts that aren’t in any order trying to figure out what’s happening.

And that can give you just a little kind of basic insight into what it is. The rough concepts, not necessarily read the website and then you’re a Biomimetic dentist, but it can give you an insight into saying, is this the sort of thing you’re may be interested? And if you are, there’s, I know I had the two-day hands-on course with David and David Allman. I would say even that sort of thing. I knew quite a bit. I don’t even know if the two days would be enough to then start doing it, but I know they also offer the kind of online mentorship programs as well.
So, I know there’s the Alum Center for Biomimetic Dentistry and some of the people they’ve trained, they’ve also got similar kind of centers throughout the world as well. So, a lot of it’s going to, looks like it’s been done online, which I think makes sense as well. So, I would definitely recommend if you are going to be kind of serious about it and trying to use it on a day-to-day basis, definitely try and find someone who knows –

[Jaz]Well, so much of our dentistry nowadays, adhesive dentistry, so if anything, we can do to improve our adhesive dentistry. So, what I’m going to do actually Taylor is I’m going to ask you the last question, straight up. And then we’ll go to some of the other ones. Because on this note, from what you’ve learned so far in your journey so far with Biomimetic dentistry and a year down dental school and because some of the knowledge that you have from dental school is more fresh, you’ll remember some more of the dental learnings than I do certainly. So, I like that you have that recent background plus all the courses that done in Biomimetic dentistry and how passionate you are about it. Give us your top tips on improving bond strengths. So, this could be with either direct composite resin or bonding onlays. What are the key lessons that you can pass on in just a few months?

[Taylor]Yeah, so I would say one of the main concepts that I didn’t come across at all, maybe I missed it, but in dental school was the fact that when you are forming that initial bond to the test. So, if I imagine you’ve got your caries free tooth, or if you’re using the partial caries removal, you’ve got your peripheral seal and everything, maybe come onto that with the caries dye and everything. But if you’ve got your tooth that you’re happy to then say, bond a direct composite on tooth, so, an MO that you’ve prepared and your you’re happy with when you do etch the dentine, prime the dentin and use your first layer of adhesive, I didn’t realize that, that a tease of it takes time to mature, basically. So, it takes time for that bond to form. And I’m not sure if that’s something that I just missed, but I feel like it’s a really quite important point because-

[Jaz]Is that the decoupling time?

[Taylor]Yeah, that’s right. So, it’s basically the concept where obviously there’s a different types of bonding system, so the total etched, self-fetch, that type of thing. So obviously important, first of all to understand what you’re using, but if we assume you know what you’re doing, you’ve etched appropriately, primed appropriately, and you’ve got your first layer of adhesive on there. Once you’ve got-

[Jaz]Now, what if you’re using something like a universal, so you’ve etched the enamel and now using a self-adhesive universal, and then that’s got the prime and bond mixed into it. Can you still apply? Can you still apply this philosophy of decoupling time, or does it lend itself more to a separate primer and separate adhesive stage?

[Taylor]So, I would say just based on whatever, I think if you’re using a universal bonding system, which I’d imagine a lot of people will be using, you’re naturally maybe not going to quite reach the, the absolute best bond strengths that you possibly can. But I would say that-

[Jaz]
I think we know; I think everyone who uses universal bonding agents, I think we know that. I think we know that. You know, from the papers in the past anyway, the OptiBond™ FL was so high and then everything else is always a bit lower. I don’t know, which is the king of adhesives. Now maybe could fill me in, in terms of what you’ve read, but yeah, certainly. I think when we use Universal, we know that for convenience we accept a little bit of a compromise, but we’re hoping that it’s not a massive compromise and still good enough to get a long-lasting restoration. But I think let’s go with that fourth generation or fifth generation.

So, we’re gonna do etch rinse and make it really tangible now. So, we’re gonna prime, and then sometimes we need a couple of coats of primer. That’s why I was taught, so you please tell me if- Get a nice shiny surface, get that dry, and then you’re gonna be using your adhesive. And then is that when you are waiting time? But just tell us more about how this decoupling works.

[Taylor]
Yeah. As soon as the adhesive goes on and you’ve cured it, you’re basically at that point, the hybrid layer is starting to mature. So, the hybrid layer obviously being that kind of interface between the hydroxy appetite, a little bit of the collagen and your resin monomer particles, but that bond, once you’ve cured that, that’s when the clock kind of start. So, you tend to think that a lot of the studies that they’ve done, if you were to just inject a big bit of composite right on top of that kind of bulk fill type technique, all of the shrinkage of the composite, if you do it straight away, the bond hasn’t fully formed at that point.

So, you tend to find all of that shrinkage and the flow of the composite has basically shrinking towards like the kind of greatest center of mass of the composite. And by doing that, because you’ve got that shrinkage, it basically then just pulls the adhesive layer off the tooth or weakens that bond as well. So, the concept is basically that after about a minute, you’ll have about 70% roughly of your total bond strength, whatever that total bond strength happens to be. And after about five minutes, you’ll roughly have about 80, 90%. So that’s kind of what you’re aiming to give it just a. little bit of time, but it’s not a case of- I think when I first heard that, I thought, okay, so it’s a case of you do your etch, prime, bond and then you’re just kinda sitting there waiting, not doing anything.

But there are things that you can do in that five minutes as well. The thing that they would usually suggest in a lot of the lessons and stuff would be to put just a little layer of what they call resin coating. So that would be basically your little kinda 0.5 millimeters probably of some flowable composite. And because it is such a low volume, you basically find that flow of the composite, it goes towards that hybrid layer. So, it’s kind of maintaining that bond strength. It’s not pulling it away, and that clock at that point is still ticking. So that’s increasing your bond strength there. You then tend to find as well that the rule is that from what they’ve read, that if you go more than about two millimeters in your first increment, in that five minutes, you’re a chance of losing about 50% of the bond strength in a lot of the studies. So, they recommend basically the simple rule of not getting any deeper than 1.5 millimeters within the first five minutes.

And at that point as well, you could easily be doing that first 1.5 millimeters, you could be building up your little proximal wall as well, which isn’t then connected to that composite, that’s forming the hybrid layer. So, it is not like you’re sitting there doing nothing. I think that’s a simple kind of thing to understand and something that you could easily kind of incorporate. And if you just kind of understand that that bond takes time to develop, I feel like it really changes the way. Look at things all lot the time when you’re doing composites and that sort of thing. And I think-

[Jaz]
Listen, Taylor, I’m just gonna go have a coffee for like five minutes and then that’s still decoupling. And I can justify that to my patient. So that’s the other way to do it. But no, I prefer your way, you made it really tangible there too, to add a little bit of flowable. That’s great. And then you could be curing that flowable? And that’s still, the clock is still ticking.

[Taylor]Yeah, that’s right. You would cure your flowable, and as long as, so there’s shrinkage of the kind of polymerization shrinkage tends to be to do with like the volume of the layer and also the kind of modules of elasticity as well. So, because it’s such a low volume, you tend to find it’s, it doesn’t have that strength to kind of pull away from the first layer anyway, so, that’s why.

[Jaz]So, you could be curing that flowable, you could doing the contact area, but on the matrix and then like you said, so you’re not connecting it to the body of the composite elsewhere, obviously. And then you can be just getting that. So yeah, I think fill in five minutes and I would like to encourage everyone to practice TAKING QUADRANT PHOTOGRAPHY PHOTOS. So, get your buccal mirror and make sure it’s nice and warm. Or if you’re using rubber dam, it’s not an issue because it’s not gonna warm up, it’s not gonna steam up. And then you can start taking some photos, improve your photography. That’s easily a minute that you can do there. So, I would encourage everyone through that. So that’s a top tip. So, great. You mentioned about the decoupling time. Give us one more top tip because this is such a big, huge topic. If anyone gains something from this episode, I want to remember, okay, I’ve improved my bond strength in some way. So give us one more tip.

[Taylor]: So, I think another one of the big main Biomimetic concepts, which I think you’ve heard of yourself as well from, I know you’re a Pascal Magne fan, aren’t you Jaz?

[Jaz]Of course. Who isn’t?

[Taylor]Yeah. So, the kind of immediate dentin sealing concept. So that’s basically the concept where you’ve got your freshly cut dentin and if we say, for example, this time we’re going for an indirect onlay type of restoration. I know from when I was at dental school, I would’ve thought just do the preparing. First of all, probably wouldn’t have thought to do an onlay, it would be a tune I was probably thinking of. But if I had thought onlay at dental school, it would probably be do the preparation, taking the impression that sort of stuff. And then at the time, just cementing it with your etch bond, resin cement, that sort of stuff. The concept of the immediate dentin sealing was basically with your freshly cut dentin. When you’re finished your prep, your then, just as we were saying, whichever system you’re using, the etch prime bond, obviously, your layer of adhesive and then again possibly that little resin coating over the top as well.

And by doing that, I don’t know if you’ve read some of the papers by Pascal Magne as well. He basically found that by doing the immediate dentin sealing, professionalizing that, and then cementing it the next visit because you’ve been allowing similar to what we’re sending in that first point because you’ve given it so you potentially, if you’re sending your love work away and it’s coming back in 10 days, two weeks, that’s potentially two weeks of decoupling with time that you’re doing. So, he’s finding you’re getting four times in times the bond strengths with using that kind of method. Things like that, though. There are still some areas that can kind of trip you up as well. So that’s what I’m gonna seem to be careful that you can’t just start thinking, right, okay, I’ll start doing this tomorrow. So, things like the, so because it’s such a thin layer that you’re using there, you’ve got the little oxygen inhibited layer as well. So, if you have this little thin layer of resin coat, there’s potentially say, I’m not sure exactly, but maybe 20, 30 microns at the top of that, that just isn’t polymerized. So that can also react a bit with the impression material. So, it would usually recommend a little bit of the kind of glycerine-

[Jaz]With the temporary material like bisacryl?

[Taylor]Yeah. So that, and also the actual, if you were using a kind of impression material to actually take impression, it can interfere with that as well. I think it’s more the kind of polyether type materials that can interact with it. So, you basically want to make sure that you are curing through a little layer of glycerine, similar to when you’re doing a composite and you cure that last layer through the Vaseline or that type of thing. And so, it’s definitely do that. And then also just making sure, I think some people do the immediate dentine sealing and maybe think you can just use your etch bond etch prime, and a little layer of the adhesive.

But you tend to find at times that layer of adhesive, you have to know the thickness of it as well because if it’s about as thick as the level of the oxygen inhibited layer could potentially be, you could potentially just have pretty much nothing there. So that little layer of the resin coating over the top, it provides, I think the concept is it kind of provides more of the free radicals for it to all polymerize and I’ll just make sure you have that good thickness and that’s, I think it’s definitely something to go away and read about and see if it’s something you can maybe incorporate in your practice as well.

[Jaz]I encourage everyone to read about IDS, immediate dentin sealing, but as a practical dentist, I think there are some other advantages, ie if the temporary comes away, then there’s less sensitivity. Okay. That’s a real good advantage there. The other one is at the same time as doing my immediate dentin sealing, I’m blocking out any undercuts with my G-aenial™ Flo whatever. So, you know, if you just do it for those two reasons alone, and then now, if you get some added improved bond strengths, which we think we will, then it’s a great thing to do. I think it’s very- Some dentist, young dentists might get scared away from it because it sounds very complex. It really isn’t. It’s just your standard adhesive procedure, bit of a flowable resin coating on top. And then when you come to fit it, you have the whole air abrasion.

I would suggest everyone checks out the episode I did with David Gerdolle, the episode with the David Gerdolle, Extreme Bonding. David is a very well-known Biomimetic as well. And he talked all about the main things we can do to improve our bond strengths and, and yes, one was talking about how we can use those concepts. So that’s great. We’ve covered two top tips there for improving your bond strength. Number one was decoupling time, and number two was immediate dentine sealing. Let’s switch gears to caries detector dye, because the biometric community is the community online that I see using as part of their protocol, caries detection dyes the most. And then, Germàn influenced me to start using it, and I love it. I think it’s great. I love that objectivity that it gives. So if, no one’s ever used carrie’s detected dye before, can you just explain the steps in using it? And then B, how do you interpret that information? That tooth you’re looking at now that’s pink or green depending on which one you got. I got the pink one. And then based on what you see, how do you act upon it? So, it’s three levels of questions. Okay. So why should we use it? How do you interpret it? And then how do you act on it?

[Taylor]Yeah, so I would say like you’re saying the caries detector, that it’s probably another one of those ones that is seen as a bit controversial maybe with people that don’t know exactly the method you could consider using it in. So, it’s definitely not just a case of you’re using this dye and it’s helping you see, you know, all the occlusal cases and you’re just drilling away all the red stuff. I would say, I would probably break it down a bit back to how you’re actually wanting to deal with your caries removal, Biomimetically, possibly. So, I would personally, I think the kind of caries removal concepts make sense to me. And the main things that I would usually associate that with would be forming that peripheral seal zone and getting your caries removal endpoint. If I was able just to say what both of those are. It’s the peripheral seal zone would be basically-

[Jaz]Which is exactly what we are taught at Dental School. You know, get the ADJ super clean and it’s just an extension of that and really linking it back to your bond strengths because- But you know, we said there, teach me at dental school that, oh, because that’s where your seals are most important. But that’s where also we want to maximize our bond strengths as well, so it makes sense.

[Taylor]Yep, definitely. And then your caries removal endpoint, similar to the concepts you would learn at dental school as well, but maybe just making it a little bit more tangible would be once you’re approaching the pulp, basically, and it’s something that you’re probably doing at dental school and without really realizing it, but you’re getting towards the pulp, you’re starting to get a bit cautious. Should I keep taking away anymore? So, the caries removal endpoint concept was basically, it was giving you like a tangible set of numbers to follow changes a little bit depending on tooth to tooth and the age of the patient and stuff. But it was generally looking usually about five millimeters vertically. So that would be from if you were coming from occlusally removing caries. Once you get five millimeters deep, roughly you would consider, even if there is still caries, you would be stopping there and horizontally coming from the marginal ridge of the adjacent tooth. So that’s kind of your little three-millimeter peripheral seal zone.

You’re basically then stopping there to avoid pulpal exposure. So, you’ve got your clean peripheral seal zone, and then you’re possibly a little bit of affected dentine, that type of thing with a little bit of caries life behind that, you’re willing to accept the slightly lower bond strengths and instead of basically exposing the pulp, and I think it’s at that point that the caries detector dye, I feel could be really useful. So, to use the caries detector dye, so, if I talk a bit about what it is first, so the benefits of it, I would see, it’s basically like, I think you mentioned as well, Jaz, it’s kind of given you an objective way of looking at caries removal rather than being subjective. And I heard-

[Jaz]And that subjectivity has been studied and every dentist is different in terms of where they stop. So, I was attracted to it because, you always question, should I remove some more, should I not? And it surprised me enough for a couple times. You know, I use it many times. And I was like, okay, I’m doing good. I’m doing good. And then I got surprised. I was like, WHOA had I not used this, I would’ve missed it. And I like what Germàn said on a Facebook post recently. Like, yes, there are those people who argue that, yeah, well, you know, I just use my probe. And I can feel it with my probe, but are you gonna really be able to probe every square millimeter of your cavity? Probably not. And that’s got me thinking is like, yes, he’s right.

[Taylor]That’s right. And then another thing with the probe as well that I’ve heard David Alleman as well talk about quite a lot in a lot of his lectures. He talks about, was from like a Japanese researcher that came up with it all. And I think he would be at his dental school clinic and talking to the students and a lot of the time they would be removing caries and he would tell them, you know, just keep removing it until it’s hard with your probe. And they would then ask him, well how hard, and that’s a good question as well, because like how hard is hard? So, I think caries detector dye, it’s a good way of, basically the way it works. Not sure if they know exactly how it works, but it extends denatured collagen, so it’s basically a solvent type of solution. It’s got some acid red, the carious dentin, so the likes of the affected and infected dentin.

The collagen fibers are a bit looser in their denature, so it’s able to penetrate a bit more. And by doing that, it then stains the kinda red or pink type color. So, I mean the studies that you read about it, they’re all pretty, I feel like they seem all pretty conclusive, to be honest, that it does seem to work.

And as long as you’re kind of accepting, there maybe are some limitations to it as well in that really deep dentin that you get really close to the pulp could potentially stain a little bit red, but at that point you’ve stopped your caries removal because of the end points anyway. So, it doesn’t really matter at that point. And I find from using it, A lot of the time if I think I’ve taken away the caries from that peripheral seal zone and I’ll put the caries detector dye on. And a lot of the time, like you’re saying, you do get a bit of a surprise at times and even if there’s little patches that you think you kind of look at and feel what the problem thinks. Oh yeah, fair enough. I’ve left that bit there, so and it is good then you can see the area over the pulp that you’re kind of leaving as well and you know, roughly depending on, I think you can kind of tell a little bit that the redness in terms of how red it is or how pink it is, roughly what you’ve got to work with in terms of your bond strengths and that type of thing as well.

[Jaz]So, guys, everyone listening, all those watching, there’s an episode coming up with Germàn actually, we’re gonna talk all about with whole 45 minutes. All on caries, what you’ve done is you’ve given us a nice introduction. You got dentist thinking now maybe about it. So, we wet your appetite for the one with Germàn coming soon. I was actually gonna record with him straight after you, but we’ve had to reschedule that, but we will cover that in a good depth. So brilliant. We’ve covered some Biomimetic principles. We defined Biomimetic dentistry. We talk about caries detector die just now; you gave your top tips for improving bond strengths.

So as an introduction, as a final introduction, as a final part of this podcast, I see a lot about crack management and now this crack managing cracks is very polarized. Like a lot of things in dentistry, I guess. And many schools of thoughts will manage cracks in a different way. So, I’ve been taught before chase cracks. I’ve been taught for never chase cracks. And what I do hand on heart will vary in every single case, it’s different to me. If it’s a nasty crack I might chase, but, if it’s not so mad, I won’t chase it so much. So, can you introduce us to the Biomimetic philosophy or thinking or protocols when it comes to crack? And I imagine this, I dunno, crack removal endpoints. What names have you got for that?

[Taylor]Yeah. So, I feel like the crack element of it, I think that’s one of the parts of it that’s probably especially tough for me without having the years of experience at things. Because I am kind of going purely just based on like, Theoretical lesson to what other people have to say and just kinda-

[Jaz]And that’s fine. Share, because this is new for me. The Biomimetic approaches. Absolutely cool. Just share what you’ve picked up so far and maybe in five years we’ll record again and see what your thinking’s changed anyway but share what you’ve learned so far.

[Taylor]Yeah, so what I’ve kind of learned so far would be, I’ve learned from David and David Allen, and they had quite a good way of assessing. So, cracks were kind of forming a part of. They were quite good at teaching us ways of kinda assessing the tooth for structural compromise. So, there were basically four red flags that they told us to watch out for. So, the first one was obviously cracks into dentin. The second one was any kind restoration, say an amalgam that’s got an isthmus width of greater than two millimeters. The reason-

[Jaz]Which is most amalgam!

[Taylor]Yeah, that’s right. I know most of them. Yeah. And the reason for that was basically, I think more studies by Pascal Magne and several other people that basically show that when you do have an amalgam like that and it’s got say an MOD cavity that’s more than two millimeters, instead of the usual, the tooth can flex about two or three microns. With even an amalgam in there, it’s flexing about 180 microns, which is, you know, a really big difference. So that’s one of the reasons why these big amalgam teeth, you know, do tend to crack as well. The third one was any cusps that are less than three millimeters in width, which quite common as well. And the fourth one was-

[Jaz]Let’s make that one really tangible. Where do you measure that three millimeters from? Do you measure it at the top of the cusp or the base where the cusp then joins onto the floor?

[Taylor]Yeah, so I’ve seen some different answers for that one as well. I would tend to; I’ve mostly seen from the bottom of the cusp, and you can use the like in a caliper. That’s the way I’ve tended to do it and I think that kind of makes the most sense because that’s shown you how much connection that cusp actually has.

[Jaz]
It’s the base, the main strength of that cusp comes from what’s below it. So, absolutely. That’s fine. Yeah. Yeah. I just thought I mentioned that so that, you know, people listening can think where do you know, how do you begin to measure it? So that’s fine. Please tell us more.

[Taylor]Oh, that’s good. And then, the fourth, last one, there was any kind of box there, so an interproximal box that was less more than four millimeters. So that’s another reason that a tooth will be structurally compromised because like we were saying at the start, you’re then into that kind of bio area as well. So then if you go back to the first one, which was the cracks into dentine, if I even just talk a little bit about, you know, it was Davey Alleman at the course, it was kind of a, a little talk about cracks and that type of thing, and his concept was basically he’s, I think he’s spent a lot of time in, obviously David Alleman. A lot of time they’ve spent a lot kinda looking into the engineering aspect of it and seeing how engineers deal with cracks and other industries and things like that as well. And they’ve kind of come to the conclusion that if you are to just leave a crack as it is, then it has the chance that can always propagate no matter what you do. If you’re putting force in that tooth, if that crack can continue to propagate, it might take a while.

So, their concept is that similar to the caries removal endpoint, you’ve called it crack removal endpoint. So basically, that inside that peripheral seal zone. The likes of Davey Alleman, he would tend to try and chase that crack as much as he can. Basically being, wanting to try and avoid any pulp exposure or perforation or anything like that. But he’ll feel that if you can either remove that crack or at least remove a bit of it, then you’re kind of reducing the length of the crack. And by reducing the length of the crack, you’re kind of reducing the lever arm of it. By doing that, it then needs a lot more force for them for that crack to then propagate. So, he kinda sees that as the best way of doing it. It tends to be the only thing that I see with it as well, it’s kind of challenges it is that you’ve then got these areas that you’ve cracked really high, like C factor situations to try and then restore back and you’re kind of wonder if is that any better? What you’ve gonna made there? So, I’m kind of above the main that, I’ve personally not really decided. I’m probably like yourself. I’m so, so-

[Jaz]I still don’t know. Look, I’ve been in nine years. I still don’t know what is the best way, and I think it will vary in every single scenario. I just hate cracks, man. I had like, I think episode 0.7 wasn’t my title. I just hate cracks with a passion. No one likes cracks. And there’s so many different opinions I mean, one of my friends, colleagues, Pasquale Venuti, which I know he’s like the anti-Biomimetic dentist, and that’s cool. It’s okay. And he’s very much like, don’t chase cracks, because if you’re chasing cracks, you never know where the endpoint really is. You can’t see the endpoint.

But you mentioned briefly in case anyone missed it, is that actually, if you’re removing, you know, some of the crack, you are improving the mechanics of the situation. So at least we have the four themes that you touched on when it comes to crack considerations. So, if you have a crack and it fulfills all the other four factors, so, and you think the crack is into dentin and it is got a isthmus large in two millimeters and more than four millimeters, was the four millimeters in terms of the depth of the restoration?

[Taylor]Yeah, just the depth in general-

[Jaz]Occlusal gingiva?

[Taylor]Of the restoration. Otherwise just from the marginal ridge to the deepest point. And then you’re into the Biomimetic at that point. So, they tend to say then if you are kind of beyond that, trying to bond, you know, a tough bit of ceramic into that really deep box, it creates a lot of stress in that area. So that’s when you’d maybe be considering the likes of the. The deep margin elevation with a material like composite which might have a wee bit more flex in it as well, which is another benefit of that sort of technique as well.

[Jaz]Brilliant. I think we’ve covered a lot of breadth and I think we, you know, if wherever you are listening and watching this give Taylor around applause because it’s not easy to talk about these kinds of concepts. And I’m so happy to see what you’re doing with how proactive you’ve been, how you’ve been open to the universe in terms of a learner and a sharer. I think good things happen to those who share. Please continue to share your journey. I love it. It’s wonderful, Taylor. So, thanks for making time to share your learning with all the Protruserati, and I hope you guys gained a few lessons. If anything, it may have wet your appetite to learn some more, which is a beautiful thing and maybe you disagree with some of the concepts. That’s okay as well. I can always say, guys, it’s okay to disagree with your management of cracks, which may be different in a Biomimetic way. It’s completely cool as long as you have your own philosophy. If you have a philosophy rather than winging it the whole time, which it kind of sounded like I did with cracks. I promise you; I do have a bit more philosophy to it. But yeah, no, thanks so much. Any last words, Taylor?

[Taylor]No, just thanks very much again, Jaz and yeah, today, I mean, you’ve covered it enough, but I’m very, very early doors in my career. I’m just kind of exploring all of these concepts, not necessarily then taking all of it into work. So, if anyone’s kind of listening, thinking, what is he doing at this stage to do all that sort of stuff, then I feel like I’m doing it kind of safely. And you know, I think I’m being sensible about it. And if anyone’s getting any kind of questions or wants to ask anything about anything at all, then feel free. I’m more than happy to talk to anyone. If there’s anything you think would help at all, then feel free to get in touch.

[Jaz]Reach out to Taylor, guys @thehybridlayer. Again, I always, always encourage young dentists who are keen to learn, who are proactive and who go on courses like you have and you’re doing things that ultimately is gonna improve your dentistry, improve your outcome. And you are on the journey, right? Every master was once a disaster. Right. So, we’ve gotta be on our journey and the reason I got you on, it’s because you’ve spent time to think you’ve really, you know, read the books. You’ve been on some courses, you still early, you still need to drill some more teeth. You still need to remove some more cracks. But I feel as though your journey is valid and you are learning, and your sharing is valid. So, keep going. Don’t think that, ah, you know, I can’t talk about this because I’m not experienced enough. Sharing is absolutely a good thing to do. So, keep it up, my friend.

[Taylor]Sounds great. Thanks very much, Jaz. Thanks very much.

Jaz’s Outro:Thank you so much. There we have it guys, thank you so much for listening all the way to the end. Hopefully now we’re a little bit more clued up about Biomimetic DENTISTRY. Do check out Taylor’s website. I’m gonna put everything in the show notes for you, and if you’ve listened this far, you might as well claim CPD, like it’s just four or five questions away from getting a simple certificate that you can use for your end of year quota but also to validate your learning and its of space. For those of you who like to reflect and like to make notes. You can do that. Of course. Speaking of notes, all those premium notes that you see on this side. Or if you don’t see if you’re listening, you can download them as a pdf. So, every episode within about 48 hours we publish on the app. That’s a Protrusive app on Android or iOS. Do download it, do get stuck in, join the community, and gain CPD, but also watch the exclusive monthly content that Protrusive Dental Pearl at the beginning of masking a post that was actually taken from December’s premium content of actually showing you how I fit three emax Crowns and an emax veneer under Rubber dam. A full clinical walkthrough as you’ve seen perhaps on some videos on YouTube. So, if you like that kind of stuff, do check out the Protrusive app just for you, the Protruserati. Thank you so much and I’ll catch you next week.

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One of the most common questions I get from colleagues is ‘Which Intra-Oral Scanner should I buy?’ – I don’t have the breadth of experience of testing all the scanners out there, but Dr. Gulshan Murgai does!

We discussed which scanner is best for your practice and how to choose the correct one for your needs. I hope you gain insight into the differences between the different scanners and help you move forwards a decision.

For me, one of the biggest takeaways was that it may not be so much about which scanner, but more about ‘what is the customer support and guidance like after I invest in one?’

https://youtu.be/ERvzjlQaBRcCheck out this full episode on YouTubeHighlights of this episode:

2:00 Dr Gulshan Murgai Introduction
5:43 Which intraoral scanner should I purchase?
8:03 The best scanner on the market today and why?
12:37 Aligner system available for different scanners
15:17 Customer support on scanner companies
18:11 Scanner Prices
19:12 Caries detection within scanner
20:27 Importance of scanner and what’s the best for your practice

Check out Dr. Gulshan Murgai supply company Implant Solutions Direct and also 4D Ceramix, which is a full-production crown and bridge lab

Connect with Dr Gulshan Murgai

If you liked this episode, you might enjoy the Story Of Digital Occlusion

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Protrusive App!

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Ever considered moving to Dubai to practice Dentistry? Dr. Mark Georgy practiced in Abu Dhabi for 5 years, and Dr. Fraaz Ahmed moved to Dubai 5 days ago – on today’s episode we are lucky to get BOTH perspectives of life and Dentistry in the United Arab Emirates.

Fancy tax deductible Skiing + CPD next month? Check out Destination CPD by Mark Georgy

From qualifications to registration process and income potential, we covered it all in this episode.

https://youtu.be/KGCk3YcK-e0Check out this full episode on YouTube“You have to have your license already sorted out, a lot of people just won’t reply unless you have your license, which you can do remotely, you DON’T have to come in to the country (UAE)”

Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions on hundreds of episodes + You can get EARLY ACCESS to the episode + EXCLUSIVE content

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

2:32 Dr. Mark and Dr. Fraaz introduction
6:46 Considering Dubai as the place for practice
10:34 Dental Health Authority (DHA) License
12:19 Taking risks of moving to other countries
13:54 Requirements for foreign dentists to work in the UAE
17:06 Dental Protection in UAE
19:22 Family-run clinic
22:05 Contractual issues abroad
30:00 Things to consider before moving abroad
33:34 Quality of life and schooling in UAE
37:26 Income tax and income levels in UAE
44:42 Daily life in the UAE
48:38 Language Issues
49:48 Advice in considering moving to the UAE

Enlighten Smiles sponsored this episode with their great whitening products and also their course flagship composite bonding course called Mini Smile Makeover, which is really heavy duty full sequence from peg laterals to composite veneers by the famous Dipesh Parmar.

If you enjoyed this, you might also like this episode The American Dental Dream with Dr. Kristina Gauchan

Click below for full episode transcript:Jaz's Introduction: Did you know that the very first episode of Protrusive Podcast was about my experiences and Surinder's experiences when we were in Singapore? And that was kind of the reason why I started PROTRUSIVE DENTAL PODCAST. Jaz’s Introduction:Well, so many hundreds of episodes later, another opportunity has come to talk about moving to the UAE, from wherever you are in the world, be at US, Australia, UK, New Zealand, wherever you are, and starting a new life, a new career in the United Arab Emirates, think Abu Dhabi, think Dubai kind of thing. And those are where my two guests have got experiences from. And I’m really excited to share this episode, because we’ve got Mark, who was practicing in Abu Dhabi for five years. And we’ve got Fraaz, who literally arrived in Dubai, two days ago from the UK, and is living the entire sort of initiation process right now. And he’s hoping to get started working there next month in January.

So, a lot of takeaway points for anyone who’s even thought about moving to the UAE? What is it take? Are there other exams? What’s the income, like? What’s the tax situation like? All the things that you’d want to know, before you move out to the UAE to practice dentistry, funny enough, one of the the hygienist, Bev who I work with is also there now. I haven’t caught up with in a while. So I’m actually reached out to her. But there’s lots of people I know over the years, who’ve experienced dentistry in the UAE. And it’s a place that I’ve been to a fair bit, my wife actually grew up in UAE, and we’re going there again, on vacation. So it really piqued my interest, you know, my wife is actually expecting number two in summer.

So looking forward to a summer of sleepless nights. And one of the things that we are looking for in the future and a couple of years is a bigger place, because we’re in a cozy to bed, and we’re gonna need a bigger space. So before we decide on that, my wife was like, ‘But you know, Jaz you’re recording that episode with those two guys from Dubai, let’s just hear what they have to say before making a decision.’ So I guess it’s it’s on my wife’s mind. And I know for a fact that many of you listen to this podcast, young dentists around the world, the world is changing. And now we want to experience this lifestyle where wherever village or whichever city we grew up in, we have to reflect on whether that’s the place you want to practice your dentistry, and that’s the place we have to raise your children. And that’s a place that you want to retire. So the world is now your oyster. And you can call anywhere you like your home. So let’s listen to what Mark and Fraaz have to say about moving to the UAE and I’ll catch you in the outro.

Main Episode:Mark and Fraaz, welcome to this very special edition of Protrusive Dental Podcast. Great to have you. Mark I’ve known you since Dawson Academy days has been many years since I first met you. Mark just introduce yourself, if you don’t mind.

[Mark]
Thanks, Jaz. It’s great to be honest and honor. I’m a big fan and since we met in Dawson all those years ago. Yeah, so I’m a dentists, officially based in London. I’m a GDP I’ve got a special interest in endo, and went to Uni and King’s in London and graduated around 2009. And I’ve bounced around a little bit from working in Cornwall to London, then Abu Dhabi in the UAE for five years.

[Jaz]
And what about New Zealand? You mentioned New Zealand in our prior to that as well.

[Mark]
I did! Yeah.

[Jaz]
How do you skip on that? How do you miss that one? How do you forget?

[Mark]
A little bit of a nomadic lifestyle? Yeah, so I did six, it was more of a working holiday. So I didn’t count it as a proper place. But I did six months of kind of bouncing around New Zealand working enough just to have some more beer money, you know, to keep going. But yeah, that was fun, too.

[Jaz]
Amazing. And now obviously you’re based in Switzerland?

[Mark]
That’s right. Yeah. So I’m winding down my sort of practicing time in London to focus on being here. My wife works for the UN and so you know, so we decided to make Geneva, Switzerland our base It’s beautiful out here. So you know I had a camp in both foot for about a year and a half, two years. And I was commuting between London and Geneva which had its challenges but now I decided to really focus on being.

[Jaz]
Amazing and Mark for the for those of you who are who don’t know yet, Mark’s the one who’s behind this amazing ski trip in Morzine The Dental CPD destination, CPDs website, so please do check out the links below and also we’ll talk a bit more towards the end but anyone who’s up for a tax deductible ski trip there’s a few places left so come and join us if you can, but now I’ve also got Fraaz.

And Fraaz you talk about yourself man it was just the timing was just beautiful man. I saw your Instagram post and it was like one of those like bye UK, Hello Dubai kind of thing. Literally you at the airport I appreciate you so much for giving your time and you must be jet lagged and stuff to talk about your very recent now move you’re literally must or you probably jet lagged in the Dubai Mall right now.

[Fraaz]
No, to be fair, because I don’t have my three children here yet. So my children are about five o’clock which is what Dubai time nine at 9am. Anyway, so I’ve been enjoying the lions.

[Jaz]
Very good. I bet you are, Fraaz. Tell us a little bit about yourself or where do you qualify from and do a little background before I started picking up both of you in terms of finding out what is going through your minds.

[Fraaz]
So, I’m really your typical humble to GDP, so graduated from Liverpool 2012. When I’m working Southwest Wales for a bit, so back to the values that was good. I completed my masters in 2015, with Manchester University, restorative and aesthetic dentistry. Steven Davis was the guy who really got into TMD. So I love TMD now because of him, then there are lots of small courses during that time afterwards. But that’s not my formal sort of education, been bouncing around from Southwest Wales to then Manchester and Oldham. Went to Wigan for a good period of seven or eight years. And then before I’ve moved here, I finished a spell back home, home from his Cheadle, South Manchester of the year. Now I’m here. And I feel like I’m back right to the beginning.

[Jaz]
Yeah, well, you’ve been bouncing from Wales to Manchester, Cheadle. Whereas Mark’s been going from like, UK, New Zealand. Abu Dhabi. So you had different experiences. But let’s start right the beginning guys, right? So dentists listen to this, who maybe is now thinking about it, and I guess I would be lying if I said, I’m not interested. I am definitely interested. I’ll tell you why. I said to so my wife’s pregnant, we’re expecting number two. And I keep sending these links to my wife. Thank you. I keep saying these links. My wife say ‘Okay, check out this house. Check out this house.’ Because we live in a cozy, too bad and we need the space.

I’m thinking, you know, projecting two years forward, like we need the extra bedroom. And my wife has been really hesitant because she said, ‘Oh, Jaz, you told me that you’re recording this podcast episode. Maybe just hear what they have to say.’ So here we are. To any dentist who’s thinking about moving to UAE to be able to practice dentistry where do you begin? So let’s talk mindset. Mark let’s start with you. When you were moving to UAE you told me a little bit already but share it with the producer it you were it wasn’t just UAE you were considering few places you also considering Singapore and stuff. Why did you end up going to the UAE?

[Mark]
Right? Okay, so the backstory I guess for prompting the move was, you know, like I said to you earlier Jaz, I was in predominantly NHS practice in East London, which was great. As you know, and probably all of your listeners are familiar with that kind of Treadmill. Dentistry, it gets tiring physically, mentally, you’re kind of so I kind of drew a line in the sand. I was like, this is not going to work for me.

So we took the plunge, my wife and I were decided to take a kind of extended holiday slash sabbatical. We were bouncing around Southeast Asia for a few months. So while we were away I was we were both applied to jobs all over the place. And I was applying to jobs globally. I was applying to jobs in the UAE, to Singapore to see you know, where we wanted to end up. And while I was in Thailand, I’m one of the recruiters that I’d sent out my CV to has said, right, we’ve got an interview for a practice in Abu Dhabi. And I did the interview, you know, while I was on holiday over-

[Jaz]
Skype zoom kind of thing, yeah?

[Mark]
Yeah, exactly. That was kind of like the first preliminary one. I know. You know, they were happy with me. They wanted to see if we could take it forward. And then you know, it was helped by the fact that my wife has, has family there. So her parents were living there. So that was that kind of obviously made the decision.

[Jaz]
Parents okay, we said you family, I didn’t appreciate parents. That’s a big deal. That’s pretty cool.

[Mark]
Absolutely. Yeah. So we made the move much easier. You know, we had a base there, we’d already been a bunch of times to visit and things like that. So that was that was-

[Jaz]
And is that why Abu Dhabi and not Dubai, for you, personally, because parents were in Abu Dhabi?

[Mark]
Yeah, so the parents were in Abu Dhabi, which definitely helped. Dubai, and I’m sure Fraaz will probably already echo this. Dubai and Abu Dhabi are kind of two different animals. One is kind of the older, more sensible parrot. One’s the wild child. But, you know, they’re both super fun places to be with, you know, I’ve always liked and preferred Abu Dhabi. It just kind of, we were drawn into it, the green space and the seas, like kind of is the backdrop for everything really in the city. So yeah, that’s why we’re drawn that. But yeah, a couple of interviews later and you know, kept going and we ended up there. Yeah.

[Jaz]
Great. And Fraaz, ou’re obviously in Dubai right now. So you tell me did you go through a process of thinking about different places to move to and again, I guess my question is, why did you move from UK to now in Dubai and you’re obviously taking your family there as well? And did you consider any other places or was it always gonna be Dubai for you?

[Fraaz]
Dubai was actually my wife’s dream. And then this fully because the dream then changed as she got happy. Just live in the UK life. We will Welcome to UK when she got happy there, I was sort of like I want to do something else. Dubai really came along similar to Mark in the sense of we actually have family here. So that’s why it was the other location that’s easy to move to. My inlaws, I have a lot of in laws in Dubai. That’s the main reason for here. And then literally, it was over a phone call. So last weekend of June, my brother-in-law calls then goes, ‘We’re opening up this polyclinic. Do you want to join in?’ I’ve had my DHA license for a good, I think five or six years? Like, ‘Yep, let’s just do it.’ We just made the decision on the phone.

[Jaz]
What’s the DHA license? Is that something that you had, yeah?

[Fraaz]
Yeah. So, the Dental Health Authority, so the equivalent of sort of the GDC for Dubai.

[Jaz]
And how did you have one six years ago?

[Fraaz]
So they’ve got like a fairly simple website as he goes through like Cherian portal. You just follow the flowchart, submit your documents, certificates, things like that. You do have to do Prometric exam. So I just went to a like a center in Salford, did set of exam on there fairly straightforward. Yeah, that was it, then you just get your license. You have to get a job though, to make it active. So I actually still don’t have an active license yet until we get the practice up and running. Yes, it’s fairly straightforward. As long as you don’t mind the-

[Jaz]
It was always in the back of your mind, then? Because if you had this license, you must have at one stage had the intention or the desire in the back of your mind? Right?

[Fraaz]
Yeah, so it’s actually quite funny, because when I got the job in Cheadle, I did my NHS to private transition completely. And I’d given up on the sort of the Dubai dream because I just had a bit of an issue with applying for jobs I just didn’t quite get a sense of, let’s say professionalism was a bit different to how it was in the UK when it came to contracts. I’m not sure what Mark’s experience has been like over there. But I just thought this is how much hustle we’re having with jobs now, remotely. I totally want to, I was too scared to take the plunge, I would say, to move my whole family over, and then have contractual issues. That’s how it felt. And then it was just that June, that phone call where just the opportunity came up. And I was like, ‘Yeah, we’re going to regret it if we don’t try it out.’ So, I’m here-

[Jaz]
And one thing I want to see is on your Instagram, I see you know, you have some beautiful dentistry and looks like there’s no shortage of patients and stuff. And so did you feel as though you’re taking a big risk? Like imagine someone who’s got like, a steady income as a dentist, maybe a mortgage, I don’t know if you had one or not etc. and then to sell up and give up everything to move. That’s a big risk, in a way. I guess it’s helped by the fact that you’re moving to a family sort of venture, I guess. But tell me about your thoughts in that regard?

[Fraaz]
Yeah, so I think financially, yeah, there’s a financial risk, but I think over, although I know I think to a lot of my older colleagues, I would still be see it as like a fresh new dentist. I feel like after what, just over 10 years experience? I feel like you build that confidence in yourself, you know what you can do. I’m quite confident in the level of customer service and Dubai, a lot of it is about service. So I know that I can bring that service to here. It’s just about you got people through the door. I think we’ve got the location right. And then we’ll see. I think another person that helped me was I don’t know if you’ve had James on one of your podcasts already. James Martin, so-

[Jaz]
Yes.

[Fraaz]
He was somebody as well, I was speaking to a lot. And he changed a lot of my mindset with the whole thought of money. So you realize it’s quite, it’s something which you don’t really have to have much of an attachment to? There’s always ways to make money. So you do what you love. And you’ll always find a way.

[Jaz]
Well done for chasing your dream or as a wise man, you chased your wife’s dream. So even more brownie points and whatnot, so well done. And both of you, I did right by your significant otherss sounds like. So before we-

[Fraaz]
I hope so.

[Jaz]
So before we come on to the spicy contractual things, which definitely piqued my interest. Mark, what are the requirements, like if dentists in the UK is thinking, ‘Okay, I want to go like, for example, when I had to go to Singapore, I had to like, agree to a position, I had to get some paperwork with the SCC, but there wasn’t the exams to do.’ I guess Fraaz already touched on it. But do you want to summarize in a paragraph? So what are the requirements that you need tickbox as a UK and maybe international dentists to work in the UAE?

[Mark]
Sure. So kind of, for us, that there’s quite a simple process in terms being and I can talk about the HAAD, the Health Authority Abu Dhabi, which has now transformed into the DOH, Department of Health. So they operate kind of independently. So between Dubai and Abu Dhabi, there’s two separate governing bodies. The first step in terms of is your accreditation. So you have to go through something called the data flow, which is like where you submit your papers, work through, you know, it’s an outsourced company that will validate everything, all of your degrees and your references and things like that. In terms of exams, there’s for Abu Dhabi. There is nothing that you have to do if you’re graduate from the UK, Australia, New Zealand and a couple of other countries, I think the US as well. So from that side, it’s fairly straightforward. The requirements are just that you have all of your paperwork is in order.

So I actually applied without having had the job, you know, in my hand, and you can get through all of the paperwork, it’s kind of get somewhat accredited. And then finally, the last step is once you have the job, you kind of attach that on to your license. And then you license and gets attached to a facility, which is kind of obviously the practice that you’re going to be working. If I missed anything out, I think that’s, that’s pretty much it. It’s a straightforward process, it is timely, it took a good like three or four months minimum to kind of get through all of that, because they will send back things for more rubber stamps.

[Jaz]
That’s an important point, because that’s three to four months of loss of earnings and something that a dentist should keep in mind and then plan for and accommodate for. Fraaz, anything want to add to that, because it’s all very fresh in what you’re living through right now?

[Fraaz]
Yeah, the only thing I would say to add, well, I wish I knew there was a Prometric exam for the DOH license, because I think it’s quite easy to then switch them across, I believe. So I would have maybe done it that way around. But anyway, it is done now. And regards to, if anybody’s thinking of it, because of the amount of months it takes later, they do come back and forth with small tweaks you need to make. My advice if you’re thinking get your license done now. Iit’s not. It’s not too costly. I can’t remember the exact cost, it’s on the top my head but I think it was less than 1000 pound when you equate it for the license. So if someone’s thinking of it, just go and do them get your two or three licenses sorted-

[Jaz]
And that’s a one off rather than an annual release renewal. Right? So one off,

[Fraaz]
There is an annual renewal fee but it’s fairly inexpensive. I think it was a few 100 dirham, which is-

[Jaz]
Oh it’s like GDC money, it’s like-

[Fraaz]
No.

[Mark]
No.

[Jaz]
That’s a lot of benefit.

[Fraaz]
You have three UDAs. All three UDAs pays for your renewal.

[Jaz]
You know what, on this topic, and this might be complete rumor, this might be false, right? And this might be, I might be talking complete garbage. But one of my old principals told me that some of these Arab countries, that there is no such thing as dental protection and stuff because if something bad happens, something wrong happens. It’s Inshallah, that they say that it’s what it was meant to be. Is that correct?

[Fraaz]
Mark, I think you’re probably in a better position than I am since I’m at the beginning of the journey.

[Mark]
Okay, well, yeah. So, I mean, there is indemnity, but I think it’s related to the facility rather than the clinician. I know, certainly, that I didn’t have indemnity that was directly associated to me. And my practice owner was kind of deducting a small fee, but it was nothing like what we’re used to paying in, in the UK. I mean, I have also heard stories of you know, you know, surgeons that, you know, if something goes wrong, they’ve got the passport, and then they leave the country. I don’t think, I think those are all urban legends. I don’t think they’re actual reality. But yeah, I think that certainly that the level of litigation that clinicians face in the UK is not not there, in the same way.

[Jaz]
Like in Singapore, they had dental protection stuff, but my fee was like, a quarter of what we would be paying here, basically. And that’s how it was and even then, it was like, a must, it must have been compulsory, I guess. But it was very rare for litigation to be at the top of someone’s mind as a dentist and I imagine it’s the same there.

[Mark]
Yeah, I mean, I think in the same way that you practice defensively or you practice carefully and you always try to do the best for your patients. It goes without saying right? That’s how you get to operate in anywhere.

[Jaz]
Just because you don’t have it doesn’t mean you end up being reckless. Of course you’re supposed to stay true to your ethics and whatnot, but it’s just a requirement wise it’s good to know that okay, maybe a medical legal, just wanted to get the medical legal landscape, I guess.

[Mark]
Yeah, absolutely. Yeah. It’s different in the sense that you know, I didn’t pay any dental indemnity protection while I was there are that was significant. It was only coming out of, it was not even noticeable. So yeah, it’s definitely not the same figures that we were looking at in the UK.

[Jaz]
Sure. And for us, what’s next for you now? So you got your license years ago, in a way and now you’re waiting for it to become active. Now tell me about this polyclinic, this sounds like a family kind of, are they doctors? Are they creating a clinic with different specialities?

[Fraaz]
So my wife and her sister or two sister they’re all chiropractors. So two of them obviously my wife comes over. They will be having the chiropractic side in the polyclinic. This is where I think if Steven Davis just does listen to this, he might be cringing a bit because I incorporate them into my TMD wear. As to do a podcast on that, I think chiropractors of TMD. So they’re there.

[Jaz]
Let’s make that happen for us. And we’ll get your wife on, we’ll have chat again about that, you know, you definitely piqued my interest. And we need to geek out on TMD stuff for sure. Yes, carry on.

[Fraaz]
Sounds brilliant. We’ve got like a medical GP, obviously very different to the UK, because all insurance based here, or just pay as you go, then we’ve got some aesthetic sites like laser hair removal, like the HydraFacial stuff. That side of everything I’m not really getting involved in, that’s my sister in law’s husband. So I just called him, he’s just a very good businessman. So he’s got a couple of yachts here and car hire. And this is his next venture. And then I’m basically essentially similar to a typical UK setup where I’m almost renting the space and doing my own thing within the polyclinic.

So with those, we have a license on the six specialities on the clinical already. And we need to now get the radiology license and then the dental license will be something we’re doing afterwards. So we’re doing that now. We’re currently in the process of it. Once that’s granted, then I can attach myself while I’m attached with the license on the practice, and that I can attach myself my personal license to be able to work as the dentist inside the clinic, if that makes sense. So I have like a flow diagram of how everything’s attached.

[Jaz]
Sure, sure. I mean, your situation is very unique. If you want to go down, the more Mark way of applying to a cold practice, someone you don’t know, principal who’s looking kind of thing, essentially, is they probably have to do a bit of paperwork, you have to do a bit of paperwork, and they sort of need to sync together to activate the license. Is that a good gross summary?

[Fraaz]
Yeah, to my knowledge, yeah. So as I got that far with a few job offers, where we got to the contract stage, and that’s where everything sort of fell through. However, it was just that they just need to activate my license attached to the clinic as Mark pointed out before.

[Jaz]
Fine. Now, before I ask you about the contractual issues, I have a very good friend of mine, who practices I’m not gonna say in which country, but country we all know very well. And then he also considered going to Dubai. And now I’m thinking very carefully. Should I continue or not? I’m going to continue. So he was Indian background. But he had a very good Queen’s English. He had the Queen’s English, okay. And so he felt really betrayed when he went to Dubai and having some interviews by principals and stuff. Because this is what the principal said to him. He gave him a contract, which was he actually no, he didn’t give him a contract. He considered it but it didn’t, because this is what he said to our our brown skinned Indian dentist. He said to him, ‘If I shut my eyes, and I give you the contract’, basically, he’s trying to come say that he can’t decide where he’s is an Indian dentist, who is your British dentist, basically.

So it’s racism there basically incident that will either contract or give you either offending the Indian or offending the Brit. Because, you know, I can’t believe that when I open my eyes, you’re a brown guy, but you speak such good English, that’s kind of direction was going and I’m not saying that all principals like this. But that was one N equals one experience that with that I heard of him, and then he end up going to different country, he’s thriving, he’s doing very well. So that’s one thing that I had heard, obviously, might be very different to the kind of contractual issues that you’d come across. And the professionalism, you mentioned, that word professionalism was a bit different. And that’s, you know, funny enough the experience I had heard, so tell me Fraaz and Mark, any stories that you have anything like be careful with this or any lessons?

[Mark]
Fraaz, I’ll let you take this one first.

[Fraaz]
So my experience is fairly limited. Of course, I know, racial issues, I understand where you’re coming from, but there’s no issues of prejudice from that. My contractual issues were more when I was looking for a job or how to be quite plain about it, I pretty much told the two jobs that I was going for, that I needed to come on a similar salary to what I was earning in the UK, in order to be able to fund and keep my family lifestyle, the same it was at that time. So we’ll try to figure a way where we could see if I did actually earn that amount every year-

[Jaz]
Of retainer? On your first few months that we had that thing, we had six months retainer that, okay, if you grossed above it, you get more, but as a minimum, just to help you settle in you have that. So it’s a good thing to have, I think when you’re moving abroad, and I think it’s very fair that you asked for that.

[Fraaz]
Yeah. So I think they were trying to work out how they’re going to put that in the contract. And then the two clinics I applied for, there were then I’ll speak like a general dentist from the UK. He was like the manager you could call it and they were owed by saver, the businessman that one was there from different countries. We’ll try keep it as anonymous as possible. And I think it was the communication between there that they had issues. So it just came to where there was just delays and delays. I think so do you have a contract and other contract? And then it’s just mutually we’re like this is just not going to work out.

So let’s just leave it so that was with those two jobs. It turns out the racial prejudice though. I’ve not felt it personally. Obviously, this is my own clinic. So are we from a social media marketing and so on? I’ve not had any, I’m gonna have a feeling of that either. So for me personally, you know, I don’t have any stories, but I feel like especially where Dubai is now is even different to where I used to visit 10 years ago. But this way, I think Mark can probably give a lot more insight and knowledge on two things.

[Jaz]
Yeah, Mark, tell us about actually be not only any contractual issues better than actually being a wet thing, a dentist in the UAE in Abu Dhabi.

[Mark]
Okay, so well, I mean, so in terms of the my working environment, and you know, the practice, just to give you a bit of background of where I was working, because my situation was a little bit unique as well. And the practice I was working for was owned, and, you know, by just two brothers that were working in the practice, so we had an orthodontist who was working in the practice, and, you know, prosthodontist, that was working in the practice, and they were brothers, one was like, CEO, and the other guy was like, in it. So they cared a lot about their patients, they cared a lot about, you know, the equipment, the materials, everything, and how the practice was operated. So, I think a lot of the problems where people may encounter issues with these contracts and things like that is potentially where there’s kind of, I guess, a separate business entity that has got no relation to the dentistry and-

[Jaz]
Like a corporate, right? Like-

[Mark]
Yeah! Corporate.

[Jaz]
You’re kind of describing a family run clinic versus a corporate really?

[Mark]
Absolutely. Yeah. So and, you know, the corporate jobs, you know, exist in clinics, and they exist in hospitals in the UAE. So you know, you can find fine, every permutation of that. And I think the family run business in the UAE is probably getting smaller as a proportion of clinics. So, you know, I was lucky to, you know, effectively by chance, stumbled upon that opportunity. And not only that, you know, we had a polyclinic in the sense of dental polyclinic, we had an endodontist, periodontist, you know, pediatric specialists. So, everything-

[Jaz]
Were they all trained within UAE or did these dentists qualified from around the world?

[Mark]
Yeah. So they’re all from all around the world. Our endodontist was from Turkey, my pediatric specialist was raised to do sedation clinics with was trained in the US, but he was originally Libyan heritage. We had prosthodontists from Syria, the orthodontist and the other owner were both Palestinian. We have Lebanese Periodontist, so it was great. I mean, they’re all from I guess, you could say the Middle East and Middle Eastern heritage. But yeah, we had a very intimate-

[Jaz]
I love that about Dubai, man. I mean, guys, you guys might know this, but maybe I’m saying it wrong. But I think one in five of the people in UAE are actually Emirati, like maybe that’s the wrong stat, but something like that, right, like, so people are from all around the world. And I remember being on holiday in Dubai, and being in this lovely restaurant and the South African couple were eating next to us. And the man who has been there for like 20, 30 years described Dubai as Disneyland for adults. And I’ll never forget that.

[Mark]
Yeah, you’re absolutely right. It is a little bit like that. Yeah, you did. The Emirati population is only 20% of the full of the whole country. So yeah, they’re a minority. But, you know, it’s an amazing place in that sense. And, you know, I have never experienced that kind of racial prejudice, it’s sad that the people do, I’m sure it exists it probably in the way that it does everywhere. But you know, luckily, it was an issue and I think it’s not something that’s common, but I’m sure it does exist.

[Jaz]
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Yeah, but I’m kind of glad I didn’t get it out there in terms of like a Just be careful kind of thing in case you come across this but yeah, hopefully it is just a one off kind of thing. And it’s not going to affect anyone, we kind of covered already in terms of processes and how long it takes, make sure financial advice, make sure you have four to five months worth of supply to feed yourself and your family before you go out there. If you were to do something like that, before you get your affairs in order. And anything I just want to add so far before we now talk about quality of life, which is what life is about right? It’s not about yes, it’s about the dentistry, is so important. But you know, how can you nurture and raise children in a country like that the school system, the income, all these things, but before we get on to the fun bits, anything you guys want to add in terms of contractual getting to work there, the systems or anything like that?

[Fraaz]
I think in terms of jobs themselves, I just speak to a lot of dentists who are already here, I think it’s very limited with applying for jobs when you’re not in the country, for a couple of reasons. So number one, I think you almost now. So given you have to have your license already sorted out, a lot of people just want you to reply to unless you have your license, which can also remotely, you don’t have to come into the country, which is great or-

[Jaz]
That is golden advice right there, the thing that you told me.

[Fraaz]
And then number two would be if you are really serious, and you can’t take the financial hits to come over, maybe some of the busier times or busier periods, unless you physically present yourself to this sort of clinics after do some research. Because a lot of people in Dubai will just go jobs like that they literally walk in with a portfolio and be like, I want a job, let’s negotiate type of thing is from people I’ve heard secondhand, but I’ll show Mark, if that’s similar to what you would say or something a bit different for your experience.

[Mark]
My weigh in was a little bit different. But you know, I think as you said, for us, I think no one will give you a look in without the license because it can be such a long, lengthy process that will filter out so many people. That’s something that you definitely have to have, you know, 80% done or pretty much done. And then I think it’s in the same way that you select any job I think, a little bit of reflection and time taken to choose a good fit is important, especially important when you’re moving abroad as it is in the UK.

[Jaz]
Guys, episode one of the podcast is all about my experiences moving to Singapore and came back and at the time I talked about the Singapore dental classifier on the SCC website, there was like this monthly PDF that would come out with all the sort of different vacancies. Where do you begin to look for a job in the UAE as a dentist? Is there a community forum? Is there something that’s like the BDA equivalent like a website? Is it indeed? Or I don’t know? You tell me.

[Fraaz]
I use them. Indeed. Just Google jobs with the main two. And then through some of the dentists in Dubai, they’ve got like a British dental Whatsapp group, which I still need to get myself into. There are people just post on there. People just post on the WhatsApp group like looking for a dentist and we know anyone. There’s not so much of how in the UK we’ve got like Facebook groups and what I tend different Facebook groups among dentists, so if you have an argument of one dentist, you can join another one. You don’t really have that over here. As such, there isn’t like a UK or British Dental Group or Facebook, to my knowledge that everyone sort of uses, dollar mark Wales you used?

[Mark]
I mean, the only other one that I can think of there’s a golf based site called bayt.com, which I think they post jobs on but and then actually, you know, I send my CV out to recruiters so the recruiters would have actually called me when the opportunities came up. And that was how I got in.

[Fraaz]
I think, just to be careful of, just last a tad is there are quite a few scams that go around as well. And some of them can be quite realistic because there’s just as you mentioned rubber stamps before then they love rubber stamps over in Dubai. So they’ll send you lots of official looking things. So you have to be careful as somebody who can be quite tricky scams. Yeah.

[Jaz]
That is really valuable, man. That is good to hear that. Well. It’s sad to hear but it’s good to have our wits about us and antennas.

[Fraaz]
See that Mark? Mark, I think enjoys a rubber stamping. Group of stamps.

[Jaz]
I think you both have been through enough rubber stamping. Right. Let’s talk about quality of life. You both got three children, right. So I know Mark, your youngest is two. Fraaz, how old your youngest, and your eldest?

[Fraaz]
So they’re five, three, and one.

[Jaz]
Wow. You’ve got such a young families. That’s amazing. So I mean, you bet. I mean, Mark, you’ve already experienced a schooling system there to some degree. Fraaz you already see at the very front of your mind, you’re thinking about where my kids going to school and stuff. So a lot of dentists when they’re moving, a lot of people in general in any career when they’re moving, they’re either at the very beginning of their career, or maybe towards the end of the career. So children come into the factor for to those young dentists maybe starting a family and stuff. So how does it work?

Schooling, I’ve heard conflicting things I’ve said schools can be very expensive, but at the same time, I was saying to Mark to get domestic helpers is like, amazing. I get nannies and stuff very accessible. So Mark, let’s go with you. What advice do you have to a dentist who’s thinking about taking their family like you guys did to UAE?

[Mark]
Sure. So we had actually had both two first kids while we were living in Abu Dhabi, my eldest Jonah started school there. So we had him in the lease in Abu Dhabi, which is the French schooling system. And, you know, the quality of the schools is amazing. The teachers in our school certainly were all civil servants from France that were there working there. So you had and it’s the same for the British schools. So they’re all privately funded schools. So you have an American Academy, you’ll have B sack which is the British schools schooling system.

So wherever you’re coming from, you can actually almost transplant your kids. And they can have the same sort of educational continuity that you had. That they were having while they were back home. So the schooling is good, it’s expensive. And there is competition. I think the competition is even tighter in Dubai to get places. So people you need to apply early to get spots, but you know, your kids can get in everywhere. In terms of fees. Yeah, the fees are not cheap, but you know, equivalent to, let’s say, private schooling in the UK, I think.

[Jaz]
Okay, they are similar, they’re not like astronomical out of reach kind of thing. Like, if someone’s already paying for private school in the UK, they could probably then also transfer that to Durham’s and afford a school in the UAE. Is that fair to say?

[Mark]
Absolutely. I mean, I can give you a rough ballpark, I think we were paying about 30,000 dirhams for our son’s school. So and that was like, for the French system. So I don’t know what the other schools in Dubai are like, probably the range is big. And I’m sure you can pay up to 100 per year if you want to-

[Jaz]
Of course, so Fraaz, what are you thinking for your children? Have you found a school ready for your eldest?

[Fraaz]
Yeah, so the eldest two will, because in January, there’ll be six and four. So they’re, they’re going into the January, we find a school for them. Echo what Mark said about the competitiveness. January seems to be a decent time because a lot of people leave the UAE and new people sort of join just seems to be the way the system is over there. So places do free up. So we’re quite lucky. So we’ve got our places in school we wanted and they’re with their cousins, because I’ve got cousins the same age.

So yeah, so we’ve been quite lucky though. Most of our family helped my toast my sister in law did all of that. All I did was, have you found the school was good, but wife, a sister in law communicated all I did was to deposit by let’s transfer it that’s all. I was just transferring the money. That’s about it. I think in terms of cost, I think maybe a little bit higher than the average of the UK but not much more because my eldest two who are already in private schools at the moment this may be in great British pounds maybe two or 3000 pounds difference over the year per person so I suppose it’s not a crazy jump are a-

[Jaz]
Little bit dearer. But I guess the elephant in the room is, there’s no income tax. Let’s just get that out now. There is no income tax now. Have I got that wrong or right? There’s no income tax in UAE. Right?

[Fraaz]
No, there will be a 9% corporation tax on businesses come June. Next year. That’s coming into effect. But I suppose like the UK just find a good accountant. Miles away. No. So way the system.

[Jaz]
Amazing. Well, that’s one good thing. In terms of income levels, though, you know, when we talked about the first episode, when I called with Singapore, and when my guests are in there talked about what you can earn as a dentist in Singapore, it was really important that we reflected a range because if you ask how much you can earn the UK, you’re gonna have a range, right? Associated with a monthly take home will be in a wide range, it could be from 3000 to 40,000.

In the UK, it could be, right? If you think about it, so maybe not as wide as that. But as a remuneration kind of concept. Do you think you can live the same lifestyle, if not better in the UAE during the same time dentistry that you’re doing here? Or is it going to be a bit more of a squeeze on your finances moving to UAE as far as you get the vibe and as far as you feel? God, Mark, you go first? Because you-

[Mark]
Okay, all right. Yeah. So I’ve done time there. Yeah. I mean, I think you can definitely match your salary in the UK. So I didn’t really take any hits in terms of what I was taking home.

[Jaz]
Like the net, right? Because the gross might be low in Income tax. Right? So we’re talking net?

[Mark]
Yeah, exactly. Exactly. Okay. So if we’re talking net, maybe it was effectively is about the same. I think the key thing here is also makes a big difference what the environment and the system that you’re working with. So for example, our practice was mainly treating Emirati patients. So we had an Emirati base and we were treating using one particular kind of insurance or mainly one kind of insurance.

So one thing to this important to note is the patient base wherever you’re going, because if they change the insurance rates that they pay out to you that can impact your pay almost overnight. Right. And that happened while I was there. So but you know, as I arrived, and towards the end of where I left, yeah, it was matching matching what we earning in the UK. So that’s your same range that you could have in the UK exists.

[Jaz]
Thank you and Fraaz, what are you expecting because obviously you haven’t worked there yet. So what are you kind of expecting? It’s scary, I’m sure but what have you got in terms of financial planning?

[Fraaz]
So I think in terms of like, I think with like dentistry, going back a little bit, you’ve got different personalities. And I think of applying the same personalities. So going back to the big DF, so like, VT purse, I was type person, I said, I need to become good at extractions. So I don’t care what that radiograph says, I used to go for everything. And I got myself to a lot of problems. But that’s how I learned maybe dangerous in the UK climate, but I got through it. And I learned a lot, so very much sort of going in with that similar sort of approach. So I’m trying-

[Jaz]
You’re just focusing on the quality of dentistry and in a good advices, you’re gonna see, you’re gonna hopefully, see that reflected in income over time.

[Fraaz]
Yeah, yeah, exactly. I’ve made contingency, obviously, got my financial sort of plans in my mind of, you know, what your thresholds of how long you can sort of live for and so on. I mean, I sort of haven’t tried to too much look at the other markets. Obviously, you’ve done your normal, you’d almost have to compare yourself. But I almost feel as though like it with me. If you look at everyone else, sometimes you may confine and restrict your own ideas. Sometimes it’s good to let your mind just go, what do you think is right, and do what you think is best if you have the confidence. And then you’ll tweak it. So my first child wants is, I call it my tweaking 12 months, I’ll learn and then we’ll take it from there. So my assumption at the moment is I don’t know.

[Jaz]
That’s totally fair. I mean, I wouldn’t expect to know all the answers, but it’s good inspiration for someone who might be thinking of moving there in terms of okay, what to keep in their mind. So, I guess a summary of that is yeah, the earning potential is there. Would you say and here’s interesting when you say, based on you Fraaz, your perception and Mark your experience, in terms of the ceiling, in UAE?

Do you think it’s higher for income in terms of if you look at the averages in the UK, from your colleagues and stuff from what you feel. And then perhaps a ceiling? And you are you do you feel as though the ceiling might be higher because of this whole you know, you see on Netflix, Dubai blinging stuff, and it’s a very affluent place, and maybe the top denture you’re doing, is that a fair perception?

[Fraaz]
HSC Mark, before you answer that, if I give you my perception, and we’ll see how that lands with your experience, sure. Because it might be different to all so because in my mind, generally what I’ve learned is, end of the day, even in the UK, you’re going to hit the ceiling. See, it’s it’s hard to put a finger on it, until you make it into a business which then you’re almost no longer a dentist, you become a businessman and your dentistry is a secondary, you either open a practice or whatever dental type of business you go into, or you hire associates, things like that. And I feel the same exact same thing with Dubai, just like Dubai is a place where Dubai is of our business. How would you meet it? You moved to Abu Dhabi, that’s how I understand it.

[Jaz]
Mark, what do you think about that?

[Mark]
Yeah, I mean, I think you first kind of knocked it right on the head, you know, that there is probably a ceiling that you are going to achieve with being an associate in the same way that you probably will in the UK. And that ceiling can be super high for some people that are putting in implants, you know, eight hours a day versus someone that’s, you know, doing our simple class twos, but, or not so simple class two. But you know, that’s in the nature of it. But yeah, you I think the word of caution, I would say is that it’s, you know, people have this perception, and it’s probably a well crafted perception of the UAE and Dubai that they sell an image of the streets being paved with gold. And as soon as you come here, it’s out of your pockets.

And, you know, you start going to the vending machines to buy gold bars, and you have a cheater in your car, you know, some of these images do exist. That’s there. It’s not something that there is a real Dubai and a real life and there’s like people that are kind of living a normal life and that’s kind of the reality of moving anywhere, right like and Dubai or Abu Dhabi is no exception. There’s normal, normal life that’s going on. And I think by moving there, you’re not suddenly going to be erupting and cast.

[Jaz]
Yeah. And then when I remember when I moved to Singapore for work, and I had a great time there. But then I had to keep telling myself that whilst I’m here in Singapore on holiday, I need to appreciate the holiday is not real life, and that your real life experiences are going to be different to experience on holiday, you won’t be eating out lavish every single day. You gotta get you know, think about and visualize what daily life might be like. And I suppose that’s important to keep in mind when you go to visit a place I’m sure you guys would agree. The other thing I want to cover is final bits is like daily life in the UAE, like the heat in the summer is unbearable, they say and also in terms of the timings, is it right that a clinic would open maybe in the morning and then take like a four or five hour siesta kind of thing and then open the evenings, Mark what was your hours like?

[Mark]
So our hours were not like that. Actually, we worked. So when I first arrived to Abu Dhabi, we were working six days a week, which was at back then very normal. So we were working. And we only had Friday off. I was wanting to convince my boss that we have to close on clothes, what an extra day. So we’re going to have a two day weekend. And now I think officially, actually, so where it was a Friday, Saturday weekend, I think it’s shifted now in the UAE. So you’ve got to find it, you know, Saturday, Sunday weekend. So that makes things a little bit easier. The work hours are long, but no, we didn’t have, you know, the siesta time in the middle of the day. And it was a normal, sort of, I think we started at 10 and finished at six or seven, something like that. So that’s kind of how our clinic was run.

[Jaz]
Fraaz, what about you in terms of the jobs you apply for and also the polyclinic, in the future, have you decided on timings?

[Fraaz]
I’m actually still in the process of deciding. I have come to understand that if you don’t open a certain hours, which can be quite early morning and late afternoon, early evening, then you are really going to miss out on sorts of clientele so I’m still deciding at the moment. I like to my take on an associate and so on. So I’m not to set but I think we will be doing a similar pattern to what you said maybe not four or five hours, but a couple of hours close in the middle of the day.

But everyone do the school runs and so on because Dubai is a bit early than some of the American timing. And they will probably reopen but I’m still yet to decide. But I’ve come here with the mentality of for the first few years it’s gonna be like, it’s gonna be hard work not used to my nice cushy associate four and a half day nine to five and 9 to 5 and 9 to 1 as it was in Manchester, with my clinic given me all my patients and yeah.

[Jaz]
Yeah, I’m excited to follow your journey, Fraaz. I have every faith in from what I’ve seen so far. So now, I wish you all the best and my friend honestly, we all we’re all rooting for you everyone listening right now. We’re all rooting for you. Exciting story. And again, so thankful that you gave up your time fresh in Dubai right now and how exciting that we had your sort of input from that as well. I guess the final bits to talk about now before we wrap up this podcast is any final bit of advice that now you’ve thought of now that we’ve discussed everything, to anyone who’s probably thinking of moving to the UAE for work from wherever they are in the world US, Australia or wherever, anything that we haven’t covered yet that you want to leave everyone with, because we’ve talked a little bit about lifestyle.

I mean, one thing we didn’t discuss a lot about is having a nanny and a domestic helper, but from what I understand that’s quite a thing there. That’s quite common place to have that for childcare, and that really helps massively, but anything else on that vein, either work related, or culture or quality of life related that you want to leave the listeners and watchers with, Mark?

[Mark]
I mean, you know, I think we’ve covered most of it, I guess, you know, the UAE did give us a really great five years, we were privileged to enjoy a really great time there. I think the one of my motivating factors and was being able to be out in nature, and I think, you know, it isn’t necessarily the as I said before, the bling bling culture doesn’t have to be the basis of you moving there while it exists. You know, we did a lot of camping trips in Oman and diving trips and Oman and things in the beach and you know, hiking mountains and things like that. So we had great communities and in you know, in the gym and things like that. So there are still cheap beats and stuff. So there is every kind of lifestyle that you want to pursue there you can find.

[Jaz]
And Mark, is there any point have any language barriers or anything issues that thing’s worth checking on after five years, did you find the fact that I don’t know if you do know Arabic or not, but any issues like that?

[Mark]
Well, so yeah, so I’m Egyptian by heritage. So I speak Arabic. My Arabic was not great when I arrived. But it certainly got a lot better because as I said a lot of my patients were Emirati and it’s a tough, it’s a Scottish of Arabic, really, it’s a challenge to understand. But you know, they’re all really great. The patients are really nice and patient and the official work language is English, right? So you don’t need to speak Arabic to move there. So-

[Jaz]
Yeah, that was the same in Singapore, you didn’t need to know Chinese or Malay or anything like that. And it was workable in English. So it’s good to just know that’s the case. Fraaz, do you speak Arabic or any of your colleagues where they already have any language issues?

[Fraaz]
No, I’m the only one who unfortunately my family that’s not like bilingual so my wife speaks Arabic, which is more the classical Arabic. My kids, we’re trying to get them into that. So Dubai hopefully will help and then see my in laws. So like the odd one out in that respect.

[Jaz]
We’ll have to follow up and make sure you’re doing okay and Fraaz, anything that we haven’t covered yet. They want to leave as a final thought of this podcast.

[Fraaz]
Yeah, I think my similar intentions of living here have quite similar to Mark’s where I’m not trying to chase the Ferrari or the Rolls-Royce or the villa that’ll all be nice if it comes. But that’s not the intention, the intention is to, to enjoy life for what it is over here. A couple of things that pulled me in that some of you might be thinking of is like the safety aspect, a good example is just now. So as you know, we’ve had issues with be setting up for this podcast, I tried to run over to die.

So to try and get like an adapter for the headphones, I’d left my laptop, iPad phone, everything, just on the Tim Hortons counter, just went over and I know what’s going to be there, when I come back. You know, I know it’s not gonna be taken or anything like that. So simple, small things. So safety, that’s a big factor and the lifestyle I think you can make about what you want, really. But again, as Mark alluded to sooner, you can lose a lot of money as well, if you decide to pursue the Dubai bling pathway. So you have to be quite careful and know your personality quite well. Keeping up with the Joneses, I think is quite easy to get into over here.

Jaz’s Outro:Of course, in any way of life in any culture. Mark, Fraaz, thank you so much for making such an enjoyable fun podcast about moving to Dubai, I guess my wife will have to listen to it and make of it what she will. And I guess you’ll hear from me, for my principals who are listening, don’t worry, nothing’s gonna happen. I want to be one practice for a long time. But if you piss me off too much, I’ll be on the plane to Dubai. Thanks so much, guys. Well, there we have it, guys, thank you so much for listening all the way to the end, I hope there was lots of nuggets, lots of food for thought, maybe you are settled wherever you are working, maybe you’re happy where you’re working. But it’s sometimes good to know what dentistry might be like in another country. So hopefully, you’ve experienced that today.

And if you’re someone who’s actually actively looking for a big shift, and maybe you’ve been thinking about UAE, I’m sure there was lots of nuggets in there for you as well. This episode is not suitable for CPD, there wasn’t enough meat in terms of CPD, but most episodes are suitable for CPD and CPD certificates. And obviously, that’s all on the app on Google and on Apple, and even the web. So you go to protrusive .app as a website, or download it on the Apple Store, or the Google Store, and I’m constantly adding exclusive content, some of the new content I’m working on now is a full clinical video of me prepping and bonding four units of ceramic under rubber dam.

This is a case where also I had an interesting black triangle when I was trying in the ceramics and how I manage that by sending it back to the lab and how my technician was expertly able to fill in the black triangle and how good it looks now. So lots of learning points in that. And that’s all in the Protrusive Premium Section of the app. And you can also of course interact in the community section and be able to download the videos for offline listening. So in case you have choppy connection, you can just have it downloaded to your device. So that’s all of the Protrusive App. Thank you so much. Once again, I’ll catch you same time, same place next week.

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I admit it. I have relied FAR too much on my lab technicians to help design my chrome partial dentures. This needs to change! I realised that I want to take control of the denture design process – who better than the King of Removable Prosthodontics education Dr Finlay Sutton to help us ‘Make Dentures Great Again’!

In this episode, Dr. Finlay Sutton clarifies the philosophy behind Scandinavian Chrome Dentures. He also explains what each appointment entails to help those earlier in their career.

https://youtu.be/3aS7kZZUM_0Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content

The Protrusive Dental Pearl: DENTURE DESIGN CHEAT SHEET! Dr. Finlay came up with a Universal Design Sheet. It covers all aspects of missing teeth – all different combinations and patterns of tooth loss. It covers teeth with good prognosis and also teeth with dubious prognosis

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

2:15 Protrusive Dental Pearl
4:05 Dr. Finlay Sutton’s Introduction to Partial Denture
6:31 The Scandinavian Partial Dentures vs other designs
11:24 Scandinavian approach for Chromework
12:56 Acrylic-based Partial Dentures
18:04 Indications for Chrome Palate on Complete Denture
21:17 Acrylic dentures with a wire mesh inside?
22:49 Cast Partial Dentures Protocol – Appointment by Appointment
32:13 Patient Reviews
34:39 Average treatment fees

Join us for The Scandinavian Approach to Partial Dentures with Dr. Finlay Sutton in Reading, UK on the 13th of January OR the 14th of January

If you enjoyed this, you may also like another episode with Dr. Finlay about Chrome Dentures Made Easier

Click below for full episode transcript:Jaz's Introduction: I love restorative dentistry. But the thing I always enjoyed the least I guess is DENTURES, complete dentures because I had a bit of experience. And I did a restorative post and I did loads of complete dentures I quite enjoyed.Jaz’s Introduction
But chrome dentures, for whatever reason, demographics exposure, didn’t get enough chance to practice the art of chromed dentures. And to be honest with you, I never got on with surveyors and I never really understood denture design. Now fast forward many years, and I started to get a more elderly patient base and the demand for good quality denture work increased. So, I had to match that demand. And I’ve been relying too much on my technicians to help me with the denture design and touchwood, I’ve had some good results so far. And what that did, it inspired me to learn more, I want to take control of the denture design now, hence why I’ve got Finlay Sutton coming next month. So, now it’s December. In January 2023, he’s coming to Reading I’m bringing him down south because I’m allergic to the north. And I’m just so excited to start implementing everything he’s teaching, but this episode will go a long way in teaching you about the philosophy of SCANDINAVIAN CHROMED DENTURES as well as for the younger dentists, every single sequence of Chrome Denture Provision, what is done at each appointment and why you do it in that order.

Hello Protruserati. I’m Jaz Gulati, and welcome back to the Protrusive Dental Podcast. It’s almost coming to the end of 2022. It’s been a crazy year for the podcast. We’ve had so many episodes, we launched the app this year. Like I am so proud of what our team put together. Thank you for hundreds of you who’ve been downloading on iOS and Android and sending the feedback and good vibes overall. So, really appreciate that. This episode like 98% of the episodes of Protrusive are eligible for CE or CPD certificates. All you have to do at the end is answer a few questions to validate your learning. And my team will email you a certificate, you also get early access to the episode. You get exclusive monthly content. So, last month it was the full mouth case discussion with Alan this month is through the loop view of fitting for ceramic units. This is not found anywhere. But on the app only. And the future, we’ve got Vertie prep for plonkers course exclusively on the app and loads more to look forward to. So if you’re a true Protruserati, download the app right now on iOS or Android. Or if you’d like to consume it all from the web, go to protrusive.app.

The Protrusive Dental Pearl
Today’s Protrusive Dental Pearl is actually going to be read out and spoken by Fin himself first ever Protrusive Dental Pearl, which is spoken to by my guest. Fin, take it away.

[Finlay]
Okay, so I think one of the most difficult things with partial dentures are designing them. And so what I’ve come up with this a universal design sheet and sequence. So, it covers all aspects of missing teeth. So, all of the different combinations and patterns of tooth loss, I’ve got two sheets, which you can laminate, just print it off, laminate, put it in the surgery, and then you can apply that to any case that comes in. So, it covers both teeth with good prognosis, the good support teeth, and it also covers teeth with dubious prognosis that may need to be added on to.

So, I think that’s the main Pearl here. And but the other thing I think is really important with top tips and things like this is, it really is attention to detail. So, getting really good at dentures does take training and practice and dedication and reading, you know, so it’s not going to happen overnight. But like anything that is hard to do. That’s worth doing. It’s hard to do, really. So really go for it. Thank you.

[Jaz]
So if you want to access to this PDF, there’s two ways to get it. One, is if you have the app already, you go to the Protrusive Vault, it’s been uploaded to the Protrusive Vault already. And number two, is if you go on www.protrusive.co.uk/denture-design, that’s denture-design. You’ll be able to download this very comprehensive design document that I heavily encourage laminating and using as an aide memoire when you’re designing your dentures, let’s join the main episode with Finlay Sutton.

Main Episode
Finlay Sutton, welcome again to the Protrusive Dental Podcast! How are you my friend?

[Finlay]
I’m really good. Thank you. It’s great to be here.

[Jaz]
It’s so nice to have you after that really epic episode. We did Episode 56, which you covered so much ground really like we talk everything from Chrome dentures for bruxists to ideal design to immediate dentures, and we had lots of questions from the community and that was just brilliant. And I am super excited Fin to be learning from you next month. It’s been one of my, in terms of courses, on my bucket list to make sure I get to see Fin and I want to learn partial dentures because I’ll be honest, a little confession I’m really bad at them. But, so that’s why I wanted to come to you to learn, but you’re too far away from you, Lanarkshire. So I’m bringing you down to Reading, it’s a sold out course. And we are just absolutely buzzing to host you.

[Finlay]
Absolutely. So, well thanks very much Jaz, I’m super excited about doing that. And it’s gonna be really, really practical. Because I think that’s the end of the day, that’s what we do is a subject. You know, we are dentists, and we treat people, patients. So and that’s what it’s all about. It’s just case, after case, after case, there’ll be shown was a little bit of work done by you and the delegates too because what I’ll be wanting you to do is to design the case before actually show it. And then I’ll then show the case and tweak the whole thing. Because at the end of the day, what I’m really wanting is for every delegate to go away, knowing how to design a partial denture, a really good partial denture, for any patient that comes in through the door. It’s as simple as that. That’s what I want to do.

[Jaz]
And that’s exactly what I need. Because although I’ve been doing a lot more chrome work and partial dentures over the last three years, just patient demographics has changed over my career the last 9, 10 years, I am relying far too much on my lab, to do the designing for me, and I’m going by their best judgment. And so I can’t wait for that all to change when I am a little bit more savvy on designing so that practical exercise that you’ve got inside that course that you plan, I think that’d be really key for learning. And I know you’ve been teaching all over the world for so many years. And you refine the art of education and personally from seeing your speak more didactic, like big, you know, 400 plus kind of sessions, by the way, we have me and Fin we’re just talking.

Fin recently lectured an IMAX theater, which is mind blowing. But even then you are just so such a brilliant educator, your energy is wonderful. So, thanks again for coming on. Today, we’re talking about Scandinavian Partial Dentures. Now, I always having to think about this Fin and I was thinking, a dentist who scores across on Spotify or on the app or on YouTube and and comes across his term. What could that mean to them? And maybe some dentists might think like IKEA, let me think does the patient just build their own partial denture? Is this like the smile direct club for chrome dentures? What are Scandinavian Partial Dentures? What makes it Scandinavian?

[Finlay]
Okay, so I’ve thought about this. And it’s something that people ask me all the time. What I think is really important is that if we go right back to basics, and the way that I was educated in the UK, here that my textbook was this, which was the Davenports, and Heath. Basker, Davenport, and Heath, and this is very, very much like the British dental journal textbook on it. And if you notice here, in this design there, we’ve got a few of these little struts coming up. They’re little minor connectors.

And these sorts of things are in the Scandinavian principle, crossing the gingival margin like that, in the interproximal area, these are areas that patients can’t actually clean. It really is a no, no, it’s breaking the rules completely. So, the overall concept about that it’s a hygienic approach to design. And the other thing is, the other Bible I used when I was doing my specialist training was McCrackens here. And this is the latest edition or it certainly may be a new edition, but look at this partial denture on here. And this partial denture there.

[Jaz]
And just describe it for our audio listeners, if you don’t mind just describing it.

[Finlay]
That has a plate on it. So, there’s a plate design. And if you imagine a plate, if you’ve got a free-end saddle, bilateral free-end saddle on a lower denture, if there’s a plate covering the gingival margins, what’s going to happen underneath that plates whilst it is worn. Just think about the plaque retention, the accumulation, the inflammation that causes and the Scandinavians have got 50 years of research to show that if things are covered like that, on the gingival margins like a plate, it really increases periodontal problems and also caries too. So, the whole concept about the Scandinavian approach is to keep it open.

So, where the gingival margins of the teeth are, then we don’t want, I don’t want any component crossing the gingival margin, because any component sits there increases inflammation. So, I think the best way to try to visualize this is that if we’ve got any missing teeth there, we’ve got underneath that we’ve got the bass so we could call that the sublingual bar or the lingual bar or the palate, the plates at the top, the major connector at the top so that the basis and all the bits for the denture, come off that base. So, when we’ve got the base there, if we’ve got a missing teeth saddle, we just want the minor connector to come up into that saddle area, and then rest on the teeth either side of that saddle area. So, everything sweeps up into the saddles and onto the teeth. So with the Scandinavian concept, if the denture is made really well, we should be able to get TePe Interdental Brushes between all of the teeth with the denture in place with it in place. So-

[Jaz]
I think that’s brilliant. I think that the data that I used to come across as a DCT and restorative, when I wrote the paper on resin bonded bridges many years ago, it was that partial dentures in the literature are likely to increase your caries or incidence by three times. And it’s been shown that there’s conflicting studies, but some studies show that you’re more likely to get periodontal disease, or caries. But I guess it depends a lot on how you design it. And one lecture I remember going to was an implant based lecture even though I don’t do implants, I just remember very clearly a really good point, the educator made Fin, he said that, you have to be very careful with a patient who is edentulous, because what they have gone through in their life to get to that stage is like a lot of disease processes, a lot of neglect to some degree to be able to end up in that position.

So, when you’re doing your implants, be mindful of that. And maybe that’s why we’re in a peri-implantitis happens. And if you apply that same concept to partial denture wearers, then maybe part of the reason why they lost the teeth is the reason they may lose the teeth again, so just make sense to make them as cleansable as possible. Do you also apply a Scandinavian approach to acrylic partial dentures? Or is this philosophy exclusive to chrome work?

[Finlay]
So, it is exclusive to chrome work, and I 100% agree with what you said previously about patients that have got multiple missing teeth, you know, they’ve suffered disease processes, but the beauty about the Scandinavian approaches, and you touched on it perfectly, then because they are removable, resin bonded bridges. That’s what they are. And this is the other difference between Scandinavian and the way that was taught in Britain, the rest seats in the Scandinavian approach, a much bigger and wider, smoother. And we have backings and support on the anterior teeth too. So, they are just like a resin bonded bridge wing, like the retainer parts. And the beauty about these and it’s very important for these patients that are going to be potentially losing teeth in the future. Because, you know, we don’t have a crystal ball, how long everyone’s teeth are gonna last.

The prognosis is quite often dubious for these cases, I don’t like taking teeth out. And I know you love teeth as well, natural teeth are fantastic. Let’s keep them even if they are not great teeth, we can put a backing on them, we can add to it in the future. So, these things are totally future proof. Now, if we then move on to acrylic based dentures and my personal opinion about acrylic based dentures are they are temporary appliances, I totally get that. If we’re working in healthcare system like say the NHS, we may not be able to provide a metal based denture for a patient. So, I think it’s important to retain good prosthodontic principles. So, for instance, if we’ve got a free end saddle, and we’re going to be providing an acrylic base denture, then extend it fully, right up the retromolar pad, so you’ve got a good support on the lower. Same for the upper use the palate, it’s brilliant for support, and use the tuberosity for support too. That’s really important.

Essentially, though, acrylic dentures are temporary appliances, they are gum strippers, unfortunately, because it’s hard to get to support. This is the important concept for the Scandinavian approach to support is king. If we can rest the denture on the teeth, and it’s not sinking into the soft tissues, stripping the gums, then that’s brilliant. Now, and this is really important having a great technician, sometimes a very, very occasionally have made a long term acrylic denture for a patient. Now-

[Jaz]
You mean like long term partial acrylic denture, right?

[Finlay]
Long term partial acrylic, and this chap had missing two to two. He had retained three, four and then missing posterior teeth. So, this nice sort of symmetrical situation. So, we made an acrylic based denture. But Rowan fashioned, little metal rests outs of 0.9 millimeter wire, which you’d use for normally for making clasps with. But if you bash the end, you can flatten it. And then, we had little rest seats on both sides. So, one on the four, one on the three on both sides, which meant that acrylic based denture had a rest. So, it stopped it from sinking in as much obviously the main-

[Jaz]
And in that scenario what made you then continue with that long term partial acrylic denture rather than either going for chrome in the outset? Was it periodontal reasons? Was it prognosis reasons? Or was it support reasons?

[Finlay]
No, it was actually because of finance for this particular patient. So, it is less expensive to do this. But I don’t normally have my arm twisted with that type of thing. It’s normally the acrylic is a temporary and generally they are immediate dentures, which are used for one, I’ve taken out, hopeless teeth. And then we’ve placed them and then that immediate denture then becomes a definitive, which is a metal based Scandinavian concept. So, that’s it’s a really important thing. And the reason that I don’t do there’s two big reasons I don’t do acrylics as long term partials is that number one, they break and snap and crack. And patients come in for repairs, if a patient and when they come to see me that. So, I would say if I was doing an acrylic based denture, then it would maybe be four to 5000 pounds to do that. So, a patient will be cross if that breaks. So, they are very much a temporary appliance for the patient. And secondly, they’re just really good as a diagnostic tool as well. The great you know, if we’re taking out a load of teeth, I can put this immediate mark one in. I call them mark one dentures. Mark one goes in.

[Jaz]
I love that.

[Finlay]
That’s a diagnostic appliance, and then we can move on to mark two later on. So when patients come to see me, that’s how I planned them, they’re always mark one and mark Two, if we need to extract teeth.

[Jaz]
Amazing. And when I come to your course next month, I’ve got a couple of cases on the go, who are wearing mark ones. And I’m going to design my mark twos the chromes when I come to see you and learn from you. And really interesting ones, an eight year old chap who I did an alveoloplasty because he had severe over eruption of his anteriors with too much bone, not enough space for the teeth aesthetically with the teeth. So, I did an alveoloplasty, bit of surgery, and now he’s wearing the mark one, he’s very happy with. But he needs a lot of general dentistry, crown work, restorative work. And so, I’m really looking forward to that fun case, and a few others, which I’ve had an honest conversation with him, I said, ‘Look, I’m gonna go to this guy called Fin, I’m gonna learn from him, give me a couple of months. When I come back from the course let me design you a denture.’ And they’ve been fine with it.

They’ve understood that what they have in this acrylic partial denture is a mark one. And I show them an example of a chrome and discuss the benefits and patients are on board with that. I digress a little bit, but I just want to ask you, because this is a thought that I’ve had is upper complete acrylic dentures, which I know you lots of education on and it’s a beautiful art and your videos on suction from them. Your upper and lower is just amazing. When would you consider an upper complete denture with a CHROME BASE? What are the indications because I’ve seen a few those I’ve done one in the past. I couldn’t tell you what the reason rationale was behind at the time, but I’d like to hear from you.

[Finlay]
Okay, quite simply, the metal base strengthens the denture, it reduces the potential for it to fracture, and it reduces the potential for an unhappy patient. Because if the denture breaks, it’s quite easy to fix, but it’s quite difficult to repair the patient’s confidence in it. And, you know, so as a rule, this is how I go and I always break the rules because there are certain circumstances that we have to- But anyway, generally, as a rule, if I’m doing a complete denture opposing natural dentition, which is called the combination syndrome, I’ll use a metal reinforcing base in the denture. So, that’s number one.

Number two, I do it for implant supported dentures. So if I’ve got an implant supported lower, you know, with two lovely locators, really secure bottom denture biting onto a complete upper, again, metal reinforced to the upper. And also, obviously the lower two, you know, the Implant Supported Denture, if there are any implants in the maxilla, as well, and I’m doing full upper overdenture on implants, metal reinforce always because of particular. And then the other. I think the fourth reason is history of breakage. If a patient comes in and they’ve got an old denture that has got this wire in, because they fractured it previously, and maybe they’re very warm the teeth, bruxists tendencies, because bruxism still occurs in patients that have got no teeth. So, it’s really just to add that extra strength, just as a little caveat just at the end. Why don’t I do it for everybody?

Well, getting retention on an upper denture with a metal base is slightly more difficult because it is marginally heavier. It’s just only few grams, we’re talking like a metal reinforced upper complete dentures 25 grams, whereas the acrylic base is usually around about 19-20 grams-ish. So, that can just slightly offset retention, if we’ve got a very flat maxilla. And also, if we’ve got a patient who’s got high frenal attachments, that means when they smile and talk, that frenum exposes the edge of the denture and the seal, the peripheral seal breaks. So, it’s those two cases where I’d say to them, ‘Look, I’d prefer to do an acrylic based denture for you is more likely to break. Would you like a spare as well?’ So, I then offer a spare. So, then they can wear one on a Monday, different on a Tuesday and swap it and then wearing them together.

[Jaz]
I think that was an emphatic answer for that question. That was absolutely brilliant. I really love that. So, when you have a metal base, how does that compare to an acrylic upper complete denture with a WIRE MESH inside? Is that just a waste of time? Or it does not have some benefit in terms of giving it rigidity?

[Finlay]
The only benefit of a wire mesh is that if the denture snaps or cracks the acrylic, then the two edges are still held together. So, it’s not a catastrophic failure for the patient, they’ll still be very uncomfortable and not great. But let’s say they’re on holiday. And it happens they can probably limp along until they get it sorted. But they don’t offer anything other than that. And sometimes we, Rowan, I think they actually weaken it. And then the other aspects of a metal base in the opera is what’s really important is to have an acrylic post down. That’s crucial. So the denture has a better peripheral seal. And also we can realign the denture should it need it as well, which just makes it future proof, much better suction.

[Jaz]
Lovely little gem there. The next question I have, as we get towards the end the questions is quite a big high level question. And I think to to make it tangible. This is aimed more at the young dentists who are starting to make their first few dentures or slightly more experienced dentists like me who just doesn’t get to make enough volume of chrome dentures, and it’s nice to revise. We can make like a little handout for this is what are the STAGES in general? Obviously, there are nuances and we have to deviate away from the rules, but a very standard patient for a partial denture, what are the titles or sequences of the appointments? And how many appointments would you typically take?

[Finlay]
So, I think if we look at it, really, I’m looking at a list here, and on average, to fit a chrome, it’s seven visits for a metal base denture, talking about metal base dentures. So, let’s go visit one. So, we’ve got our consultation with a patient and we have a look in the mouth, we make a diagnosis, I’d take a photo. And from that I then do my first design because that goes into the patient’s letter. And that’s my first thing, I get my first design done, number one, the first active treatment is a visit two and that is primary impressions.

‘So, I do my primary impressions to record the whole thing. And from that, I then Rowan post those models, we cast them up and then we can have a look at it and we can finalize that design. So, I say to Rowan this is what I want to do. This is my aim and design. This is the model here. And then we put it on the surveyor and we have a look at it. And Rowan says to me, ‘Yes, we can do that.’ Or, ‘No, we need to make minor changes.’ He’ll say, ‘Look, sometimes it’s just not possible.’ I’ll say something that he can’t actually do, he might not have enough space to put a tooth in place. Anyway, it’s just a good discussion.

So we do the definitive design then, and they will tell me, ‘Right Fin, I want you to take a little bit off the teeth here for the guiding surfaces, or make some space for rest seats in these areas. Because just like with resin bonded bridges, they have to fit in an hour.’ So, sometimes we’ll have an undercut, you know, the lingual surfaces of the lower teeth go inside like that, I might just have to shave a little bit off to make your level

[Jaz]
I just want to make a point there, Fin. Sorry to interrupt but that’s such a huge point. Because a path of insertion often dentists thing that path of insertion is applicable to removable dentures, we think of denture as part of insertion, path of removal, but resin bonded bridges and indirect work also needs a path of insertion. And it becomes extra important with rigid materials like chrome denture work to visualize that path of insertion, and it doesn’t often need much prep, it just needs a little bit. I like red flame diamond burs, soflex discs, just to get those planes, is that what you use as well?

[Finlay]
Absolutely all the time. Just little tickles. I call it a dusting of the teeth, more than grind to shaving a touch off to fit. So, absolutely. So, visit one is design prelim exam. Visit two is primary impressions, definitive design. Visit three is then definitive impressions. So, my working impressions and I always say to the patient, this is the most important, this is the most important visit of the whole thing. Because I’m wanting this thing to fit and I need to record your mouth exactly as it is. So, I’ll do my adjustments. And I’ll then do my working impressions. And then visit four will be jaw registration. So, that’ll be you know, wax rims, or a gothic arch tracing. If I want to find CR, I’m either making the dentures in intercuspal position, or I’m making them in centric relation. So that’s my jaw. Number four-

[Jaz]
At that stage, do you take a face bow record? Do you personally?

[Finlay]
Yes, I do.

[Jaz]
Do you take a face bow record?

[Finlay]
Yeah, I do face bow as well. So now, just going back to intercuspal position. And this is really important. This is why there’s not a set rule of thumb in terms of visits, sometimes I can actually skip a stage, if I’m doing my working impressions, and the patient’s got a really stable intercuspal position. And those models can be mounted really easily, then I don’t need to do a jaw reg, at that. I don’t need an extra jaw reg visit. I can put a bite in. And just do that if need be or quite often they just fit together beautifully just by wrist articulating you know so and a – It was really good. It all everything fits together beautifully like that. So normally though, I will do a bite, a jaw registration at visit four isn’t it? I think we’re at now I’ve gotten the list, and then visit five-

[Jaz]
I’ve lost track as well.

[Finlay]
So, let’s do so primary says one, definitives in, two. Bite at three. Number four, will be try-in. Tooth try in at this point.

[Jaz]
This is with the chrome and the wax attached together?

[Finlay]
No. Definitely. And this is a common sort of misconception the chrome is made after the trial is done.

[Jaz]
Got it.

[Finlay]
And the reason being just like we wouldn’t put implants in randomly in the mouth without having knowing where we’re going to put the teeth to start off with. I want to engineer the chrome to be in a perfect position to where the teeth are going to be placed. So, the chrome try-in comes after just purely the chrome try-in comes after the tooth try-in. So it’s tooth try-in and then it’s chrome try-in and then it’s finish after that.

[Jaz]
Now, with the chrome is tooth try-in to check the aesthetics and make sure the chrome will be in the right place. I guess there is a place for the chrome you might modify the design based on the tooth try-in but then when you go to the stage after the tooth try-in and just to clarify, the tooth try-in is wax and acrylic teeth. That’s it right?

[Finlay]
Yes, it is.

[Jaz]
And then the visit after it chrome, wax and teeth together?

[Finlay]
No, no, it isn’t. It’s purely bare chrome try-in without teeth.

[Jaz]
Got it.

[Finlay]
And with these Scandinavian dentures, there’s lot of tooth to contact. So, you got multiple contacts. So, I don’t want to have wax teeth getting in the way of me just checking that this chrome framework, the metal bases fits in beautifully.

[Jaz]
Your visualization is improved?

[Finlay]
Yeah, it is. It’s visualizations improved, everything. So, so once I know the chrome fits, I’ve already done the to try in, I can just go late to finish.

[Jaz]
Would you recommend for a less experienced colleague, a younger dentist to at that stage, if they’re following your principles, and they’re learning from this? And they want to apply, what they’re learning. The tooth try-in make sense, the chromework try-in a lot of dentists would do that earlier on in the chain, perhaps off the definitive straightaway. Would you recommend that the less experienced dentists or for a tricky patient maybe to do a chrome and tooth trying together? Everything’s in wax still? Or do you truly feel that has no benefit, and rather, is better to go to the fit if you’ve already done a separate tooth trying and a separate chrome trying?

[Finlay]
Yeah, so the only circumstance that I would do, add in an extra stage of doing the chrome and teeth would be if Rowan one is setting the teeth up and arranging them feels that there may be a little change in the tooth positions from the first try in to the finished denture. If he feels that, there may be some very important retentive elements on front teeth along a bit of front, is the aesthetic zone stuff, if there may be some changes that he has to make, or we have to thin the teeth down so much, that the color may change as well. Because when we, you know, when the ground out of the back, the chord changes. It’s really, if there’s going to be an aesthetic change. That’s when we do metal try with teeth on trying. So-

[Jaz]
Got it. Got it.

[Finlay]
Yeah, that’s just purely. So, essentially, if we go back, we just need to recap this, this is quite an important concept. So, normally, and I’m just doing it on my computer here, because I’ve got it here. So, we’ve got number one, primary impressions, number two working impressions. Number three is the jaw registration to prescription. Number four is tooth try-in. Number five is metal base try-in, bare metal base try-in. And then number six is fit. And then it’s reviewed after that. That’s the my general rule of thumb approach.

[Jaz]
I take, since all everything I picked up from you, from Episode 56, about trying in dentures and using occlude spray, you taught us so much. And I took a lot away from that. And even just from that, the last four chrome’s I fitted, the patients come back at review. And there’s no ulcer. There’s no adjustments, the occlusion’s spot on, everything’s been really good. So, either it’s got lucky, or I really implemented everything you told me from that short podcast episode. And I’ve gained a lot from that. So tell me, what do you usually see? Because you take so much care and time to get these right in various stages. And for those who need it a gothic arch tracing, if you’re repositioning the the bite, do you often have to do much adjustments at the reviews? And how many appointments are included? When you when you quote a patient for a fee, in terms of quoting correctly, how many review points do you build into that fee?

[Finlay]
So, I’ve built in two, because on average, and I’ve reviewed my cases since introducing the Scandinavian concept. And on average, I’ve 1.7 reviews for patients with metal based dentures. So quite often, it’s just like one review, and then we’re off we go. So, it really worked beautifully. And interestingly, the way that I was taught the British standard approach, the reason that I changed to the Scandinavian approach was that I wasn’t getting good consistent results. And it wasn’t predictable, and not on average, in my specialist practice. And I was a specialist at this stage. I was reviewing my patients four times, I had to see them four times with the sort of RPI system and that sort of system that I used to learn approach so it’s much better. So, I just find it remarkable that virtually it’s between one and two review visits. It’s amazing like-

[Jaz]
Well, I think I definitely need to buy my technician a bottle of wine because I think kudos to my tech because he’s been doing a great job and he’s helped me a lot with my design, Fin. I’m hoping to change that so I can I can lead the design held by.

[Finlay]
You know what, it makes me really happy that you have that success from this. It’s really wonderful that you know, your patients are benefiting from this. It’s lovely. So, great.

[Jaz]
Oh, it’s great. I have so much more and more confidence in delivering partial dentures and it’s a really important thing to cover. I’m starting to get a reputation now, Fin to help drive the areas of dentistry which are not perceived as sexy, so treating TMD in general practice, occlusal appliances, or recently hosted an acupuncture course in Reading with David Johnson who came by did a wonderful thing. Now with occlusion, we were doing a lot work with occlusion, so things that aren’t considered sexy. And now obviously, one of the reasons I bring you on is because some people, a lot of dentists, they’ll go on the composite course, they’re gone the Botox at facial aesthetics, but partial denture education, I feel it’s something that’s so necessary of dental school. And I think guys like you, and my good friend, Rupert are really and Mark Bishop, you guys are making removable prosth, sexy.

So, I have so much respect for all of you, and keep doing what you’re doing. But I think young dentists need to appreciate that we need to charge appropriately for these amazing devices that are just a miracle. We look at it as a work of art, it surely is art. How much if you don’t mind disclosing do your cases typically cost into it for patients in terms of your fee for an average, but like you describe the average sequence. And I think this will help people realize that we’re under charging, just like I teach we under charge for clothes appliances, grossly. I think we undercharged for partial dentures, but you probably have a stronger opinion on that than me.

[Finlay]
Absolutely. So, I think that my average fee for a metal base denture for one single is it’s about 10,000 pounds. And I think that it’s really, first of all, they are worth it. And you’ve touched on this beautifully, just then when you were talking about they are works of art. Now, I strongly believe and I’d love to stand up and with these implants, people that just really are extremely dismissive of partial dentures. And I’d like to have a battle with them. And say that I’m actually right. Okay, which looks better, you know, a really good partial denture, what is aesthetically superior, when someone’s got a high smile line, and missing teeth.

So, the best way to replace the missing tissues is with a partial denture, if we have a really, really skilled technician, and there’s a great clinician, they’re working together as a team, I think we can beat hands down, fixed prosthodontics, you know, with with this, I think the detracting factor of a partial is we’ve got other clasps, and, you know, those clasps have to be hidden some way, you know, we use gold and we put them back as far as possible. That’s the main detracting factor. And, and also, the thing is removable, so the patients do have, you know, within the dental profession, we have negative connotations about dentures, and also within the general, too, so, but, you know, like, we’re both both of us are pushing these non sexy areas of dentistry because I think they are sexy. I do, I think, you know, we, I restore patients lives, I totally changed their life with these lumps of plastic and metal. And I probably changed them better with these sorts of things than with, you know, with fixed restoration, where it’s extremely hard to engineer gum work to look like natural gums, the white is not too bad to deal with, you know, the teeth themselves, but the gum work is. And I do believe that we should charge for these sorts of things, too.

And I think, the ultimate testbed, and I used to work in the hospital system, I was a consultant at Manchester dental hospital, and I was, will be treating patients with cleft lip and palate and with missing, you know, big defects and that type of thing. And also normal patients who would be referred in as in patients without these problems, but were difficult denture cases, I’d get to the end of the road with them. And some of them may be weren’t totally happy with the outcome. But I could say to them, ‘Look, we’ve tried everything here.’ And the patient would buy that because they’re not paying directly for the, you know, actually say, okay, consultant, you know, professional, I know you tried your best, and they’d accept that. Now, it totally changed when I went into practice and worked as a high street specialist making referrals that patients would come in, and then I’d be charging, you know, between five and 10,000 pounds for a denture. If the denture wasn’t totally right, and the patient wasn’t totally happy with it. I couldn’t say to them, ‘Oh, we’ve tried everything. I’m really sorry now’, and then off they go. And they’re a happy camper. Not at all.

So, this is why I had to change from what I was previously taught to something more predictable. And this is where meeting John, he’s a very old dentist now, you know, he’s in his 80s. But he’s probably one of the best British removal prosthodontist ever, who learns off Charlotte Stilwell, who’s the Danish prosthodontist that brought it to Britain. She brought this concept here. She’s a specialist, Charlotte works in London. And I went on a course. And it completely changed the way I did things, you know, so, and that’s why I learned Scandinavian concept. So, my reviews went from four, and not very happy patient to two, and happy patients.

[Jaz]
Amazing.

[Finlay]
And it was amazing. And also like yourself Jaz, you’ll be understanding that you sort of engineer of practice to the type of work you want to do and the type of patients that you want to treat. And that happens over time, as well. So, there’s something really important as well about this is I only do two clinical days or week treating patients now, I’m 51. I do another day, which will be is today actually, I’m actually doing online, Zoom consults with new patients and phone calls, just to filter them out and make sure they’re okay for coming in.

Now, I find that two clinical days is enough for me, because my patients are referred to me so they’re quite difficult, there may be technically challenging and most attentive, potentially challenging. But also, they do have personality issues, potential personality disorders, were the densest, that’s referred to men, it’s just found them hard to manage. So, they’re quite tricky to cope with. So now, I personally can only really handle two days of working with these types of patients. So each day, I’ll be seeing maybe six patients a day, four of them will be lovely, absolutely great. But two will be really hard to manage, and will really test my metal and my patients.

So, I find that two days is absolutely enough to keep my sorts of mental health good. Now, in order to do that, though, I have to charge a lot of money to sustain, it’s like two days of intense work to keep me in a living. So therefore, my hourly rate is currently 750 pounds per hour of clinical work in order to you know, fund that, that process. So, hopefully that just explains my situation Jaz.

[Jaz]
It does wonderfully. And I think we should appreciate the how much care intention experience that you have behind you also having a specialist status. But the reason for asking you that question, and Fin, thanks for answering this, honestly, and giving it all away. I really appreciate that. Because I think dentists need some inspiration that actually everything we do, when we put so much thought and care into it, and to adopt a mindset whereby A) you’re worth it, and B) not to undersell yourself, because these patients are tough. And sometimes the difference you can make, even from a single resin bonded bridge, but I speak to dentists all time, who are just way under charging for a single unit resin bonded bridge. I’m like, forget that it’s a resin bonded bridge, it’s not an implant, you are giving that patient a tooth, you’re restoring the patient’s smile.

[Finlay]
Yeah.

[Jaz]
And then once they think of it like that, but patients also kind of compare it to an implant and they shouldn’t be that much different today, you know, they shouldn’t be like one is like 300 pounds, or 3000? No, no, it should be a charge much more probably. Now, when you apply that to denture work. I mean, it’s very obvious that you’re restoring someone’s function and aesthetics in a huge way. And you just have to subscribe to Fin’s newsletter to see the amazing work. So, I’ll put a link at the bottom for that. But anyone who would like to join the waiting list for the course in Reading on the 13th and 14th of January, please email me DM me, we’ll get you on that.

So, we’re looking forward to learning from you Fin. And actually one of the reasons I asked you to selfishly. Well, the reason I asked you to come on both Friday and Saturday, and I was really keen to fill those spots is that we can have you to ourselves on Friday night, we go out for a nice dinner with everyone a Christmas themed dinner. No, not Christmas theme, it’s next month. We’ll think of a new visions New Beginnings kind of dinner. And I think everyone’s really looking forward to. Just getting to know the man behind the dentures. So, Fin thanks so much for discussing Scandinavian Dentures. The philosophy, just makes so much sense. And telling us all every little detail, you’re so giving with your information that other episode we did 56. I learned so much from that personally. And then I love the style of education that you developed. So, thanks for making dentures sexy again, once again, and appreciate your time always.

[Finlay]
Thank you. It’s a pleasure. Absolutely.

Jaz’s Outro:
Well, there we have it guys, Finlay Sutton. Thank you so much as always for listening all the way to the end. If you’re listening or watching on the app, you can not only download the full transcript, you can also download the notes. The notes include a sequence by sequence cheat sheet and on the protrusive vault. You can also download the PDF of the Pearl he described which got every single design. So that’s all on the app for you if you want it. Alternatively, you can get the cheat sheet but not the notes on protrusive.co.uk/denture-design. And if you wanted to come and join us for Finlay Sutton live course in Reading UK on the 13th of January or the 14th of January. So, if you just drop me a DM @protrusivedental or email me jaz@protrusive.co.uk, and let me know, we’ll put you on the waiting list. Thank you, Protruserati and I’ll catch you same time, same place next week.

View Details

This podcast will change the way you think about pulpotomies and endodontics in general. Georg Benjamin explains that severe throbbing pain (or classic signs of IRREVERSIBLE PULPITIS) does not necessarily mean a pulpectomy is needed. Instead, we can consider a pulpotomy for permanent teeth to preserve radicular pulp tissue and maintaining a vital tooth!

Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE answering a few questions + EXCLUSIVE content:

https://youtu.be/PoWDRz714uQCheck out this full episode on YouTubeProtrusive Dental Pearl: Check if your anesthetic is successful by carrying out an objective test by placing EndoFrost (-50 C) on the tooth (about 10 secs) and checking for a cold response. If the patient is not fully numb yet, they will still feel something. If they are sufficiently numb, this test gives you (and some nervous patients!) confidence. I like this before placing rubber dam as I hate ever removing the dam to top up LA!

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

2:02 Protrusive Dental Pearl
4:47 Georg Benjamin’s Dental Podcast Journey
7:10 Georg’s Endodontic Journey
11:46 Case Discussion: Pulpal Diagnosis
16:17 Pulpotomy
19:37 Direct Pulp capping
22:26 Indirect Pulp Cap
23:58 Pulpotomy Protocol
26:59 Classifications of Pulpotomy
30:52 Bleeding Time Protocol
33:31 Patient Communication
35:34 Treatment Decision-Making
38:57 Success rate of pulpotomy
41:10 Early and Late failures
42:30 Long-term treatment
45:14 Unhealthy pulp
48:08 Materials and Products for Pulpotomy
50:54 Leaving carious dentine as base

For our German Protruserati, check out Georg’s Dental Podcast

If you enjoyed this, you might also like this episode with Dr Ammar Al-Hourani ‘Is Single Point Obturation Acceptable?’

Click below for full episode transcript:Jaz's Introduction: Grab your onions Protruserati, because this podcast will change the way you think about a pulpectomy, you will probably do way LESS EXTIRPATIONS and committing to a root canal.Jaz’s Introduction:
And this episode really challenges our beliefs that we hold in terms of what requires a root canal treatment, ie we were trained that irreversible pulpitis equals pulpectomy, which is a root canal right? Now, that’s what I was taught to. But what is happening now in endodontics, is brilliant. And Georg explains it really well, with his lovely German accent, we go over the fact that nowadays, whenever a patient comes to Georg, with irreversible pulpitis , that you know, severe throbbing ache, it does not mean root canal for him anymore, it means a PULPOTOMY OF THE PERMANENT TOOTH, it means a pulpotomy of a vital permanent tooth, which then hopefully, will preserve that radicular pulpal tissue, and therefore, the patient will not require a root canal treatment anymore. So, it’s pretty different.

Now, maybe you’re already seasoned in this, maybe you’ve already using MTAs, and whatnot. And that’s amazing. Good for you. But for a lot of dentists, I imagine this is like, wait, what do you what do you mean, we don’t have to do I commit to a root canal anymore like we can, we can actually do a pulpotomy for an adult, let alone one that we have diagnosed as, quote unquote, ‘irreversible pulpitis’, which actually Georg argues, is a poor term. Welcome, Protruserati. I’m Jaz Gulati, I’m your host. And if you’re new to the podcast, welcome. It’s great to have you. If you’re a veteran, and you’ve been with me for many years, it’s always a pleasure to have you.

This one’s a really cool episode, I didn’t think before I recorded it, that I’ll be having so many moments of laughter with our guests, Georg Benjamin, who was not a specialist in Germany, he is pretty much limited to endodontics. And he’s been following vital pulp therapy or pulpotomy of vital adult teeth for a long while now. And he’s got some great views on it. And if you listen to the end, we say some very controversial things about certain groups in dentistry. So, I apologize to my friends by offended you. It was all a little bit unjust but a little bit serious at the same time.

The Protrusive Dental Pearl
The Protrusive Dental Pearl I have for you today is and I’m really hoping I haven’t shared this one with you already before, but it is how do you test for OBJECTIVE ANESTHESIA? So, as you know, guys, I’m a big fan of buccal articaine infiltrations, for lower first molars and even lower second molars, if I’m doing a root canal, or a crown or a large restoration, I am no longer reaching for an ID block, I am doing a buccal infiltration with articaine. I’ve got a video on YouTube showing exactly how I do it. And I get about 90% success rate with this. And I say there’s easy patients and then there’s difficult patients, the difficult ones being the thick bone and whatnot. And yeah, probably successes 80% with those guys, but more normal anatomy than I’m probably getting 95%. So, if you balance it out, it’s about 80- 90% success rate. And so, one thing I started to do to really make sure my patient is super numb is instead of subjective, instead of asking the patient, are you feeling quite numb, is that is that really numb, it’s much better to be objective.

So, I get some endo frost, so minus 50 degrees on a cotton pellet. And I put it on tweezers, and I press it onto the tooth. And I leave it there for about 10 seconds. And hopefully the patient will feel nothing at all. Now that for me, gives me so much more assurance that that tooth doesn’t require a supplemental anesthetic. It does not require an inferior alveolar nerve block. And that’s worked really well for me. So, in those times where I put the coal on, and after about six seconds, they say you know, I just feel a little bit, either give a little bit more articaine into the gingival tissues, subperiosteal region, or I might even in a tricky patient, give it an ID block at that stage. So, it really helps me in my decision making.

So, next time you’re not sure, do a objective test by putting endo frost on the tooth and just seeing the response before you start your therapy. Now by this point, usually I already have rubberdam on as the last thing I do before I then continue my treatment because most of times, they won’t feel the end of frost anymore. This episode is brought to you by Enlighten Smiles, the good guys Payman Langroudi et al who support this podcast so dearly. Thanks so much. I love using Enlighten Whitening, I’m getting great results. My patients, they got some awesome trays, and their gel is always fresh. And of course, if you want some training, you have to check out the one-hour webinar that Payman does, as always is in the link section. It’s also on the YouTube for the freemium version. And if you’ve not already downloaded the app, the Protrusive app, oh my god, we’re getting so much traction. We’re getting so much good vibes on the community section and the exclusive content is just gonna blow your mind. The amount of things I’ve got planned for it. It’s gonna be amazing. So, if you haven’t downloaded Protrusive app yet, what are you waiting for? Download it. Let’s join Georg Benjamin to discuss vital pulp therapy aka pulpotomy for adult teeth, no more irreversible pulpitis. Georg Benjamin. Welcome to the Protrusive Dental Podcast. How are you, my friend?

[Georg]
Oh, I’m fine. Great to finally be on a different podcast as well.

[Jaz]
Well, it’s for those who don’t know, Georg is a host of his podcasts was mostly in German, I believe. Tell us, you’ve been podcasting way longer than I have. Tell us about your podcast and in Germany and what kind of topics do you cover?

[Georg]
Basically, I started podcasts in 2016, which is now basically ages ago, and actually, I remember in 2018, everybody in the podcast environment was talking about, oh, which podcast peak, it’s over now. It won’t rise anymore. And I was basically inspired by the dental hacks podcast, basically, the American podcast, which is now very dental podcast, they kind of split up, but I’ll admit they’re still doing it. And I was kind of surprised how Americans talk openly on their podcast, about certain things like, oh, well, I got everyone in my team, an iPad. I mean, they’re just a $1,000. So, I got 10.

[Jaz]
Sounds like a very American thing so.

[Georg]
Things you would never hear on a German podcast, it was like, Yeah, talk to my text advisor. And afterward, we found a way to make it work. Yeah. Well, at least my podcast is called SaureZähne Dental Podcast, actually, the name wasn’t very SEO, anything. We just started started enjoying the dental hex and started our own podcast. And actually, we were the first German dental podcast for our dentists. And it was really good networking too. I mean, who should I tell you that I saw how you grow with your podcast. You know, you even have an app, which is really great. And it’s the networking part is so good. I just can encourage everyone to start a podcast. Today, there are so many podcasts on how to start it and how to present yourself. I started just without anything. I just started about a name at first and started recording. It was so much fun, I can really recommend to everyone.

[Jaz]
Amazing for those who who want to listen to a German Dental Podcast, check out yours. I can’t even pronounce it. But it you know, it’s amazing that you are so dedicated and I’m sure every dentist in Germany probably knows your podcast today would do this in English guys. Don’t worry, be reassured. We’re gonna do an English podcast today on vital pulp therapy as you in our preamble, our pre chat you described as vital pulpotomy for adults, because dentists are more likely to be like, ‘Oh, okay, I can visualize what that means.’ So before we get into that, just tell us a bit more about yourself. Are you limited to endodontics? Are you an endodontist? Or do you just love endodontics?

[Georg]
It’s very interesting. Basically, in UK terms, I’m a general dentist. But I spent most of my time with endodontics. That means now I recently opened my office, I have scope CBTC. So, everything you need today, for endodontics. But actually, when I graduated in 2010, I basically didn’t have any or when I heard this term pulpotomy of teeth, I was only thinking about milk teeth, and never heard about anything else. It was really interesting. When I was a young dentist at my first dental job, I was in an office in a rural area close to Berlin. But they were like two dental offices in a town of 10,000 people, and very well, really bad. So many patients, it was crazy. I mean, after two weeks, all my afternoons are already fully booked. But it’s like the best start for young dentist. And we had an interesting approach to pain treatment, if someone came in refer a reversible pulpitis. And the pain treatment was basic, very simple, because we didn’t have a lot of time, it was a full pulpotomy.

And we basically just placed a cotton pellet on it with a Ledermix, which is like an antibiotic steroid mix, which is very popular in Germany and covered at Cavit. And we call the patients on the next day just to see if they’re fine if we should need to root canal treatment, or if the whole thing bought us time. Actually, it surprised myself a lot, how much times it’s actually gave us and when we started to do the root canals later on. It was quite useful, but pulp was still vital and the root canals. And it was basically we had to do anesthesia, rubberdam, of course, and it was pretty much standard endo. And I was always chatting with my boss back then. It was Dennis. ‘Dennis, how come this pulp cells and they are still vital even it’s I know. How come we can’t place anything on it like MTA. So we don’t need to do the endodontic treatment. And you know back when it was like if it’s irreversible pulpitis it’s no way out completely. It’s a one-way street.

[Jaz]
Which you know that everyone who’s listening so far. I mean, not everyone but I’d say 98% of the colleagues, the Protruserati listening right now probably think the same as what I thought as well, which is when you diagnose irreversible pulpitis, that’s it. I mean, that’s the end of the line for the tooth. It needs a root canal if it’s even possible, right?

[Georg]
Yeah. And basically, maybe the terminology is wrong. Not saying but it’s not very easy terminology. If it’s irreversible, we don’t have to do it. If it’s a reversible, we have to do it. But if it would be have a different name and wouldn’t have the name I will suppose that it’s a one way street, we might think different. But let’s be honest, it’s very easy diagnostic tool to say. That’s the street we take here. That’s the street, we take there, and fine. And basically, I did some endodontic continuous education. And I met Martin Trope who basically showed us a really nice study from a guy called Mr. Bowden from the US an endodontist, who basically treated young molars of young children basically, with full removal of decay. But he called the direct pulp capping with MTA.

But basically, when I look at the clinical picture, it was basically a partial pulpotomy because you really removed all the decay nichts apart a couple of times, just placed MTA on it. And it worked. And the thing is, you know, okay, it’s one study, let’s see, but this recall rate was 97%. Yeah, it’s like enormous. Martin Trope was joking, but private detective was hired to get this week away. Unfortunately, Georg couldn’t attend the last German endodontic Society Meeting due to some restrictions, because I wanted to ask him that. But with these results in mind, I kind of started in a different office where it’s getting more and more endodontic focus to treat these cases. And I remember one case, where basically everything went wrong, Jaz, seriously, everything. Yeah, it was a deep cavity assault on the x-ray before I basically knew that. Some partial pulpotomy is better than the direct pulp cap due to the literature, which is outwear on these topics. And I did a partial pulpotomy places-

[Jaz]
Before you progressed with this course, let’s paint a picture, how old was the patient? And what was your pulpal diagnosis before you started?

[Georg]
Yeah, basically, the patient was maybe in the mid-30s and adults. My diagnosis was basically in reversible pulpitis because the patient didn’t get any pain. And-

[Jaz]
I want clarity, reversible or irreversible. I couldn’t hear it.

[Georg]
It was reversible pulpitis .

[Jaz]
Reversible, okay.

[Georg]
Just imagine, you see deep caries close to the pulp, and you’d be like, okay, the tooth is vital. The patient doesn’t have a lot of pain, but we need to treat it, it’s pretty sure. And basically, entered the tooth, did a partial pulpotomy, placed my MTA. And back then I basically had a two-step approach for the first place the MTA, did a temporary filling, and we call the patient to see if the MTA has set. And when I was placing the temporary refilling, which was Cavit at this time, I basically suddenly saw how the blood from the pulp came out. And we’ll say okay, this will not gonna work at all, because I’m out of time, I can’t do anything anymore. It is how it is.

And maybe she will be there as a pain patient the next day, but she didn’t come at all. And you know, if the patient doesn’t come up, you basically already know what happens. You went somewhere else in Berlin at least. But basically, the patient came back, I think a month later because the temporary filling fall off. And basically, the MTA and it was hard. And since this was a partial pulpotomy I could do my cold test and to correct normal. And I just placed my composite on it. And that’s it. And then, I kind of realized maybe I didn’t trust the pulp too much things.

[Jaz]
You didn’t have faith?

[Georg]
I didn’t have faith at all with a pulp. I mean, I kind of like-

[Jaz]
Like most of us, right? Especially if it’s caries, like, you know, you’re gonna think okay, ‘Mr. Smith, you need to have a root canal treatment for sure.’ So, I don’t think that’s surprising. I think most of us would, I think there’s a real paradigm shift for us.

[Georg]
Yeah, it’s a paradigm shift. And actually, now there’s new literature out of which it makes it easier back then, it was eight years ago. This is how we noticed that we are actually old, Jaz. But you know back then, whenever you had such a treatment, you should always say it was reversible pulpitis because still wasn’t really allowed in a irreversible way, kind of you know, but the interesting part is, actually there’s this term called Vital Pulp Therapy. And it’s actually sometimes a bit misleading because vital pulp to me could mean anything, it could be in an indirect pulp cap, a direct pulp cap, partial pulpotomy, full pulpotomy. In the last e-meeting. I even learned the term mini pulpotomy, which is interesting. But I like this term. It’s from a British guy I forgot to sorry. And basically, I’ll focus pretty much on the pulpotomy part because it’s the more interesting part.

[Jaz]
Okay, before we get to that, Georg I just wanted like back to that case that you mentioned that lady who had this positive experience where you thought that okay, she’s gonna come back in pain or it’s gonna go necrotic and it was fine. Eight years on now. Do you still see this lady? Have you seen her? Is everything still, okay?

[Georg]
Actually, with this woman I didn’t saw her again. I saw her husband. But she also had like a really bad root canal to the teeth, which needed treatment. And she didn’t like my fee behind it. So, she never came back. But I know that she was fine for quite some years. But I started recalling and documented these cases after that, actually, because it has gotten a bit more interesting.

[Jaz]
And with that case, for the younger dentists listening which everyone actually, when you had that deep caries, which you knew was close to the pulp, but your diagnosis was that you know, it was still reversible pulpitis at that stage. There wasn’t signs of deep throbbing pain, keeping awake at night, nothing like that. Why did you not consider just removing as much caries as possible, but leaving some caries over the pulp and just restoring like that? Do you not think that perhaps dentin could have been the best insulator, the best base, in that case, the best lining if you’d like.

[Georg]
Oh, you’re touching a really topic, which are feeling really strongly about it, I would like to put it in the end of the podcast, because-

[Jaz]
We’ll find out. Stay tuned until the end, we will find out why Georg prefers to actually go into the pulp in that case and do a pulpotomy which leads us nicely to what you were just going to explain.

[Georg]
So, let’s focus a bit on the pulpotomy part because it’s quite interesting. First of all, basically pulpotomy started more or less in traumatize tooth. And therefore, we have a lot of really good literature about pulpotomy and permanent tooth, you just say, chipped, central incisor, the pulp is exposed. And we basically know from literature, even if this young patient is running around with this open tooth for a week or so. But we just need to remove two millimeters of the vital pulp. And it still will work. Yeah. Which is surprising because the pulp has an immune system, and therefore it’s fine. Of course, we have probably cases where it doesn’t work. But spec showed that in his enamel studies, that it worked and even like later on with his patients, and which is interesting. And this pulpotomy has a high success rate. But let’s be honest, it’s all young patients on traumatize teeth, no caries, of course, it works very good. So, what’s with the teeth we see in our office and interesting there’s like study from Iran, actually. But they did a multi-central study with full pulpotomy in permanent teeth and compare that to a root canal treatment. And actually, the results were comparable.

But we have to be careful when we’re this study. Because you can also always make studies and kind of get the same result if you don’t read them well. And I’ve never been to university and never, of course I’ve been to uni. I’ve never worked at university. I’m really not good to literature, Jaz.

So it’s the first time I didn’t see it. But actually, in this study, which is was quite good. The RCT group just brings sterile water. And you know, in vital case it probably works, but not as good as maybe a stronger disinfectant like sodium hypochlorite. So-

[Jaz]
Okay.

[Georg]
So, the results are pretty much the same.

[Jaz]
So, for the actual root canal therapy prior to the obturation for this RCT group, they chose to use sterile water. And-

[Georg]
Yes, that’s it.

[Jaz]
But we know, let’s talk. That’s not even the gold standard, we know that we should be using sodium hypochlorite. So, why would you do that for a study? Surely, that’s negligent?

[George]
Yeah, you could do it. I wouldn’t go so far to and maybe they wanted to have the RCT group to be a bit less successful, but they both more or less get 80% success, and which is actually 80% percent success. If you just look at by the vital pulp therapy group, multicentric, a lot of different dentists is quite good actually. When you look at the molar, it’s much easier to do a full pulpotomy and a molar, play some MTA and restore the tooth right away than to do a root canal treatment, but I always have to advocate if people are now saying, ‘Well, it’s an alternative to an RCT. No, actually it’s a more predictable pulp cap. I would say pulpotomy is more predictive and a pulp cap. But let’s be honest, a lot of people out there and I have done the same, came from the university, done a pulp cap and it went horribly wrong. That’s a patient-

[Jaz]
For students, just for student listening young dentists, vital pulp cap just recap. Direct pulp cap, indirect pulp cap, what is the difference? Just describe what kind of materials you would use in each scenario.

[Georg]
Let’s say you just removed an old insufficient restoration, maybe an old GSE amalgam whatever, and you accidentally see that vessel open pulp. Yeah, or maybe you nicked it. And basically, in this case, I would just like use calcium silicate cement that could be an MTA could be biodentin, could be whatever and rinse it a bit with sodium hypochlorite usually I use 2%. Some people suggest 3%. Some say I always use 5% because it’s the only thing I have to offer, doesn’t matter in my eyes. And basically if it’s like, doesn’t have a lot of symptoms before, it probably is fine. Yeah, I probably best-

[Jaz]
And that’s a direct pulp cap, right? And then you know what it when I trained we were using dycal.

[Georg]
Yeah, dycal was actually quite bad idea, because it-

[Jaz]
Of course.

[Georg]
There’s literature that dycal, carelife, self-setting calcium hydroxide products work less successful when freshly mixed calcium hydroxide. It’s quite surprising. But I was taught that in university because already back then everybody should know it from literature. And basically, it’s better to use a freshly mixed calcium hydroxide and two places on the pulp. If you come up with it, I basically use MTA because due to my endodontic background or endodontic 70s. I think it’s cooler. But if you look at the literature, they are both are great. Maybe it’s a cotton product that resolves.

Yeah, we see that sometimes old pulp caps, but the pulp is still vital. And sometimes in this scenario with the direct pulp cap, I tend to avoid it by doing something I would call now learn that term. It’s called mini pulpotomy. Because before I come to the mini pulpotomy, because I noticed I did some pulp caps with really cool materials. They’re called Bioceramics effing unfair still went wrong. And then noticed that sometimes even it’s just a small pulp exposure. And the bleeding stops by itself, which is basically by the book, the best indication sign.

[Jaz]
It’s a good sign.

[Georg]
Yeah, it’s a good sign. Actually, I now with my experience in vital pulpotomy or pulpotomy, I rather see the pulp bleeding, and look for it, I would just like freshen up it with the diamond burs at high speed. Just don’t remove anything, just touch it two, three times, see, okay, it’s really bleeding. Because I noticed sometimes that there’s some blood in the pulp chamber, which kind of finds its way but when it stopped when you open it, you really don’t see a lot of really nice vital pulp tissue. And remember that story when I come back to the decay part. So, but first, I hope I don’t jump around too much the indirect pulp cap.

[Jaz]
Yes.

[Georg]
I also already told you at this podcast, that I like to remove all the decay even if it’s an hour Cochrane Review, which basically states that I’m basically dentin Bavarian, who removes too much dentin. That’s fine. Yeah, in cases where I have deep caries. And I really thought I would expose the pulps but I don’t. Even if I removed everything, sandblasts everything. Then I will do following, still use sodium hypochlorine like to clean something. Yeah, because-

[Jaz]
So, you’re basically killing the cavity even though you don’t have exposure?

[Georg]
Yeah, you know, we cleaned the cavity, because we have one study from Michael Sander, who basically did vets and even in an indirect pulp cap, a successful rate was much better when without, which was interesting. In my logic, it’s quite logic. And then I will just pass again, calcium silicate cement, this can’t go pretty fast as the biodentin. Just cover the dentin, close to the pulp, not everything. And basically covered with self-etching flow. Because I’m really lazy. I don’t really like to wait for the biodentin to set. In my hands, it works very good. Some people like to wait 12 minutes until it sets, that’s fine. Some people even do the two visits, which is fine and do a cut back. For those indications, a metric is really a good choice. And that’s it for indirect pulp cap.

[Georg]
Yeah, let’s now go to the real pulpotomy part. And now’s the interesting part that you have someone coming to you could be an young patient or patient with a big decay. And of course he has pain, maybe even at night. And I always say, of course he has pain. I mean, if you have like Swiss cheese, very close to the pulp and you feel everything. Of course, the pulp is irritated. And so the question is always, how much is the pulp irritated? So, of course I do my pulp testing, I do an x-ray to kind of see if there’s no lesion on the x-ray. Although we have to kind of say if it’s a huge lesion, we probably say that’s a necrotic and our cold test was basically a false positive. But if it’s like really, really tiny one, I wouldn’t give it too much of a thought actually, yeah.

[Jaz]
CBCT maybe if you’re, in that would you consider that?

[Georg]
I have a CBCT. Actually in this case, I wouldn’t consider it because now I strongly believe it’s a vital pulp therapy now and then confident, but I handled the root canal treatment, I really like to consider it. But it’s a case by case decision. But the past, I went more and more for the pro CBCT. Because it gives me a lot of information I need. But for example, these cases, you see maybe something on one root, which is like an enlargement, not to be lesion. And when you kind of take out your measuring tool and measure, it’s more than one half millimeter. Because if it’s more one half millimeter, referred, it’s probably more likely to be lesion. If it’s less than half a millimeter, it’s probably not a lesion. Yeah. But so rule of thumb, I heard somewhere, I can’t credit anyone, but it was a great tip. I got but usually in this vital case, ideally, if I would do CBCT in this case, I probably would expect I don’t see a lot of it. So, since I wouldn’t probably not to wear root canal treatment since I don’t see anything, it doesn’t really bring anyone a benefit. But remember just in case, and everybody who’s a dentist knows that. This one will be a no for sure. Because it’s such a big caries. And I don’t have to point out if it’s molar or premolar or whatever.

You just know that feeling. And in some cases, even you think about which posts I’m going to place or whatever. And it’s interesting when you enter these cases, these really deep caries we see in the dental practice, I considered my first choice of treatments always a full pulpotomy. If it’s really, even me if it’s pain, we don’t bother around with partial pulpotomy, due to pain management reasons, actually.

Because, of course, if you would be a patient and you accidentally, it would have like hidden caries nobody saw with all the technique we have, I would probably consider in your case of partial pulpotomy, knowing that we have an full pulpotomy as the second option as well. Because your patient, which is a dentist and we both know what we’re doing.

[Jaz]
But you know, one thing before you then maybe continue is coming on to the difference between the mini, the partial, and the full pulpotomy. It seems like you know, for me, the pulp chamber and a molar sometimes is very, very small. So I mean, what is really in millimeters difference between and the protocol, I guess between a mini, a partial, and a full? For me, it’s just you’re tickling the pulp chamber, you’re going to make it bleed, and then you’re going to put your MTA on top. So, I’m surprised that there’s three classifications of nicking the pulp chamber.

[Georg]
Actually, there’s a really interesting German PhD thesis that she found more. But let’s say the mini pulpotomy is really easy. You just have a pulp, you just push the burs really gently on it. And you know, it’s-

[Jaz]
How big of a bur? Because this is important, you know how they used to say like, ‘Oh, if it’s like a half a millimeter exposure or etc.’

[Georg]
Yeah, okay, I know what you mean. Basically, I have Komet bur, which is a ball, which will really long shaft. And basically, I think, a millimeter in diameter. And I have also a bear cut which one is always sterilized for this kind of process. Because I just don’t want to use a bur, just used for excavation, where efforts they will kit I take out you can argue that it probably doesn’t matter. But that’s a different discussion. And referred, I would do mini pulpotomy and the partial pulpotomy. And by partial, my ideas to take two millimeters away. But now it really depends on the molar, for example, from which angle do you look at, from the occlusal? Or from the lateral?

And from the lateral, it’s quite hard to distinguish sometimes. And there’s interesting studies about pulp caps about pulp expose on the occlusal and pulp caps on the lateral. And of course, on occlusal I our work better. And I would say we probably can transfer this knowledge to the pulpotomy as well. But it’s harder to do partial pulpotomy if you just nick a pulp horn and kind of remove it. And so you don’t know, did I do a full pulpotomy on one root of smaller and the partial pulpotomy of the other one. And to make it short, if a doubt, go for full pulpotomy. What is full pulpotomy? You just go until the root canal entries.

[Jaz]
Like the orifice, a bit literally like the canal orifice?

[Georg]
Yeah, pretty much. That’s the full pulpotomy. You basically take the whole pulp chamber away. And actually it sometimes makes bleeding control quite easier than the partial pulpotomy because you just have some root canal orifice where it’s bleeding and you can kind of just use your sodium hypochlorite, which is my first choice. Sometimes I even use sterilized cotton, the foam pellets to put some gentle pressure.

[Jaz]
And one thing that maybe someone may not appreciate and I’m just thinking out loud here is if you’re trying to stay within the pulp chamber and not actually damage the pulp tissue in the canals, it’s fair to say that with you’re hypochlorite, you’re definitely making sure that you’re definitely staying within the pulpotomy. You’re not forcing any hypochlorite into the canals, is that an important part of protocol?

[Georg]
Actually, it’s important that we don’t put our syringe like an endodontic treatment and place it directly into canals. But actually, it’s a typical question you’re pointing out, Jaz. Because a lot of people are afraid, will sodium hypochloride destroys a pulp? And basically, just say, ‘Did you ever get a sodium hypochlorite on your skin?’ Yeah. And the question is some say yes, some are ‘What’s happened?’ Well, it burnt a bit. But did it went through your hand? No. And actually, it lower concentration that used to be in the First World War, instead of infection agent for open wounds. And so, of course, the sodium hypochlorite can disolve necrotic and vital tissues, but that’s good news. It’s basically doing parts of your pulpotomy for you, but in a chemical way. And that’s why it’s like the best thing you have here.

[Georg]
And now we have to talk about bleeding time, because that’s the most obvious question when it comes after it. And it’s really interesting when you look at the literature, and we have now recommendations from the German Endodontic Society from the ESE. And it’s great when we have, for example, Dominica, where we could wait two minutes, and then he goes on with this partial pulpotomy, wait two minutes again, until he reached the full pulpotomy. But Dominican Country is really great. And Mayan, but he has a lot of time and patience.

[Jaz]
Yeah, but what are you waiting for? Like if you enter the pulp chamber, and then you just wait two minutes to let it bleed out?

[Georg]
Yeah, basically, you place, your sodium hypocholride and wait for the bleeding to stop. Basically, actually, in the ESE paper, you are allowed to wait for five minutes, for example, first to a partial pulpotomy wait five minutes, bleeding is still there, when you do a full pulpotomy wait five minutes. And if it’s still bleeding too hard, you basically go for root canal treatment. And that’s actually a recommendation, which is for every general practitioner out their fight gods, but we have to think that it’s just a recommendation. It’s not a law, we have no science supporting this bleeding time. And, of course, there will be now someone on university under endodontic department who wants to kill me for that statement. But that’s fine.

Actually, I love having discussion with my German endodontic department because I say and have some minor literature to prove it. But the bleeding time doesn’t really matter. But that’s just my science opinion. But it’s okay to have it. Because I noticed that sometimes there are also other bleeding control agents out there, which don’t have any signs of doing so I don’t mention that. But if we just look at milk teeth, they basically use ferric sulfate that works great. Yeah. Could you use ferric sulfate in a permanent molar? Yeah, probably you can. Is your science on it? No. Pretty easy. So, I basically come to guessing and some people are afraid that we are hiding some symptoms which are inside the pulp and which costs pain. But let’s be honest, if the patient has still has pain after full pulpotomy, you do a root canal treatment.

And that’s it. Did you lose anything? No, you have a nice pre-endodontic build up? Probably? Is it hard to drill through MTA? No, it’s quite easy. Because MTA is like under filling out an amalgam. You really say ‘Yes, great. It’s so easy to remove. It’s not tooth colored composite, or GIC, which is template so easy to remove.’ So go for it.

[Jaz]
But a real-world issue here, Georg, is then is fee discussing, you know, setting your fees for the patient and extra time that’s going to take to then need that and then you need to have a patient on board that, okay, we’re trying this. If it doesn’t work, then you need to pay for the root canal treatment. And then he just needs additional procedure and having a patient on board that, you know, had you just had the root canal treatment, you’d be out of pain. Now, It’s a shame that you don’t have a pulp anymore. But we’ve been doing it for many years.

[Georg]
I know what you mean, actually, in the beginning it’s quite easy. You just present two plans. One is pulpotomy and one is root canal treatment. We don’t know yet what will happen. Probably if we have time to plan that, you say pulpotomy is one appointment where it’s just maybe half the price. And root canal treatment is two appointments. So, it’s double the price It’s logic. And basically, the people are crazy, always on your side. If you say we try to avoid what kind of treatment or I don’t like it, I told you, but I don’t like it to point it out as an alternative to what kind of treatment but for example, it could be a false positive, so there’s no pulp inside. That’s just the necrotic, of course, you have to do a root canal, pretty much, pretty easy. And so for the beginning, it’s actually quite good to do it. Actually in Germany, we have the problem that our health insurance billing system doesn’t really have this pulpotomy position for permanent teeth. For milk teeth, they have. So it’s kind of, you have to be a bit creative. Unfortunately.

[Jaz]
We know what that likes in the UK we know how to be creative in our systems.

[Georg]
But basically how it works. Just because you’re from UK, Jaz. So, a guy from the UK said it also too easy meeting he waits for 10 minutes.

[Jaz]
Oh, my goodness. Okay. He must have been in private endodontist. Not a health board. Yeah, nothing insurance base there. So, that that makes sense. I mean, there’s so many questions going on my mind now. So, you’ve described the mini pulpotomy, your sink the bur through a little bit, let’s say a millimeter. Partial is up to two millimeters that you go into the pulp chamber and full is you reached the canal orifice. One thing I want to know now is still that decision making.

So, what I’m hearing I’m guessing Georg for you is that irreversible pulpitis. I’ve been awake all night in pain, I need to put a cold bottle next to my tooth to get out of pain. That classic irreversible pulpitis. You’re suggesting to me that you will still try to assess the bleeding time and potentially go down the route of pulpotomy. In this day and age, 2022 Qatar World Cup coming up. And you’re saying that now you’ve shifted away from okay, there’s two things RCT to, actually, I’m going to go for pulpotomy. Am I hearing you right?

[Georg]
Yes. But there’s also a little but. For example-

[Jaz]
Let’s see the nuances.

[Georg]
So, for example, if you now have a businessman who will be at the World Cup in Qatar next week. It’s a different patient management in this case. I would say, look, I would strongly believes this will work. But it could be but emergency dentist in Qatar says that I’m the worst dentist of the planet, because I started the RCT and did not finish it. So, and it really depends on for example, now I’m more or less don’t have my own patients anymore. I have I get referrals. So it makes it a bit more complicated as well. So, let’s say the next 14 days he’s in town, and would be fine, if it were something I would probably go for pulpotomy.

The younger they are, I tend to more say pulpotomy is my first and only choice, because it just makes sense in my eyes because I did a lot of the treatment of teeth, broken canals, broken instruments, and I know how many things can go wrong and I break even instruments of course, yeah. So, it’s for my logic, my first choice. And if you have your first patients where you’re doing it, always do a full pulpotomy. Dentist always wanted to do a partial pulpotomy in their first case, always do a full pulpotomy. Just trust me. I talked to really cool people like Ness retire from John who did research on it. And she even said, which is something scientific. The full pulpotomy tends to be a clinical better than the partial one.

[Jaz]
Then, why not always do a full pulpotomy? It’s only like a millimeter, two millimeter extra pulp tissue. Let’s just go for it.

[Georg]
Yeah, I mean, there is a partial pulpotomy which has some advantages. And one big advantage is that you can do a cold test later on to see if the tooth reacts to it. But full pulpotomy, you can’t do a cold test because-

[Jaz]
I didn’t know that.

[Georg]
Pulp chambers for and that’s really drawback, but it’s still safe for your first case, guys remember me saying that. Go for a full pulpotomy. I know where people sending me x-ray. I did a partial because I was afraid. Okay, do full pulpotomy before. Okay. Firstly, then get experience. And that’s fine.

[Jaz]
All I’m thinking Georg is the next time your uncle, your brother, your father, your mother, your nurse, your receptionist, your neighbor has signs of irreversible pulpitis or that very deep caries that you just know it’s going to be an issue, then perhaps your first full pulpotomy should be on this kind of patient.

[Georg]
Yeah. And actually, right now, I wouldn’t have any problems to do it on any family member on any staff member to do full pulpotomy. Because I now have the confidence. But we talk about failures as well. Because without talking about failures, it would be very misleading this podcast. Yes. Yes. Basically, you can basic distinction between early and late failures. Yeah. First of all, how high is the possibility that the patient will be better on the next day and still have pain? I can tell you, that’s a pulpotomy as a pain treatment works in 91%. Well, as a pulp ectomy will work at 99%, and from an emergency dentist point of view, and you had to do a podcast recently, I think.

[Jaz]
Yes, yes, we did. With Sanj Bhanderi.

[Georg]
Yeah. Was a great one.

[Jaz]
I’m sure you would have done.

[Georg]
Yeah. And for those 8% more success, how much time do you spend? So, I can tell you whether it’s pretty much less likely that the patient will show up the next day and have pain.

[Jaz]
So, the lesson there really is if your main occupation is an emergency dentist who does not have the privilege and the pleasure of following up your patients and you’re delivering a service and that services, get this patient out of pain and keep them out of pain, then perhaps in your setting, in your environment, you should stick to pulpectomy Is that a fair statement?

[Georg]
Depends from how many patients in a waiting room. Actually, it’s during the corona pandemic, yes. And Garrett even suggested from his time in Lebanon, to just place dexamethasone, just to injection with dexamethasone close to the pulp, just doing this filtration. That’s the best word. And it will resolve the pain.

[Jaz]
Like intrapulpal?

[Georg]
No, no, it’s just like an regular-

[Jaz]
Like a buccal infiltration.

[Georg]
Buccal infiltration.

[Jaz]
Okay.

[Georg]
Yeah. And he’s suggested with a braided wet back, when was Lebanon. And maybe now it’s beginning of the Corona, because everybody was afraid of aerosols, that should be a treatment option we got considered. So if you have really a lot of patients, you basically have to take the one with the past coming out, he’s your first choice, everyone can get injection. If you have a lot of patients more or less, no severe swellings, I would go to full pulpotomy with everyone and just play some temporary filling on it, and it will work quite good. And of course, if we have such cases where the bleeding is so extensive from the canals, no matter what you do, it won’t stop these cases, you do a pulpectomy. Of course, yeah. Because you can’t really tell them even in emergency but bleeding out of the tooth is normal.

[Jaz]
But well, it is true. But early failure, you said was the next day pulpectomy 99%, out of pain pulpotomy 91% out of pain. And then so if someone comes in with an early failure, does that mean they now advanced to stage two, which is the pulpectomy is that what happens?

[Georg]
Basically, after full pulpectomy. It’s pretty easy. Actually, interesting with my failures, it’s actually you have a gender part in it lots of more female patients have an early failure. Which is interesting. And usually, the early failures in the first seven days, yeah, even like now tennis to hot drinks are still cold after full pulpotomy if you feel something cold. That’s something wrong. You can basically say, okay, maybe that’s a real recession. It’s a palatal route, and where you can kind of get some signals.

That could explain it. But after full pulpotomy, you don’t feel any cold. And so if I still feel something, it’s kind of odd. Really, I would say in the first seven days, it can happen. Yeah. Remember the 80% success from the Iran study? And I think we can relate for very good, very good, but it’s not like that every fifth patient will be visit you next week and have pain, because we have also late failures, but somehow to get necrotic. Or, yeah, basically, they get necrotic somehow.

[Jaz]
Well, the interesting thing here, and the dilemma we have is that if we start in the in the future, because look, Georg as much as we’d love for everyone to pulpotomy. And I think this episode is gonna go a long way, hopefully, to start making dentists think about this. And so that’s what I love about speaking to people like you generating new ideas, not even very new, like relatively new, because we know the lecture is now getting out there, which is amazing.

And we’re sharing these new protocols and ideas. But the dilemmas it poses are also new, which is the whole thing about cuspal coverage, if the patient now needs to spend additional, I don’t know, 900,000 pounds, 1000 euros, because to be able to get to a point where the tooth potentially needs a pulpotomy, it’s the same thing as it potentially needs pulpectomy. It’s got a huge amalgam of fracture, it needs cuspal coverage. And then the extra dimension of doubt that you have now is should I put a crown on?

What if two years later we had to then drill to the crown and do an RCT? Which is the same dilemma we have, and we have deep caries, right? So, this is another layer of complexity.

[Georg]
Yeah, but in my hands, actually, the full pulpotomy makes things simpler because we don’t have nose guessing. Spheres, deeper divorce leavings decay. Okay, how was the pulp studies anyway? We don’t know where it. And with the pulpotomy, we have one advantage we saw was it vital? Was it necrotic? Or didn’t look well? Actually, it’s really hard. There’s not really a good book about how the healthy pulp and a lot of picture of healthy and unhealthy pulps which it really comes down to experience and I even myself say something on it. Yeah.

And for example, you just mentioned your staff member I just had a staff member opened up the pulp and there was a small moment where I said OKAY, it just exposes the pulps a bit. I just do a mini pulpy and we’ll be done it was great. But it was like no, she had pain. I go for pulpotomy, and they looked at the path and you don’t use could see the pulp but was not really bleeding very good. So, I did the full path to me it still was not being very how I saw some bleeding I was like, oh okay. I still went for the biodentin on top, placed my filling but said okay, let’s look. Next seven days and you know the seven days Oh, over she still have some symptoms on hot. So, I say no, we have to probably do adversities pretty sure after seven days if it’s a pain has not gone up seven days. It’s quite good sign. I mean, she has a short distance to the dentist’s differentiates at work and experience fame. So, when the next

[Jaz]
When the next patient cancels, she’s the one in the chair.

[Georg]
Usually, the last patient of the day or something like that. We always find a way. And therefore when you kind of have a look at the pulp and you kind of still don’t feel really comfortable, it’s probably not working.

[Jaz]
And what is the unhealthy pulp look like? Like a vital but unhealthy pulp that gives you that feeling in your stomach, that’s not going to work for them less experience. Because look, think about it, Georg, we are used to a living less way less experienced then we are used to opening up the pulp chamber with one motive; kill, kill, kill. We don’t even probably look at the we just go through the bleeding, we stick some hypochlorite right in the canal and we put the pressure inside. We don’t even look pause and see. What is the health status? What is this pulp looking like today? So you need to enlighten us.

[Georg]
Yeah, it’s very difficult to tell. But even when I look at Dominica, we could use studies where he did a lot of pictures of really nice pulp and say, and she says that’s unhealthy, but suffering like, oh, wow. And there are some things where you can say the color methods, if it’s really pinkish, and it’s probably it, if it’s more brownish or leathery, let’s say this one, it’s probably nothing. And sometimes I mean, you can just pop the pulp and if it feels like it’s one block of very liquid, it’s probably not working. And I even had one case where I did want it to do kind of some pulpotomy at the central incisor and just rinsed it a bit.

And suddenly the whole pulp was in the vacuum sucked away. And I was like, okay, probably that was not unhealthy pulp. Pretty easy. But it also has a case with a young patient, where I had on the referral sheet, root canal treatment to ferrule, and I looked inside, it was a healthy pulp. Apparently, the pulp kind of went away, did put two people by the file, which was interesting. And so I don’t have the answer for you, unfortunately. Yeah, but my answer so I like bleeding pulp, if it’s bleeding, and it stops its-

[Jaz]
What if it’s that term, hyperemia? You know, we always see that the patient in pain comes in, and it’s just flooding in blood. Is that encouraging for you, as someone who’s not looking it as a pulpotomy?

[Georg]
Let’s say it’s this way, if it’s really hyperemic, you probably have no chance, because you would need a really strong leading control agent, or even something where you just close your eyes place MTA on a cupboard, or is probably not gonna work. I wouldn’t say never. But it’s not that-

[Jaz]
Okay, good to know that if it’s too much bleeding, it’s hyperemia, go with your gut, and then that is an unhealthy pulp.

[Georg]
That’s why I basically like the time of the five minutes, which is basically I don’t want to say it’s literally have to stick to it. Because some people are very dogmatic about what’s in the literature. It’s a recommendation without any proof. And but I like it and I would say if it’s still bleeding very hard after five minutes, you left sodium hypochlorite on it. It’s probably your restorative material will not work. Yeah, but I also found that some MTAs work better than the other. It’s just interesting. And since people are always asked me for products, biodentin has the best literature from Zepto don’t outwear so it’s my first choice when I have for example, a really young kids, which has a bleeding it’s a little bit itchy. Yeah, that’s the best way to describe it. But I still want to keep it. Sometimes tend to use material from CERKAMED, Polish company, BIO MTA+, because it’s bit better-

[Jaz]
That’s a cool name. Bio MTA plus a second every single good thing endodontics BIO MTA+, and just that’s the best product name there is in endodontic surely.

[Georg]
Second mate, is a nice company, they’re not good at research.

[Jaz]
The real wet fingers dentists of the world.

[Georg]
Basically, it’s for surrounded by wet finger dentists. And but it works good in situations where the pulp bleeding is a bit bitchy. The other materials which are also very interesting because ultradent and just released, MTAFlow White, and the material has like an agent in the liquid, which is less problematic when washing away and wash away fluid can longer-

[Jaz]
So, less water soluble?

[Georg]
We have, who knows. Actually, just that company told me that it’s something which is very, very common in the concrete industry but only to people in the dental industry habits and other products. Then there’s also products from Angelus MTA REPAIR HP. It’s also quite good. And I tell you why it’s important that we have some different materials because we didn’t talk about one thing which is tooth discoloration because some MTAs even the classic approved MTA have some radiopaque and acids, which when it’s combined with sodium heparin, discolors. And they have different concentration for example, second one has also this radiopaque and bear.

So, I would rather use it at a molar and tell the patient that’s a tooth might discolor that won’t turn black, don’t worry, but it will appear more grayish. And if it’s a first premolar, you’ll see it. And then we also have to take in consideration that in every manual you take out and buried and in better say, as I only placed it on basically on the non-bleeding pulp. And the reason is when even like when materials come in contact with Bloods, which I suppose not discoloring. Of course, if there’s too much blood with iron inside, it will discolor Yeah, it’s very natural. So that’s also reason to spend a bit more time in controlling the pulp and that’s why it’s a pulpal bleeding. And that’s why I’m not a fan of this five minutes in vets situation.

[Jaz]
Well, we have to now wrap up and talk about okay, why is it that you’re so anti-leaving some caries weight where you can get a good bond? Because your peripheral seal will be good, you know, the seal is a deal and when a kid so why not leave caries dentin as your base?

[Georg]
Yeah, I mean, I tried to make it short. Basically, it’s the concept is very good. And I liked it at the beginning a lot and did it a lot, even with this deep caries one and I got failures, failures, well, I’d say I would have done a pulpotomy. versus refill so on, it’s a good idea. But let’s be honest, if you think about it, that the ceiling sounds better than it is even like a healthy tooth bacterias crossing, it’s the whole time it’s not sealed in the way because we don’t have sterile and violent at the mouth. And the basic is carriers model everyone is talking about as maybe a flower model, if you take aways in a tuition vans, and when nothing will happen.

[Jaz]It’s a disease of the surface, as you said.

[Georg]And it’s a simplified model. And it’s really easy to understand, and it’s far completely okay. But you have to always say it’s a simplified model, who says where we are not some backs in the decay, who don’t need sugar, they just live on pulpal fluids. So, this box is really simplified. Now, I, myself doing the same thing, but I have a friend from the University of Munster Germany, who can say at a much more convenient way. Actually, we have a German podcast on it. But-

[Jaz]Very good.

[Georg]But he basically says we are some bacterias who are irritating the pulp and you know, functioning and one of the advisors of the seal is a deal theory, which he stood on grade z is research says come on, it’s just of course the pulp is irritated. It’s what’s the deal about it. But I would say clinically speaking, I tried it. In some cases, I’d even still do it. For example, in cases where we have a lower molars. And really cervical dentin cariers widened the distal, where, you know, if I would do it directly, I would destroy a lot of tooth in these cases, I would just try to push some GIC inside and monitor it. And, of course, there are some patients where it makes sense to use this approach. But it really also depends on your personal setting where you work in. And for example, if I have the time, if I have rubber dam magnification, of course I can remove more. And look if there’s a pulp, and we have a success rate of a vital pulp treatment of the Pulpotomy, which is so good. I would even say-

[Jaz]That’s 80%, right? We’re talking about 80%. Right?

[Georg]80% Actually, if you look to literature, it’s the lowest

[Jaz]And how many years are we talking? Five years? 10 years, what do we have?

[Georg]We don’t have 10 years we have five year max, that’s a pretty basically. And that’s why now the Cochrane Reviews favors leaving of the decay. I say it on purpose leaving of the decay. And anyways, if you have have, like, a new rule area where not a lot of dentists, it’s a good concept. Let’s be honest, and so whole technique with children. Really good concept. Yeah, let’s be honest. But the success rate of this treatment, after the beyond our study, whatever, it’s not so good. If you just look at the numbers, it’s mainly 60%. We have had really strict success criterias if it’s not working on the cold test anymore, where basically you said that’s the failure, but it’s really strict. But if you look at other studies, newer studies 90 percentage area with the success waist, and we don’t-

[Jaz]Vital pulpotomy once again.

[Georg]For me, irreversible pulpitis, everything you want permanent teeth. And that’s a lot and then you basically think last beyond our heads 11% success with partial pulpotomy. And you basically, ask yourself, what did they do wrong? And it’s not written in a study. And it’s not a criticism. I mean, it’s a great study in the evidence is much higher than everything else. But we don’t have any comparison studies. And of course, everyone in university, ‘Oh just do a randomized control trial.’ I don’t know how to do a randomized trial. It’s kind of even, like when you think about it, I would like to do a randomized trial, but I don’t believe in selective caries removal.

So, I should do something I’m not believing in, guess the results! Probably it will turn out better than my vital pulpotomy. And that’s something because I’m just biased. Even with like, a lot of centers, you will get basically, this result, either one is trained in the vital pulp therapy on the selective cariers removal. And I don’t condemn myself, but I for myself, from my experience with my failures by the pulpotomy, and selective caries decided, I don’t want to do selective cariers removal anymore. And I hope I am not will be like so. You noticed all dents like in the early days, we did all this review with all the carriers. And it works much better when you’re selective approach.

And, you know, I’m not sure about this. And I’m not following up on my cases to really know how my success rate, and my weaker rate would be really bad. But that’s a problem in all dentistry. And it really depends. Now, I’m basically in private office, I have time to place my rubber dam treatment plan. Of course, it will work in my hands quite good. And let’s be honest, if I would believe and select cavity, these cases would all work very good as well. Yeah. So, I don’t like this dogmatic approach a while. There are some reasons to look at the pulp and see if it’s vital. Like I’m just kidding. Yeah, but it’s nothing I would say to vet or vet. But for us in the practice, and I worked in a rural race, just remember the tooth with a deep caries, and so we’ll be ended for sure. And I don’t really have time, Z has good cases to start. Because you don’t have anything to lose. And it’s not an experiment. I really hate about experiments. Sometimes you’re doing experience.

It’s nothing new. It’s probably even older than spec. I think, even like before the First World War, some people were doing research on it. And it was just forgotten knowledge. I mean, even selective caries removal is nothing new vessel really nice this article about it from the 50s where we extracted first molar of children and kind of compared selective carious removal and they use the full caries removal, new metrical calcium hydroxide back then the MTA of that time. So we’ll come in waves and just to complete it, I’m not dogmatic of any way. And I would really be happy to see some literature that I know is a functioning group and Berlin is working on it, I would say, there’s not a perfect study you can design to really convince everyone due to the bias, and-

[Jaz]I mean, yeah, clinical dentistry is played with this issue of not having amazing evidence when you compared to other fields. So, this is what we have to accept. So, there’s still a lot to be discovered in term

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Did you know that Dentistry was voted the unhealthiest career in the world? Multiple times. That’s right, we’re number one! The grim reality is that we take on all sorts of professional and personal risks on a daily basis.

I had the opportunity to sit down with Dr. Rohan Verma, a clinical dentist and fitness coach to record this wholesome episode. We talked about what steps we can take to improve our health. At the end of our conversation, we also talked about diet as well. I hope this episode will address our unique professional challenges and help you become healthier and more mindful about everything you’re doing for mental and physical well-being.

https://youtu.be/xubc_XpSrzICheck out this full episode on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

1:51 Dr. Rohan Verma’s Introduction
3:46 Mental Health Awareness
6:39 Biggest mistakes dentists are making with their health
11:09 Posture Issues
14:50 The significance of sleep
16:52 Importance of setting a routine for better health improvement
24:16 Working out routine
29:09 Dr. Rohan’s stand on different kinds of diet
31:29 The benefit of calorie counting

Check out Dr. Rohan Verma’s Instagram to get some tips on how to improve your health – as well as a Dentist he’s an online fitness coach.

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Do you believe that Resin Bonded Bridges are exclusively a temporary or short-term solution? Lots of our colleagues around the world mistakenly believe this. It’s not a secret that I am a fan of this treatment modality—I want to break down the misconceptions about them because IN THE RIGHT CASE they can be a very predictable tooth replacement option.

In this episode, Dr. Salman Pirmohamed shared successes and failures and what we can learn from them to improve our clinical protocols from abutment selection to adhesive techniques.

Claim 75 minutes CE on Protrusive App.

https://youtu.be/rKJyqcb6uqICheck out this full episode on YouTubeThe Protrusive Dental Pearl: Always visualise your path of insertion – do you need to do some additional prep to get a more favourable path of insertion?

It’s not just for dentures! For any indirect crowns/bridges, it is important to assess for a path of insertion. Make a visualisation of this – you may have to prep more or prepare the adjacent tilted teeth to allow for a suitable path of insertion sometimes.

Salman’s Webinar on Sunday 4th Dec LIVE: https://buy.stripe.com/4gw14Pb8Q47Q8yk5kk

Need to Read it? Check out the Full Episode Transcript below!

Highlight of this episode:

1:48 The Protrusive Dental Pearl
3:17 Dr. Salman Pirmohamed’s Introduction
8:16 Resin-bonded Bridges being underutilized
9:43 Resin-bonded bridges over the years and its Protocol
12:18 RBB – functional for patients?
17:26 Case Selection Criteria
20:25 Case Number 1
22:43 Case Number 2
23:16 Dahl Technique on RBB
24:57 Cantilever as the standard design of choice for RBB
27:40 Case Number 3
29:25 Case Number 4
32:47 Mesial cantilever vs Distal Cantilever
37:34 RBB Lab Prescription
39:43 Incisal Overlap
42:06 Pontic Design ideal for RBB
47:48 RBB Clinical Protocol
1:00:09 Zirconia RBB protocols
1:06:46 Periodontal Splinting
1:15:21 Two failures with Resin-bonded bridges

Have a read about this evidence-based literature as referenced by Dr. Salman

Survival-characteristics-of-771-resin-retained-bridges-provided-at-a-UK-dental-teaching-hospitalDownloadAlso, check out this paper written by Dr. Jaz Gulati

Resin-Bonded-Bridges-−-the-Problem-or-the-Solution Part 1DownloadResin-Bonded-Bridges-−-the-Problem-or-the-Solution-Part-2DownloadIf you loved this episode, you might also love this Group Function talking about Dahl Technique and ‘Maryland Bridges’

Click below for full episode transcript:Jaz's Introduction: This episode is dedicated to any dentist in the world who thinks that RESIN BONDED BRIDGES, or dare I say Maryland bridges are a temporary or SHORT TERM SOLUTION.Jaz’s Introduction:
I’ve got plenty of friends in North America and in Singapore who felt that way. And I just feel like it’s a massive misconception because resin bonded bridges, or sticky bridges or adhesive bridges, call them what you want. They are such a fantastic and UNDERUTILIZED TREATMENT modality to replace missing teeth. Hello, Protruserati. I’m Jaz Gulati. And it’s no secret that I’m a huge fan of these bridges. I’ve published about this technique before and something that I did a lot of in dental hospital. And I took this into private practice. And the funny thing is that when I started to work in the practice that I work in now in Reading the dentist whose list I inherited, who was working there for 30 plus years, he was also a huge fan of resin bonded bridges. So, I’ve had the privilege of looking after and reviewing patients who’ve had their resin bonded bridges, both anterior and posterior in service for 34 years, 32 years loads in the 27, 28 year mark, plenty in the 20 year plus mark. So, he was fantastic at doing them.

It really validated my belief system in resin bonded bridges. But I know what you’re thinking, you’re thinking, ‘Jaz, that’s like N equals 15. How is that even valid in this world of evidence based dentistry?’ Well, let me tell you, the evidence is out there. And we will discuss it today because resin bonded bridges are extremely successful in the right cases. And we’ll discuss what those cases are and what clinical protocols we use to get that kind of success because I’m joined today my buddy Prosthodontist Dr. Salman Pirmohamed, who you may remember from Episode 97, about face bows. If you want to learn more about face bows, when to use them, when not to use them. You can go back and listen to that episode.

The Protrusive Dental Pearl
Now for this one, I’ve got a Protrusive Dental Pearl for you, which is relevant to resin bonded bridges, but also all types of indirect work. The Pearl is to always picture your path of insertion. Now, when I say path of insertion, most people usually think dentures right, we will always talk about path of insertion and a path of removal for your denture. But path of insertion is also relevant to crowns, onlays, and resin bonded bridges or any type of bridge. When you look at your prep, you have to visualize how is a technician going to insert and remove this indirect piece of dentistry. Because sometimes if you’ve got adjacent teeth that are tilted, it can really complicate getting a good path of insertion, in fact, recently had a tricky case where I wasn’t able to achieve a vertical path of insertion for my onlay so meaning, the technician agreed for a buccal path of insertion, it worked really well. It’s not something I do routinely or want to do. But it’s just something that worked out for me.

And it’s really important to just keep that in mind, especially when it comes to resin bonded bridges, which we’re talking about today. Whenever I’m doing a prep for resin bonded bridge, and let me tell you now, let me give you a spoiler is that there’s not much prep involved. But that doesn’t mean no prep. Minimal prep can often mean making guide planes and reducing maximum bulbosity. So we’ll talk about that today. But a little bit of work can go a long way to get a more desirable path of insertion. Let’s join Dr. Salman Pirmohamed now for the main episode on resin bonded bridges, which I hope will change your mind if you’re someone who is a doubter, a non-believer, then I’m hoping that will convert you to thinking a bit more about using resin bonded bridges successfully in general practice for definitive and long term replacements of missing teeth. Salman Pirmohamed, welcome back for the second time to Protrusive Dental Podcast, we had you before on the face bows, you know all about when and why to use a face bows and you did such a great job. And we’ve been geeking out on social media, by the way your posts, dental_story, you got to follow that account is brilliant. So educational, I’m loving it. And you’ve been posting a lot about resin bonded bridges.

Main Episode
So, let’s come on. And let’s help those who are either not warming up to the idea to resin bonded bridges. And we’ll talk a lot about that or who just want to improve their workflow. But for those who didn’t listen to the episode yet, please remind ourselves, tell us where you’re at in your career. The moment Salman tell us how you fell in love, like I did with resin bonded bridges.

[Salman]
Okay, so Jaz just to introduce myself again, because that was quite a while ago, we did a podcast on Facebook. So, my name is someone I’m qualified about six years ago. I’m currently at the Eastman doing my specialist training and prosthodontics and that’s three days a week. So, under the three days a week, very busy practices. Jaz found out this morning from my daily list three days a week in general practice, do you combination restorative and implant work. Resin bonded bridges like the real passion came about from quite a few things actually.

The first thing is Jaz mentioned, I’ve been posting a lots kind of clinical cases on my Instagram page. And the topic I get the most questions about is always resin bonded bridges and mainly from the international crowd. So, I think the UK-based census uses a lot more and maybe NHS hospitals have changed the way we replace missing teeth. But the people abroad they”re like ‘What you’re doing that you must be doing something wrong here. How is this working? How’s the occlusion settling down?’ And that’s why I thought this podcast might be a good idea and I’m happy that Jaz invited me on because I feel quite privileged to be in a crowd of people that he gets on.

[Jaz]
It’d be so good because I see the kinds of cases you do. And you also told me that at Eastman, you you guys are really pushing the bow, you got really pushing it to the extreme limit in terms of what can be possible with resin bonded bridges. So, we’ll talk about that a bit later in terms of okay, how far can you go? But yes, please carry on.

[Salman]
And the second reason is because at Eastman, as part of our specialist training, we have to have a thesis project or dissertation topic, and mine has been on patient satisfaction, it’s going somewhere quite a long title but, ‘Patient Satisfaction for Replacement of Missing Lateral Incisors’, and comparing orthodontic camouflage, dental implants and resin bonded bridges. And what’s odd is that we often recommend patients in different clinical solutions. But a lot of it’s not actually evidence based, a lot of prosthodontics is opinion, a lot of it is expert opinion, we say on what we learn from our teachers and our VT trainers along the years. And I’m finding that from the research that I read, actually, that resin bonded bridges come up with an almost equal or even higher patient satisfaction rate than dental implants.

And then Jaz, to finish the story here with the last reason I got interested in resin bonded bridges, because I started a new private practice about a year ago, and mainly to do some implant work. And I thought we were doing a lot of implants and a high number of them. And these patients are coming in for free implant consultations. And it’s a great way to improve my communication skills. But what happened is they were all working out with two implants for resin bonded bridges and my principal flagged up said, ‘What’s going on? We’re not ordering implants anymore.’ And I just realized that there are some really underutilized treatment modality that can give a massive benefit to our patients. And I’m sure Jaz share the same stories with the ones that he’s done also.

[Jaz]
Hugely underutilized. And that’s the first thing I want to tackle with you today Salman. Because just give you a bit of story when I was practicing in Singapore, if you remember I used to be in Singapore some years. And that’s when I realized that actually, it’s only in the UK and maybe some few select other countries in Europe, that resin bonded bridges are done to a high standard with good longevity and popular that even in the UK. And then when people talk about it on Facebook, they say, ‘It’s not going to work. No, it’s not going to work. You know, it needs a wing and a prayer.’ And all those funny jokes come out and whatnot.

But I realized it to the extreme level when I was in Singapore because not only did the local Singaporean dentists have zero faith in resin bonded bridges, the US dentist that were working as expert dentists in Singapore had zero faith in resin bonded bridges that they thought was like just it’s a very, very temporary solution before you have an implant. That was the only sort of indication for resin bonded bridge. And even then they weren’t convinced by that. And that and so what happened and the third reason why I think it’s underutilized is commercial. Because what happened when I was in Singapore, I was working for a corporate, I’d written my paper by then dental update, so and I was doing a bit public speaking in Singapore, and I said, ‘Hey, guys, you know, we have a monthly corporate study clubs, I’d be more than happy to come in because I realize no one’s doing this.

I’m more than happy to share with you some protocols, so everyone can feel more confident doing resin bonded bridges.’ They always reply to my emails and never reply to that one. Okay, because the most of the lectures were about implants and referring to their in-house specialists for implants, because what’s going to generate more money? Okay? Implants? Now, by the way-

[Salman]
I would argue with that.

[Jaz]
Well, yeah, I would agree with you. But actually, if you do resin bonded bridge as well and charge for them, they give you a good hourly rate, and how many years ago you got to it in terms of how much you spend, that ratio will be good as well. And I know I’m gonna go in that scenario. But as a commercial viewpoint as corporate, does it want to push its dentist to refer to implant or just for multiple implants versus, resin bonded bridge? I think they had a commercial motive not knowing that, okay, resin bonded bridges can work well as well. So, that is some of the things that I found when I was there. How about you, my friend, because you’ve been reached out on social media, international dentists not having faith, why do you think they’re underutilized?

[Salman]
I think with the American dentist a lot, they actually do a lot of resin bonded bridges, but it’s always seen as a temporary solution. So, the implant guys will always show like a big surgery. And then I have a resin bonded bridge in situ. And I say, ‘Yeah, we’ll take it off in three months and then restore the implants.’ And I just think like, well, if you just left it on, how long would it have lasted because it’s been pretty predictable, so far, without proper like bonding protocols and material selection. And I think that’s really funny Jaz with like resin bonded bridges as UK dentists, we’re often made fun of from the rest of the world in terms of our occlusal management, in terms of our restorative case selection.

But I think in this one scenario, there’s a lot that we can teach other people or just share different treatment modalities, because it’s working in this public healthcare system that’s kind of really made this treatment modality so successful. The question of working in a hospital is yes, there’s less risk involved and things fell, there are patients are paying, there are patients for free. But it’s when we really push the boundaries to the extreme where then the more routine cases become so predictable when I do them in private practice over here and charge patients appropriately for what you do because it will give them that quality of life that they want.

[Jaz]
So, Salman just a little history lesson for us how far have resin bonded bridges come over the years in terms of technology, why are they in a better place now, in terms of protocols?

[Salman]
So Jaz, I think enamel bonding has been around for I think 70 or 80 years a long time ago it’d be on a core in a study on acid and acrylic bonding and enamel etching and then resin bonded bridges has started about 50 years ago, initially Rochette bridges, so you’d have this metal retainer, they’d be stuck to a tooth, and you’d have holes within this retainer because everyone could stick figure out how to bond the enamel, but no one could figure out to bond to the metal.

So, they made this because they needed macro mechanical retention with HGSC or composite resin cement, we then went ahead in the University of Maryland figured out an extra chemical etching with the basic figured out that if you get a specific procedure to the metal, then our resin cements or bond really predictably and made our bridges is kind of stuck as a terminology, but actually the correct term is now resin bonded bridges because we don’t do the electrolytic etching the way the University of Maryland did, Kuraray came up with MDP primary, which has changed zirconia bonding and changed metal bonding and that MDP primary is how we figured out how to get really predictable bond strengths, and specifically to non-precious metals, because they’re the ones that get a thick oxide layer, very predictable bonding. And that’s how it started. And now it’s come even further now we’re looking at zirconia resin bonded bridges, but yeah, it’s been a massive evolution in the last 50 years.

[Jaz]
It certainly has now, I got a couple of points there. Maryland bridge, I know is not the appropriate time to use them all. But you know what, with my patients, I do use it. With my clinical community. I use resin bonded bridges, patients identify really well. They don’t like the term, I’ve just trialed it, you know, for has a nice ring to it. ‘Maryland. Oh, why is it called Maryland? Oh, from USA! Oh, okay, this is interesting. I like it.’ Resin bondedbridges sound too jargony. So that’s-

[Salman]
I call it a sticky bridge.

[Jaz]
Sticky bridge is also a good one. So, that’s good. And then as they evolved in terms of how we use it, and I think he’s really great, you mentioned about the MDP being so important, and allowing us to get some confidence. And a lot of the studies that we’ve done in the UK and abroad, but so much good stuff coming out from UK authors, which is why I think it’s done so well like my principal, who was in the same practice for 34 years and who I took over from. So, he was leaving the practice no longer principal as I took over, so all these patients in their 60s and 70s, I’ve taken off the list, they’ve all been seeing Giles for 34 years, loads of them have resin bonded bridges.

And then I’ve seen quite a few which had been there for 32 years, I’ve seen some for 25 years, and maybe at like the 15 year mark once it came away. And that’s it. And that’s just because I’m interested in this, I’d like to ask those patients, but so many of them have lasted so long and patients are really happy. But back to that question I was gonna ask you is to what degree do you think it can actually facilitate or become functional for the patient as in your sticky bridge or resin bonded bridge, do you expect your patient to be able to function on them?

[Salman]
Yes, I have a very, like long consent process for my resin bonded bridges. And as time goes on, even though I feel they’re becoming more predictable, I think we’ve always done the things Jaz of under promise and over deliver, right? And resin bonded bridges are very much like the rest of our treatment modalities. And when I give a patient the treatment options, the resin bonded bridge solution for me is non-invasive solution that has all the benefits of aesthetics. And I promise them really good aesthetics with that ponti, didn’t work for metal retainer are one of the sub optimal aesthetics with the metal retainer. And I’m often going for incisal overlaps when it comes to discussing function-

[Jaz]
And we we will by the way, we weren’t for those listening, we will talk about incisal overlap later is really important. So, we will touch on that in terms of designing your resin bonded in bridge. But yes, please carry on.

[Salman]
For me, when I go to the functional units, I tell the patient this is not a true functional unit. Because if you think about it, you’ve got one fake tooth attached to one real tooth and one real tooth is taking two teeth weights. And so I’ll say, ‘Always be gentle with this tooth, don’t use it like a normal tooth.’ In the back of my mind. I think if they use it like a regular tooth, they probably function just as well as a regular tooth. But I always wanted to be careful. If they’ve got one resin bonded bridge in their mouth and remaining unrestored dentition. I want them to be avoiding this area of the mouth because naturally that will prolong the longevity of what we’re providing. We know that our cements are good in compression, and they’re not so good intention.

And I designed my retainers in such a way that generally that retainer is always gonna be under compressive load. But if the patient is careless with its bites and forking the wrong way, it’s in the wrong direction, that’s when your cements are going to fell. And often if you talk to patients as to how to dispose them when the bridge come off, it’s so easy, just a random chewing motion. It’s usually, ‘Oh, I knocked it or something happened and then it came off and I regret doing that.’ So, they do work in function. But in terms of consenting patients, I say it’s not true functional unit and that’s the best way to look at it. Because the majority of resin bonded bridges have been done for aesthetic reasons, not for functional reasons it is postulated, which I’m sure that, later it’s a very, very different discussion.

[Jaz]
100% agree and so the commonly replacing lateral incisors, you know, using a canine or central so that’s the most common scenario and even lower incisors which I’m really passionate about. I’m so passionate about how we often use resin bonded bridges to replace lateral incisors and one thing I’m really passionate about Salman and I don’t know if you are as well, is I think as a international consensus in dentistry you know how they had the York consensus about the standard of care should be two lower implants for the lower denture of this person right, I think the standard of care for a missing lower incisor where appropriate should be a resin bonded bridge. Okay, Exhibit A. Exhibit A I’ve got my own resin bonded bridge replacing my two lateral incisors. After some orthodontics there’s one a pontic space and I’ve seen, I don’t know if you’ve seen before, some implants in place in a lower incisor region that’s just been absolute nightmare. And so I always think such a narrow space and-

[Salman]
I’ve got better story for you, Jaz.

[Jaz]
Go on, go on.

[Salman]
So, I’ve taken this audio clip from my iTunes podcast from my practice right now, my principal about 15 years ago, his associate was doing an implant training program and my principal with hypodontia, his lower incisor, so we did an implant placed, squeezed in between the two lower incisors. And about eight years later, he began having the complications from it. And so he lost both of the adjacent teeth. And that was three incisors and is mainly because someone tried to squeeze in implant and for an implant need that seven millimeters of interdental root space which there wasn’t in that case. And for me, the solution I know is narrow implants out with these implant companies. But often it’s just easier to look at simpler solution like resin bonded bridge, my principal now has a resin bonded bridge, which ones from the lower right canine to the lower left canine.

And that’s even more these years hitting off another implant solution because he had that bad experience in the past. And I think we also need to look at modes of failure, right? If you try squeezing an implant in what are you going to cause what’s the complications of it, just because the patient pays more initially doesn’t mean things are gonna last, they may last longer but the cost of complications is a lot greater. So, there’s a lot of factors to consider.

[Jaz]
Lower incisor region for sure. 100%. So that’s the main message I gave in. You know, I talked the talk when I walked the walk when it comes to that, but on that topic or function, so part of my consent is I teach my patients about how it works. And I really say like, ‘You know, can you believe that we’ve just stuck a bit of a thin strip of metal to your tooth, like how amazing is that? It’s just stuck onto your tooth. Now can you imagine someone just peeling it away? And then, ‘Oh, yeah, it could peel away.’ So I say, ‘Look, you can do what you want. Just be careful not to bite sellotape on it, not to bite into a baguette and tear the baguette using your fake tooth, you can use the good tooth next door, but you can’t use my fake tooth.’

So anything that requires you to put the food first or a tool on that fake tooth, and you’re going to lever it off. And I think that message really gets through, the whole tearing the baguette, tearing a crisp packet. And I think as long as you avoid that, these sort of freak of nature kind of incidents, you know, getting elbow and stuff, then they enjoy a really good longevity. And patients don’t often think about it during function to avoid or anything like that. It’s more about not doing anything stupid with it. Would you agree with that?

[Salman]
Yeah, no, I fully agree completely. It’s just about advising his patients properly about how to take care of her. So last and the longest time possible, completely.

[Jaz]
So on the topic of lasting as long as possible case selection criteria, because I’m sure dentists message you saying, ‘Is this suitable?’ And I get lots of messages saying, ‘Is this case suitable?’ And thankfully, the ones I get are quite sensible. Actually, though, the ones I get quite sensible, I don’t get too many far fetched ones thinking it’s a bit of a push, occasionally, you get one which is suboptimal? Because let’s talk about what other kinds of features that think that lend themselves to resin bonded bridge. And then what are the features that don’t?

[Salman]
Or what are the red flags, right? Essentially what you avoid?

[Jaz]
Red flags, how can we avoid being too ambitious?

[Salman]
So, let’s go through the positives first. The things that lend themselves towards a good resin bonded bridge, which I think for me like first thing is enamel. It’s just enamel, enamel, enamel. I don’t know if people talk about Dentin bonding now but for me, enamel bonding is what’s always give me predictability for a resin bonded bridges and I’m very open and honest about my failures too, even on my Instagram. I’ve had two resin bonded bridges that failed, and one of them was pushing the limits, and it’s purely because of substrate that I wanted to. I was trying to replace a lower incisor and both the adjacency for post full mouth reconstruction and had quite composite on them. And I thought I can get by composites fresh and it didn’t work. And it’s purely that quantity and quality of enamel. The it is the first main thing you need for predictability of your resin bonded bridge.

[Jaz]
100%. And you can also-

[Salman]
Would you agree?

[Jaz]
Yes, please. I was gonna say one thing that I know we’ll touch on is favorable occlusions and unfavorable occlusion bite but I know you’re gonna come to that as well.

[Salman]
So ideal patient, anterior open bite?

[Jaz]
Huge class 2 div 1, anterior open bites

[Salman]
Class 2 div 1, is like the opposite? Exactly. So I’d say bruxists are for me a warning flag for resin bonded bridges, especially when I tried to maybe go further back in the mouth to replace the missing teeth. So for me it was when the bridge is usually when you’re retaining to be larger than your pontic tooth or more stable. So people often look at either replacing natural incisors of the essentials or the canines. I’m quite happy to do that. Because the mouth we know it acts like a lever the functional forces are heavier at the back of the mouth, like a nutcracker in the lower at the front. So for me resin bonded bridges will last better at the front of the mouth.

More and more people say why don’t you do posterior resin bonded bridges and I have shown a few cases of mine on social media. But for me, they’re really really really case selective. So for me, posterior resin bonded bridge to replace, for example, an upper second premotor or for first molar is, it needs to be the perfect case there needs to be some existing into space. I don’t want to be relying on the DAHL approach too much. Because I know the occlusal forces there will be greater and so I’m worried about bruxists.

[Jaz]
The first ever group function I did was a question someone asked about, ‘Can you do DAHL using the resin bonded bridge technique?’ And yes, obviously we can. But then when I talk about that scenario with the first molar on adult I’m a bit more reluctant in private practice to do that. But in hospital I’m sure you’re seeing loads of the 17 year olds post orthodontic hypodontia probably using the canine as the abutment tooth in DAHL so the only contacts are on the retainers and then everything just settles. Am I right that you guys are still doing that?

[Salman]
In terms of replacing lateral incisors, Jaz?

[Jaz]
Yeah.

[Salman]
Oh, yeah, that’s a routine case for us. I just fitted a resin bonded bridge to place an upper five off an upper six. And we often know that post ortho patients may not end up in the most standardized occlusion. So this-

[Salman]
Split, split, nicely.

[Salman]
I’m very diplomatic, Jaz. So, we were looking at the existing volume of bone to replace the upper second premolar and we did all the implant planning, she’d been consented we took a CB CT, and we found like half a millimeter bone heights and it had been a major sinus lift to make an implant work in that area. And when I took the study casts, back to the lab as we do at the hospital and actually match them on the articulator, I noticed that the patient’s palatal cusps on 6s was fully out of function completely, there’s about a millimeter and a half of opening. And for me, it was just screaming resin bonded bridge, like you can bring the six back into function, you can keep your five pontic almost out of occlusion and very, very light occlusion. And we wrapped the whole winger and entire portion of that first molar. I’ve got photo Jaz if I can figure out to share my screen with that help with this?

[Jaz]
Let’s do that. So, for those guys that are listening right now we’re going to skip. You won’t get obviously see the cases because you’re listening not watching. For those watching on the YouTube or the app, which is going to be access point for general soon, you’ll be able to see the video, but first, we’re gonna skip past the video put components for those listening. Please describe what you see my friend, obviously people are watching but yeah, sure. Tell us about this case. Is that the case that you just described?

[Salman]
Exactly. So, this is the resin bonded bridge case we were planning an implant replacement, replacing the upper second premolar. And you can see when you had these articulate the study casts, the buccal cusps this patient six was actually crossbite. So I put buccal cusps in function. But the palatal cusps was totally out of function. As we managed to make a really thick, bulky looking retainer which had a maximum wraparound, which didn’t include the occlusal scheme at all. So we managed to give her a nice second premolar with a partial occlusal coverage of the six with a wraparound metal retainer. And Jaz, when I tried this retainer, when I tried the resin bonded bridge even without cement, I could barely get off the tooth.

[Jaz]
And that’s a very good point. And that’s all about respecting the path of insertion. If you’ve got a nice path of insertion, that really helps as well with some stability. Also, having an adjacent tooth next door as well, will help into positional stability as well, which is a good thing.

[Salman]
So, that’s one case and two most I have got dahl cases of 60s to where I have had to do them on some patients because some patients are not keen on implant surgery and they say, ‘Is there any other option?’ And I think as part of their consent process, as long as we advise them the risks of different options, we do it. So this is a patient, I fitted a resin bonded bridge in supra-occlusion. So, this is an upper six again replacing upper second premolar. It’s full occlusal coverage and we maximize all the way and you can see the occlusion as propped open and I think Jaz our international audience might be listening wondering, ‘What are these guys talking about?’ But yeah, this patient was asked to be occlusion on the anterior teeth and they came back in about three weeks and to stay with ICP contacts. So, it does work but my case selection is very much younger patients.

[Jaz]
I love the amount of wraparound you have on all on the occlusal surface there. I mean that is textbook from the classic studies that looks really great. And for those wondering what the hell’s a DAHL technique, please check out the episodes with Tif Qureshi, we talk all about the DAHL and there’s some I just want to point out, there’s some great work being done in the UK by Riaz Yar, really looking deeply into each and every dahl case. Monitoring them, getting digital prime scan records at every stage. T scan records before and after. So, watch your space because I think the DAHL technique understanding of how the biomechanics of it works is about to go a notch higher which is really exciting.

[Salman]
Yeah, so I’m not someone who’s going to advocate putting resin bonded bridge at the back of everyone’s mouth. So, firstly the mouth is a lever and if every millimeter we open up at the back, we’re opening three millimeters at the front and so your case selection needs to be really good because if you put a one millimeter thick resin bonded bridge retainer at the back, you’ll open up three times as much at the front but it works the reverse way around if you have a resin bonded bridge anterior in supra-occlusion you’re not waiting for much posterior DAHL to take place and the issue with that is it’s by its nature unpredictable. We don’t actually know what’s happening, which tooth is intruding, which one’s extruding and so you need to really limit your reliance on it as much as possible. So I’ll pick this posterior RBBs for very very similar cases. And I’m like you Jaz, the more I work in private practice the more I think, there was patient just go for an implant is a bit more predictable in specific situations. For anterior teeth, it’s almost my go to approach and I’ve got Sanj, good volume of an enamel.

[Jaz]
I’ll show you a risky one. Can you see this?

[Salman]
Oh my.

[Jaz]
Check this out. The same thing but it’s zirconia man, but this is an very favorable patient like he had a lot of space here. It’s just the way it worked out but this, it’s been going strong for about three years now so far. But yeah, this did sent shivers down my spine as I was doing this. Am I doing the right thing here? So, got some guidance because he is a cantilever resin bonded bridge and oh gosh, we didn’t talk about that actually the importance of cantilever as the standard design of choice and lot this busting this myth that actually you need to go for a fixed-fixed. So just talk about that, Salman.

[Salman]
Jaz, I recently had like a change of not a change of heart, I’d say. So, the evidence that everyone wants to look at is there’s a PA King paper 2015 which was the one done at University of Bristol. They went through like a whole bunch of resin bonded bridges in a hospital setting.

[Jaz]
So, the 800 I think it was.

[Salman]
The good for looking at that paper is they fitted them in all parts of the mouth. And it was done by a variety of people in different levels of specialty training, different registrars as they chose consultants and looking at differences in success rate between those people. But for me Jaz, fixed-fixed and cantilever I think our reports are like a two and a half times increase failure rate for the fixed-fixed resin bonded bridges, 2.34 I think or 2.74. But for me, it’s a bit of cause and effect also, like, so I’ve noticed that people will often sometimes pick a fixed-fixed resin bonded bridge, when they think it may not work in that specific situation. So they’re pushing the boundary, and then they go for the fixed-fixed bridge, and then they get that unilateral debond. And I completely understand that the benefit of having cantilever resin bonded bridges is you know, when it’s the bonded, you know, it’s come off, you know, you have to fix it. With fixed-fixed.

If you get a unilateral debond, you get that secondary caries. And you never figure out that debond in the first place. But I’m sure there’s some cause and effects hypothesis happening here, Jaz. Because there’s some fixed-fixed bridges that are ideal, so lower incisors for me, if the quantity and quality of enamel is equal on either side of the pontic, I may choose a fixed-fixed design in some specific situations, because I’m not worried about a differential rate of debond between those two retainers and the movement of those two teeth is pretty equal. Does that make sense, Jaz?

[Jaz]
100%. And I think I’ll just add to that, and I think what Salman trying to say is that, think of the way, let’s imagine you’re replacing a central and you’re gonna use a lateral and the other central, then yes, the ligaments, the teeth want to move in the same direction. What you want to avoid, let’s think about this scenario you want to avoid is doing a central with a canine which want to go in different ways, right? And that’s when it’s going to lead to more stress in the cement loop on one of those retainer wings. So yes, similar teeth that move in similar directions like lower incisors. I agree. And actually someone I regret not choosing a fixed-fixed on my own lower incisors. I regret it.

[Salman]
Because?

[Jaz]
Because post orthodontic retention, so sometimes you want to do post orthodontic retention. Now a bit of history here, I do have a degree of mobility on my lower incisors, orthodontics in the past is a funny little thing. So for that reason, to give me a some splinting effect. And for more predictable orthodontic retention, which actually a little bit of gaps are opened up, basically. So I wish I could have done that. And I think sometimes for the sake of orthodontic retention, or stability, when you’re dealing with mobile teeth, it can be favorable. So don’t think that oh, just because someone said you can’t do fix fix it’s not for all cases. There are certainly some indications

[Salman]
So, Jaz, I’ve got a few fixed-fixed bridges to show you. This is the first one. And it’s been five years in situ, going from the canine to the first molar.

[Jaz]
And just to clarify that it’s not a crown. It’s kind of like an onlay. It’s an onlay.

[Salman]
Exactly, yeah. So, we actually needed to raise this patient’s occlusion to restore them to place implants in the lower posterior sextants. Place the resin bonded bridge on the upper is a temporary measure with an onlay to open up the bites. And actually, what ended up happening was the resin bonded bridge, the patient was so happy with it, she has refused to have it replaced. So, this has been five years in situ.

[Jaz]
Can I ask about that Salman? Path of insertion, like I’m trying to like imagine bonding that so this four unit, technically four unit, so two abutment teeth, two pontics there. You’re trying to place it on the sixth through a sort of vertical path of insertion, but the canine probably can just ensure there was some vertical path of insertion there. But was that tricky to place?

[Salman]
Not really. No, you know, Jaz, soflex discs are really, really good for getting guide planes accurate. So, we want resin bonded bridges to be minimal prep, but sometimes just smoothing out the mesial aspects of that six with a soflex disc in any areas of undercuts can just really help open up everything. There wasn’t an issue at all. And Jaz, you mentioned about and post orthodontic retention, what we sometimes have to Eastman is when we have resin bonded bridges anteriorly on your metal retainer, you can actually create a little loop for your fixed wire to go through. And that can still connect as part of the fixed retainer, or you can do this, which actually a section from your paper, you recognized that Jaz.

[Jaz]
There we are. So, central is joined together as like double abutted if you’d like. Replacing two lateral incisors. I imagine this patient well, I know this patient had a diastema or unstable sort of risk of opening up the diastema. And this is a really clever way to to get retention as well.

[Salman]
And I’ve got one last one to show you Jaz. This is actually another one of my mouth, I say failure in my eyes, but as a success of the patient’s eyes.

[Jaz]
Great. Well, I want to talk about a failure I had seven months ago. Debonded on someone who’s dentures are replaced with a resin bonded bridge anteriorly, a couple of them central and lateral. And the lateral came away from a canine because he went to the fridge, he had some cold chocolate, and he rested it on his pontic and bit down. And so that was a freak accident because he then realized that oops, I wasn’t supposed to do that on that tooth. And otherwise, that’s yeah, don’t get many failures, but recent one share and that’s how it happened.

[Salman]
And here’s an another one Jaz. So, this is a patient who once again, we were waiting for them to be suitable for implants. They were 17 years old we’re waiting for- So, the whole point I’m sure people are aware with implants, facial growth continues with life. And it’s especially quick up to the age of puberty. So for men, we usually wait till the age of 25, with girls, at the age of about 21 because if you place an implant too early and facial growth continues, you get relative intrusion of the implant, you get much shorter clinical crown and the gum levels don’t equalize. So, resin bonded bridges we often use in NHS hospitals. Even practice outside when we get referred them from orthodontics like this patient was willing to delay the placement of implants and give them a fixed solution. In the meantime, now this patient came in with missing upper laterals and upper canines, and I placed the fixed-fixed resin bonded bridge from the central to the first premolar. And on the other side from the other central to the first premolar.

[Jaz]
Wow, so central, lateral, canine, premolar, that’s four units right?

[Salman]
Four times two, yeah. So, we placed this and you know, it opens up the bite really nicely Jaz. But occlusion settled in about four weeks really quickly. And this patient actually decided to not go ahead with implant treatmemt five years later, so he’s going to wait it out with his bridges, because he’s happy with the function, he’s not gonna have any problems. And he’s not keen to undergo surgery. But my mistake in this case, and you might notice is look at the incisal translucency, Jaz, I lost it. And this is the case where I was beginning to use Panavia and I wasn’t checking on my nurses opening and I use tooth colored Panavia instead of opaque Panavia. That’s resin bonded bridge and much greater loss of enamel translucency and I had this grey, I looked at and I thought oh my god I’m gonna have to clean this all up patient looked at it and said, ‘I’m totally happy with it doesn’t trouble me.’And I said, ‘Let me know if it does.’ And it’s been five years and it’s still fine.

[Jaz]
Ver good. But yeah, great point make sure using the right cement and use an opaque cement like you know mean we both use Panavia opaque well signs of it, which is yeah, which is a fantastic cement for that reason. But you still have to warn even with the opaque cement that okay, there is gonna be a degree of graying and it depends on the degree of translucency of that tooth.

[Salman]
So yeah, so another disadvantage of resin bonded bridge is that. So yeah, lots of incisal of translucency is an issue. It’s often why- We found replacing and lateral incisor my ideal abutment is nearly always a canine. I don’t like centrals for several reasons. The first one is patients will often notice a mismatch between two central incisors because they lose symmetry. Centrals have more incisal translucency. And finally, we said that the DAHL approach is unpredictable, right? It’s very difficult to know which way teeth is moving. And I have a feeling that sometimes when I fit the resin bonded bridge going high on the central, I think there’s some elements of labial shift of that central incisor going on-

[Jaz]
I agree. Some plane.

[Salman]
Exactly. And patients will notice because it doesn’t match up the central.

[Jaz]
That’s a great reason to consider the canine. How about this whole mesial cantilever, distal cantilever? So, when I wrote that paper, I struggled for hours, my biggest time on research was finding good evidence to suggest that other than just expert opinion that the whole distal cantilever versus mesial cantilever actually has a wealth of evidence behind it and I couldn’t find anything, Salman. So, just to clarify for those things. So, mesial cantilever would be like going from a first molar to a second premolar your cantilevering mesially. A distal cantilever would be going from a first pre molar to a second premolar your cantilevering distally. So, any guidelines terms of to you, is it a relative disadvantage for you to go distal cantilever?

[Salman]
So I think for me like firstly, we know that forces are great with the back of the mouth, right? Always. And when we often fits our retainers in supra-occlusion, we want our pontics have been very, very like it. Well I say lots of guidance in very, very light aesthetic occlusion. I think it’s very difficult to get that pontic in the occlusal scheme. If you have a distal cantilever going backwards at the back of the mouth, it’s more challenging to do that. And that will then put your cement in tension which then leads you to a greater risk of debond but that’s just me logically speaking, completely agree there’s not very much evidence and mesial and distal cantilever because at the window when we look at the anterior part of the mouth, right, central laterals, canines, we don’t consider it.

[Jaz]
It’s not so important.

[Salman]
Yeah, I would never consider placing a second premolar off a first premolar. I can’t see a case where I’ve seen that happen because I usually use the first molar and go mesially but the only distal cantilever I do regularly is first premolar off the canine and that’s a regular to do-

[Salman]
Okay. Yeah, so I’ve done a few of those well raising a first premolar from canine. But I have seen a second premolar, I’ve seen quite a few actually of second premolars being replaced by first premolars at Guy’s Hospital when I was there, and it’s always because there was no molar to cantilever off right and the patient wasn’t suitable for implant. So, they essentially did the shortened dental arch principle by using resin bonded bridges to distal cantilever off the first premolar. Now, one thing I remember my consultant saying at one of those clinics is that actually she’s noticed that the first premolar you get a bit of mobility, not periodontal disease, a little bit of occlusal trauma, but it seems to be persistent and not progressing throughout the years.

[Salman]
So, that’s very common complete denture patients. So, upper complete denture patients who are opposing lower four to four. I’ve often seen this sort of cantilevers off first premolars. And that’s the only time I see it because obviously if you’re opposing a complete denture, you’ve taken occlusal considerations into account you’re not expecting that risk of debond. So that’s the common one that I’ve seen.

[Jaz]
And another lesson there you just shared is, if you’re posing and complete denture go crazy. Do it All.

[Salman]
Similar to open bites, yeah, take a risk, it’s fine. But first canine retainer on the canine. Pontic first premolar that seems to work really well, this canines, naturally you get really good amount of enamel. You can implement incisal overlap, you got a good root there. So, another contraindication to resin bonded bridges for me is looking at the abutment tooth selection. So good enamel, we’re looking at bone support, looking at crowns-root ratio, I do take a little bit into accounts. And because I know that I’m going to be putting that tooth in supra-occlusion, when I’m relying on the dahl approach, and it was taking all the load and make sure it can sustain that kind of load, that’s going to take.

[Jaz]
Very good and just last point where we talk about the clinical protocol, seeing some lower incisors with a bit of bit of mobility, I find that as a good feature to have. If he’s got a little bit, I’ll give some example, periodontal disease, and they’ve had some little bit of bone loss. That for me is not a contraindication to resin bonded bridges, as long as the perio is controlled, but actually it can act in our favor. Because what we find is that as the pontic is loaded, instead of the forces now going into the cement, it’s actually going into the PDL of the tooth is a little bit mobile, so it gives a bit and then the cement gets loaded. So, we think it’s got a cushioning effect. Have you found that with these slightly grade one mobile patients that these these are lasting well?

[Salman]
Yeah, Jaz, mobility is not a contraindication. For me, it’s all about the stability of periodontal disease, you’re going back to those papers about like primary and secondary occlusal trauma, they went through my first year of specialist training where there is, they put the teeth in Super occlusion and they found that any mobility you get from that occlusal trauma from that heavy loading is reversible mobility, and there’s no and pocketing is reversible as long as there’s no bleeding and probing. So it’s all about periodontal disease stability. And for me resin bonded bridge is like the ideal solution for perio patients right? Because implants we know about the complications even unstable perio patients, implants wouldn’t have a greater complication rates, peri-implantitis very expensive, very difficult to manage. And for me go to treatment for private patients is a resin bonded bridge wants to stable.

[Jaz]
Brilliant, I’m definitely agreements. So, let’s talk about the clinical protocol. Let’s say you’ve done your design, but you’ve opted for the incisal overlap. So, what what we mean but just describe what you mean by the incisal overlap to someone who may not know this.

[Salman]
The docket is in my head like I just reel through every time I show you the same once you’ve got a docket in your head for your lab. I’m very, very prescriptive about how I design my resume bonded bridges.

[Jaz]
So, talk through the lab prescription, then.

[Salman]
Okay, so let’s say we’re mock example, we’re replacing a lateral incisor off the canine tooth right? So, my lab prescription, let’s say we’re looking at metal porcelain resin bonded bridge. So, we’re not looking at zirconia for now, first thing I do is I say which teeth is the Ponce, which uses the retainer because labs will get it mixed up because communication is not always the best. So, pontic on this tooth, retainers on this tooth and it’s a two unit resin bonded bridge in case they decide to go fixed-fixed suddenly, okay. Retainer design is then I say I want to base metal alloy. So, either cobalt, chromium or nickel chromium. And I want it in minimum thickness of at least 0.7 millimeters.

So, for me thickness is that really important thing I found some labs, they try to fit your resin bonded bridge into the occlusal scheme of the patient because the wider of propping it open and it’s when your metal wing is too thin that you then get that tension, you get the flex and you get the debond. And what you really want is rigidity with your metal wings so that you don’t get that tensile force on your cements.

[Jaz]
Just a little bit on that Salaman, before you continue the prescription I went around to a unnamed lab and I won’t name the lab and I was like they had a whole table of resin bonded bridges. And I started to go around I got my ones engaged to measure these wings okay, and not a single one was more than half a mil, not a single one was more than 0.5 mil and so we had a nice little chat about okay, why it’s important to respect that because that’s what you know, the papers have shown when they followed that protocol they’ve got success so why not copy that.

[Salman]
Jaz, we like the CQC for resin bonded bridges that’s in. So yeah, so retainer thickness and then I say I want maximum coverage all the way to gingival margin and on maximum wraparound wherever possible. And for me personally, I want a little lip over the incisal edge, okay two benefits and maximizing enamel and I’m also creating a bit of resistance form and it’s a seating trigger at the same time for me, so I know I’m going to cement it in the correct position. My pontic design would either be ovate pontic or modified ridge lap pontic. So modified ridge lap is my go to for healed sites

[Jaz]
Can you just because the young dentists listening, so you mentioned the incisor overlaps. I just want to touch on that so yes, cover a third to a half of the actual incisal table, incisal edge or the canine really, really great because it helps you to-

[Salman]
I’ll show you some examples Jaz.

[Jaz]
Seating lugs. Yeah, sure, pull up some photos as we’re talking. It acts as a seating lug or give you some index so sometimes when you go for a resin bonded bridge without a incisal overlap or without a seating lug. You’re sort of sometimes positioning how’s it going? It’s kind of fits in multiple positions. It overcomes that issue easily because it gives you something to grab on to incisal edge. So location wise it helps when the pontic is loaded. Now, the cement is in compression. So, that’s really Good feature as well. So, it’s a great thing to do. And aesthetically, when a patient smiles against the dark oral cavity behind the backdrop, it kind of disappears. But it’s not for every patient. I think it’s fair to say.

[Salman]
You can always trim it back. Right. So, for me sitting and I just trimmed back gradually trim are sufficiently happy trim more, trim more. And usually I get to this kind of balance where I’m happy, and the patients happy with the aesthetics. And so I get both. And I’m not worried-

[Jaz]
Do you tend to trim it the same day as a fit, I tend to do at review appointment.

[Salman]
Yeah. So, I was told to wait two weeks. For me, I’ve not noticed any difference Jaz, so what I’ll do is I usually wait a good 15 minutes that it will set Oxfam really OCD. I literally won’t touch it for a good five minutes. And obviously God , now for the next 10 minutes I’m taking off, use your personal photos, or cleaning up all the excess cements, make sure the patient’s happy. I give them all the positive instructions, and then I start trimming back gradually. But-

[Jaz]
Okay.

[Salman]
Maybe reviews a safer thing to do. I know a resin cements says, you should wait. And but not necessarily increasing the ones. Can you see this photo here Jaz, in this incisal overlap?

[Jaz]
Yes. Perfect.

[Salman]
There you go.

[Jaz]
A great thing to do. And then the next point that you made sorry. So we just talked about the incisal overlap and the importance. And then you switch gears and you’re talking about pontic so for the young dentist listening, can you explain what is a modified ridge lap design? And what is an ovate pontic?

[Salman]
Jaz, last thing sorry. Sandblasting retainer wings is really really useful.

[Jaz]
Let’s talk about that completely separately after because we need to talk about that give it some love.

[Salman]
To hide the metal shine, for incisal overlap.

[Jaz]
Okay, fine. Sorry. Sorry. To hide that. So yeah, that is relevant to hide the shine that the sort of the twinkle that when they smile basically makes it more matte. Yeah, absolutely spot on.

[Salman]
So, we always as undergraduate is four different points of types. But for me to go to is the ovate pontic, or some people might call it a bullet shape pontic. And the second is the modified ridge lap. So the ovate pontic is literally a totally convex profile that sits against the soft tissues is shaped just like a tooth underneath in terms of the bulbosity. And the ovate pontic is my go to when I’ve got like an immediate resin bonded bridge. So, I’ve kind of taken an impression, when I put my resin bonded bridge two weeks later in a patient’s quite like a retained root in situ. And on the day of fits, I extract the tooth, extracted roots, I’ve got a nice little space, I’ve asked the lab to create an ovate pontic with like a two millimeter extension into the socket, I fit it and then a soft tissue is really nicely hug around them and you get a really nice natural emergence profile.

The modified ridge lap is a technique where essentially buccally you following the ovate pontic design, you got a nice convex profile you extending all the way aesthetically to where you want to be. But palatally with the patient doesn’t see you’re cutting back your pontic completely just clear the soft tissues. Theoretically, it’s a more cleansable design, it’s much easier to keep clean with floss, and it’s still got convex profile. But because you’ve got healed Ridge, you can sit a modified ridge lap against it without any issues.

As time goes on and my patients are becoming more aesthetically concerned and finding a way to more and more ovate pontics so, I’m doing a lot more soft tissue shaping and with Essix retainers or dentures to create an ideal emergence profile. And I’m going for an ovate pontic design. And some people used to say, ‘Oh, it’s very difficult to keep clean.’ But as long as it’s convex, for me, it’s very, very easy for patients that don’t have food trapping, and they seem to like it better. Which goes against my undergraduate teaching.

[Jaz]
Yeah, there’s something really quite beautiful about moving that Essix retainer which you’ve got the composite side to mold the soft tissue or the denture or however you want to do it, pick your poison, and then take it out and use that lovely recipient area of the future. pontic just looks so natural in terms of emergence profile. Nowadays, what I’m doing is what I’m doing, not a immediate resin bonded bridge, but just a routine. Let’s switch your dentures for a resin bonded bridge kind of thing. I’m assessing the volume of soft tissue and I’m using a thermacut bur to just heat and remove this sort of architecture of the pontic I want to be and that helps it to go not 100% ovate but like in between ovate and modified ridge lap you have a spectrum goes more towards over it but I agree that you need that convexity for cleansability

[Salman]
Who was even modified ridge lap. Labs really find a struggle to make it, we asked them for a convex, so I always say when convex fitting surface. But actually if you look at healed ridge, we need to empathize with our lab that’s almost impossible sometimes to get good aesthetics and a convex emergence profile. There’s no good saying into the lab and saying achieve this. We have to help them along the way and create a profile that they need. It’s yeah, it’s always working together. That’s what it’s all about.

[Jaz]
Brilliant. And then was there anything else on the lab docket that you have mentioned yet?

[Salman]
Occlusion, so retainer, one chapter, pontic one chapter so I say and then occlusion. So, I say I’m going for conventional dahl approach depends on each patient’sleave the retainer minimum 0.7 millimeter thickness in supraocclusion and the pontic at this stage will be fully out of guidance and maybe lightly in occlusion. It is okay if other teeth are out of occlusion essentially, I’m okay with that. Because I’m going for a full dahl approach in this situation.

[Jaz]
Brilliant. You know what we talked about lower resin bonded bridges. But you know what? They can be really tough. Just like upper central to matching this upper central to another central, or even lower incisors. It can be really tough for ceramists.

[Salman]
Yeah, so resin bonded bridges. So if we’re looking at specifically metal resin bonded bridges, a set of photos helps massively. And the tips of metal are I’m sure you notice Jaz, mirror handle behind that tooth. So holding a mirror handle behind the tooth and then taking your photos will mimic the lack of incisal translucency you’re about to create in that tooth.

[Jaz]
Okay, I didn’t actually know that. Just a tip for me my friend. I love it. Thank you.

[Salman]
So, that’s the first one second thing what I sometimes do if I’ve got really concerned patient, I do a metal frame of trying. So, I’ll get the metal framework from the lab before they cast the porcelain, I’ll put that on the sides. I’ll take a photo and they’ll mimic that metal behind. And they’re gonna be really extreme, which is not necessary Jaz, but this is what you can do. You can paint dycal on the metal framework.

[Salman]
Yes.

[Salman]
Can sees in the mouth. It mimics Panavia opaque, take a photo-

[Salman]
That’s what I do.

[Salman]
That’s what you do then. Yeah. So I had to do, it’s yeah, it works really well. It mimics Panavia opaque right? And then you know.

[Jaz]
It does and just on that topic, photos are really important. And I use the cross polarization filter like e-lab and that gives them a bit more in terms of getting the aesthetics right of the pontic and then seeing the the deeper removing the specular flash as well so yeah, that really helps in shade matching technicians seem to like it. One story about a consultant actually taught me another thing with shade matching is that she will fit a resin bonded bridge from a central replacing lateral and the patient was like, ‘You know what? The shade is not right.’ And at that point they bonded it. So, what she did was that she got a palatal non precious metal veneer with it for the contralateral incisor to make it look duller as well which I thought okay you know can either another way to do it rather than kind of bridge off why don’t you stick something on so that was an interesting one.

[Salman]
Years for that, yeah?

[Jaz]
Well in hospitals Yeah. You can get away with it a lot I think.

[Salman]
Now an

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How often do you review your risk management? Do you follow the appropriate radiography guidelines or palpate canines when you are supposed to? These are not the exhilarating or rewarding parts of our clinical practice but they are fundamental and foundational.

In this episode with Dr. Lucy Nichols, a general dentist who also does some dento-legal work in the UK, she shares her 10 commandments for safer dentistry and avoiding dento-legal claims.

https://youtu.be/0MhOC-LLxbI

Protrusive Dental Pearl: ‘I don’t have time’ is just not true. It’s a lie we tell ourselves. We should reframe it. Instead, we should say “I’m not making [task / activity / necessity] a PRIORITY in my life right now”. We should reflect on what are we making a priority in our lives right now.

Highlights of this episode:

1:17 Protrusive Dental Pearl
4:33 Dr. Lucy Nichols’ Introduction
8:08 10 Commandments for Staying Out of Trouble:
Thou Shalt Take Bitewings on Children 9:08
Thou Shalt take Bitewings on Adults 13:31
Thou Shalt Always be Suspicious of a Non-healing socket 15:29
Thou Shalt Always be Suspicious of Sore Patches on the Side of the Tongue or on the Cheek 18:21
Thou Shalt Know How to Deal with a Hypochlorite Injury 21:24
Thou Shalt Not Use Chlorhexidine Mouthwash as your Root Canal Irrigant 30:34
Thou Shalt do Further Charting when you have 3s and 4s on your BPE 35:06
Thou Shalt Not Rely on Only a Single Visit Scaling without Local Anaesthetic on Patients with Increased Pocketing 40:42
Thou Shalt Not Underestimate ID Nerve Injuries 45:29
Thou Shalt Always Palpate for Canines at Age 10 53:39

PDF Infographic available in the ‘Protrusive Vault’ in the App (iOS and Android)

Check out Dr. Lucy Nichols website

If you loved this episode, please check out Passion and Values in Dentistry

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I am a big believer that the culture of your work place is probably the number one determinant of your fulfilment and joy from clinical Dentistry.

https://youtu.be/cGFpxUn6WXw Check out this full episode on Youtube. In this non clinical episode I talk with Dr. Sandy about his past experiences and the reasons he had to make a significant change in order to find fulfillment in his career. We also discuss how to recognize a toxic culture in Dentistry and how to stand up for yourself if you’re in one of those environments.

We hope this episode inspires you to take some sort of action, whether it’s small or large, that will improve your enjoyment of work.

Highlights of this episode:

2:13 Dr. Sandy’s Introduction
3:16 Dental Public Health Experience
6:16 Dr. Sandy’s Transition from Public Health to Private Practice
10:11 Taking massive action
14:10 Recognizing a toxic working culture
17:29 Stepping out of the toxic work environment
19:33 Significance of having a plan for your career
24:57 Importance of taking clinical photos
29:26 Improving Dentistry through social media
34:48 Dealing with litigations and patient complaints
41:55 Recognize solutions rather than problems

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Have you ever prepared the last molar for a crown? And just when you check the occlusal reduction, the patient bites down and as if by magic, the reduction has all DISAPPEARED?! It is the phenomenon that we call ‘The Last Tooth in the Arch Syndrome’

This episode with Dr. Mahmoud Ibrahim will give you more confidence in recognizing, screening, and managing such complications in practice. But like I say in the main episode, optimistically, this phenomenon will never happen to you AGAIN if you follow these protocols for screening.

https://youtu.be/gs1r5mlefHU Check out this full episode on YouTube Protrusive Dental Pearl: Watch out for the patient with quite flat teeth as they are more susceptible to the last tooth in the arch syndrome / bite change. They do not have good posterior coupling/stability and therefore more likely to ‘forget’ their bite as the cuspal inclines do not guide the mandible back in to maximum intercuspation.

Highlights of this episode:

2:41 Protrusive Dental Pearl
6:09 Introduction to Dr. Mahmoud Ibrahim
9:34 What is Centric relation?
10:45 Last tooth in the arch syndrome
13:14 Risk assessment for Last Tooth in the Arch Syndrome
15:52 Screening patient’s CRCP and the degree of slide
17:33 Leaf Gauge protocol for screening CRCP
30:23 Communication with High-risk patients
34:35 Case Discussion
44:36 Management of space loss after preparation
46:24 Dr. Mahmoud’s top tips to prevent the ‘Last Tooth in the Arch Syndrome
58:47 Occlusion Basics and Beyond

Join the waiting list HERE!

If you loved this episode, you will like If You are Not In Centric Relation, You Will Die

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From the entire Protrusive Community – we wish Sanj a speedy recovery – keep smiling Sanj and stay strong!

In the previous episode with Sanj Bhanderi on ‘how to extirpate properly and efficiently‘, we briefly touched on postoperative pain control. In this episode, we’re focusing more on postoperative pain and the dreaded severe pain after the obturation appointment (or in-between visits).

https://youtu.be/RJzQZNhBup0 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below!

Highlight of this episode:

2:27 Post-op pain after endodontic treatment
7:43 Flare-ups
9:46 Guidelines in antibiotic microbial management
11:03 Flare up in between visits (RCT has not been finished yet)
13:40 Crown Down approach

Dr Finlay Sutton is coming down South for his one-day signature RPD Masterclass on Saturday 14th of January 2023! Limited to 12 delegates, reserve your seat now!

If you enjoyed this, you might also like my episode with another talented Endodontist, Dr Ammar Al-Hourani, on Is Single Point Obturation Acceptable?

Click below for full episode transcript: Opening Snippet: I wanted to start this podcast with a get well soon message for our guest, Dr. Sanj Bhanderi who did such a brilliant job with our last group function on how to extirpate quickly and properly. Now, unfortunately, after we recorded that episode, and after we recorded this one, Sanj felt acutely unwell. It was actually scary hearing the news of him being ill. But I'm getting some positive updates. And so we the Protrusive Dental Community, and then all dentists around the world. We wish Sanj a speedy recovery. We hope you get well soon. We're so glad you're okay and on the mend. And we want to pass on these wishes to you. It's been quite clear on social media, what a likable guy you are, and how much we all want you to make a speedy recovery mate. So wishing you all the best and get well soon from Team protrusive. Jaz’s Introduction:I bet this scenario sounds very familiar to you imagine you’re on a course you having a great time. I personally love courses, I think you all know that. You’re on your fifth coffee, and everything’s going great. And suddenly your pocket starts vibrating. You’ve got a call from the practice or text message informing receptionist saying that, ‘Mrs. Smith, you know, the root canal that you saw yesterday, she’s in absolute agony.’ And you curse because you think wow, you know, that was a completely straightforward root canal procedure. The patient was asymptomatic before you even started. Why is this happening for me? Look, post-op pain after endodontics is an absolute bitch. It’s one of those annoying things ever actually puts me off doing root canal treatment because of the one in harmony of a chance that post op pain instance is going to happen. And I’m going to discuss with Sanj Bhandari who does such a brilliant job in that GF o one six, where we talk about how to extirpate properly and efficiently. So if you haven’t listened to that one, oh my goodness, you are in for a treat. Go back and listen to that one. But in this episode, we’re focusing more on post op pain like how do you manage that kind of scenario? What do you say to the patient? How can you prevent this from even happening in the first place? You know, it’s funny I’ve actually had four root canals on my own self and before you think, ‘Oh, Jaz is disgusting, you got caries, etc.’ No, it’s actually trauma from orthodontics. Can you believe it? Orthodontics devitalize, my lower four incisors, and I’ve had all sorts of issues and root canals and fractures, etc, etc. And now have a resin bonded zirconia bridge, hence why I’m so passionate about those bridges. Anyway, I experienced post op pain myself, it was a nasty thing. It was lots of inflammation. And so I’ve been there and I totally empathize with my patients. Before we joined the main episode I want to say yesterday I released new tickets to Finlay Sutton’s mass class. So Finlay Sutton, he travels all around the world. He’s in USA last week. He goes Scandinavia a lot. He teaches us everywhere. If you think removable prosthetics you think Finlay Sutton. He’s just a phenomenal educator and the best in the space when it comes to removal pros. Now he came on for episode 56. How to make Chrome dentures easier. So check that one out if you haven’t already either. But he’s doing a live one day partial dentures maths class on Saturday, the 14th of January 2023. So if you’d like to join us go to protrusive.co.uk/finlay, that’s F-I-N-L-A-Y. It’s limited to just 12 delegates only. And it’s very rare chance to see him down south usually have to go to practice up north, or you have to go abroad. So this is very rarely comes south. And so if you’d like to join us, including the dinner, the night before, it’d be great to have you. So once again, the link is protrusive.co.uk/finlay. And there’s also a payment plan to split your payment into three if you need that.

[Jaz]Anyway, let’s join the main episode.

Main Episode:

I recently created a gentleman I talked about this gentleman on the podcast necrotic canine very strange, severe bruxists, I think I suspect some airway issues we’re investigating at the moment, like to the extent that 50% of his canine is just shot. That canine was dark in color. My dentist who I inherited his list has been putting his, he’s had a couple of bouts of antibiotics in the past for this tooth, and he just felt he’s too young. He’s late 20s To have a root canal on a canine and he just couldn’t figure out why it went necrotic but it did. I tested everything. It was necrotic I went inside his canine. It was necrotic, it was infected. So I confirmed that, and then I did a root filling. And my goodness, and I’d followed all the right protocols hypochloride, gutta-percha, everything was done, took a high standard radiograph look good. There was no extrusion of the GP or anything. But my goodness was this chap in so much pain, and he ended up in a&e. They did some bloods on them. They didn’t find any sepsis, but they found high inflammatory markers in his blood is actually interesting enough. So that was my one really bad experience about four months ago. Otherwise, I don’t tend to get significant post op pain. But I’ve been with dentists at conferences and we’ve been at a conference on a course and the dentist nips at 11am because there was a root canal heated yesterday, the patient’s now in agony after finishing the root canal. What do we know in terms of Iiterature? You’re probably there lecturing and speaking your phone were vibrating. Mrs. Smith from yesterday? What is behind that? What causes that? Even in your expert hands, is it just bad luck? Or do you, do we know what causes it and then therefore, what steps can we take to minimize its occurrence?

[Sanj]I think it’s quite multifactorial, some of it is, it is unpredictable. There are certain conditions that seem to predispose patients having what’s called a flare up of flare up by definition, the endodontic definition of flare up is this is in between treatment after treatment of treatments been performed, and the patient gets acute pain that requires treatments they have to attend to. That’s the definition of a flare up. There are a few things that I suppose we break down to patient factors, which are we told the anxiety levels we’re talking about. There are some certain genetic factors, some patients are more predisposed to pain, period. And definitely there’s a-

[Jaz]yes, yes, absolutely. We know that from TMD, chronic back pain, the study of pain itself is we know that people are much more susceptible pain than others. Yeah, yeah.

[Sanj]So on those physicals patients, and also talked about this symptomology, it’s patient management, if you pre-warm them, it doesn’t mean that there’s not gonna be out of pain, but they can handle it, it’s when they’re not expecting their pain. That’s when it the problem started in the, you know, just increases anxiety. And so it’s been a patient management and those patients who you’re going to kind of arm bells, these patients are a bit tricky. Or if you’ve seen patients before previous treatment, they’ve always taken the two second ages to settle down or even root. So that’s the first thing in terms of the actual tooth itself. It’s the inflammatory state of the two. So pre existing lesions, if there’s an apical lesion, radiographic lesion, those teeth are more susceptible for post operative or interrupted pain. Okay, so for me, the before the endodontic treatments, we always preload our patients with anti inflammatories, not just emergencies, but routine root canals, and especially retreatment. And especially if there’s a lesion already on the tooth. We know that they’re more predisposed to flare up. So, just preload them anyway, with anti inflammatories or painkillers. And then during the procedure, you’re going to do utmost to follow what we now call is everyone knows a crown down protocol, you do not want an necrotic case, the whole majority of that canal space is going to be infected. Often, it’s actually not the apical tissues are actually not infected. Just because there’s an apical lesion that apical lesion unless there’s an abscess, or separation, it’s not infected. It’s just the inflammatory process, we need to remember that. Because the last thing you want to do is put bugs into the apical area or even worse through and it can happen easily, I do. I’m sure one of the main reasons you get a flare up is because we’ve inadvertently push biofilms through, it happened some time. So we’re just gonna do our utmost to go down, Crown down. And so as you as you do that, part of the reason for that approach is you’re flushing out bacteria progressively without with minimal risk of pushing it ahead of the instruments. This is one reason going back to emergency treatment, you don’t fish around the root canals because if the canal happens to be necrotic, in that module, two of them are flying the other one and he shoved bacteria further down, you’re going to inoculate areas which weren’t actually infected. So that’s another reason not to fish around the root canal going back to the emergent situation. So this, in this situation, when it’s necrotic, that canine, you do your utmost just to work your way down. Now some endodontists, traditional endodontist, say you should be dressing all those cases, you don’t do those in one visit. That’s another area just decrease the bacterial load because calcium hydroxide. That’s the evidence suggests it’s probably doesn’t matter. He can do those in one visit. But there is the evidence for one visit.

[Jaz]That reminds me actually that yeah, I think we’re coming to the same point. I believe there was a systematic review comparing one visit, two visit, and they found that they’re both equally successful, but you might get more flare ups and one was it is that where you’re gonna come to the

[Sanj]Post-operative pain may flare up beat the patient, they will get more post operative pain that is

[Jaz]post op pain. Yeah, that’s what I mean. So yeah.

[Sanj]Flare ups a different situation. There’s also the patient factors in terms of their immune response. Everyone’s different, we’re dealing with immune responses, which are we can’t control apart from maybe anti inflammatories. And I think the body, when this happens, again, this happens in, they’ve got lesions, apical lesions, there’s an inflammatory process been going on for a long, long time, the patient has been asymptomatic. The body’s kind of, in simple terms, the way I explained to the patients, the body’s got to use to having an infection in the tooth, and it’s reacting slowly. Sometimes when we go in, it may not being that we’ve pushed every through, we’ve changed the balance, whether it’s pressure, whether it’s something else has changed. And we just disrupt that. And it’s a short term reaction they’re going to get I gotta warn them, when there’s a big you know, radiolucent area. You think these, these are cases they’re gonna kick off with doesn’t matter what how well you do the endo is going to kick off. I pre warn those patients. There’s a chance this is going to kick off. Okay? So it’s patient management, and if it does kick off, then you can deal with that. But it’s the fact that they know about it, they often won’t bother contacting you. They’ll say I just took anti inflammatories you see them on the second visit, visit to visit and thing was fine. It was settled down. So there are those situations you are-

[Jaz]Now, Sanj you speak to your patients afterwards. You warn them big time, you document it, and you still have that you know you’re teaching at a conference and your your phone is buzzing. And you speak to Miss Smith from yesterday who had that feeling finally finished, and then she’s experiencing post op pain. Now, the temptation, oh my goodness, the temptation is so much for her to come in and then to do something and use that something is his amoxicillin 500 mg, or something like that. And that temptation is there and I don’t cave in. And that time he ended up in hospital and the hospital doctors gave him antibiotics. He got better, eventually. Okay, but do I honestly think it was due to antibiotics? I think he would have got better anyway due to inflammation is what because they found no microbials in his body. They found a high inflammatory marker in this particular instance, how should we manage it? Is it okay just to say ‘Look, don’t worry, you’ll be fine. Give it time’. Or is there ever a situation where antibiotics is justified?

[Sanj]I think in antibiotic-

[Jaz]and post op pain.

[Jaz]Yeah, I mean, with the current guidelines and antibiotic microbial management, whether it’s nice or whether it’s endodontic European whatever. I think, if you start with a systemic involvement, now it’s again you got to be practical about this. If they’ve got, there’s an abscess like you say, fluctuation swelling can be cellulitis kind of symptoms. You know, this is not just localized. An apical periodontitis kicking off there’s definitely soft tissue involvement. Then I think, in the short term, even a short course of an antibiotic with anti inflammatories dosed up, I think that’s justified. If there’s no obvious signs of an abscess, cellulitis spreading infection, then you know, it is high dose and painkillers with or without codeine, if you know if it’s affecting the sleep, something like dihydrocodeine, DF 118, something like that, just to get them through that pain. And hopefully it’ll calm down. It is a tricky one, though, because it’s a nice, there’s a theory

[Jaz]It’s so tricky.

[Sanj]When you’re in practice, and you’ve got the patient there, but you shouldn’t really throw them antibiotics, you’ve got to have good justification for doing it. If there’s a fluctuation swelling, incise it, free the area, incise it. If you haven’t finished the endo open the tooth up. In terms of leaving open drainage 24 to 48 hours, you can leave on open drainage just to relieve that pressure, but you’ve got to go back and get them back in. Okay, go back and try and get some drains, so it’s back to surgical.

[Jaz]Now in those scenarios, let’s say we we are in between visits. And let’s say we’ve done our crown down protocol where we’ve got the canals as clean as we can and we aim to obturate at the next visit. And it’s in between that initial cleaning of the canals and actually obturating the patient comes up with a flare up in between those two visits. So you’re not quite ready to obturate because you haven’t got that diary time to obturate. But the patient’s now sat there. If we were to go back into that tooth, let’s remove our a Cavit or Kalzinol and go back in, in this instance, would you recommend taking the file all the way to the apex? Or how would you manage that scenario?

[Sanj]If you’ve got the working length, and yeah, just go back in and kind of semi re-prep getting just get the calcium hydroxide out. It may be the fact that you haven’t got the dressing material later length. One thing that actually worth mentioning between appointments always dress the tooth, never leave it dry and empty. Never. Always put something in it, a calcium hydroxide, the thing to do. The difficult thing is getting a calcium hydroxide in volume to length. You can be only squirt at the top end of the crown. So it’s going to have any effect apically, you don’t get the benefit of the properties. So open it up. The fact you open the system up you relieve pressure, because it’s usually apical pressure that’s causing the pain. Whether you get separation, it doesn’t really matter. I think you just opening up the pressure, some endodontists would say you go you got your work length, go a little bit patent, you’re not gonna do any harm. If anything, you might release or relieve any microbes that sits down there. And then wash out again hypochlorite redress and close up. And then your, your chemotherapeutics your anti inflammatories and things like that. Painkillers and things like that after that.

[Jaz]Well, this was a tough question compared to an emergency one because it’s a scenario we hate, you know, as dentists and as an endodontist as well. We hate this scenario of finishing an endo and then they have that initial acute inflammatory reaction what we believe and they just, you know, just kind of wait it out and eventually it will get better. We know that. Okay. But it’s that, that patient at the end of the chair who’s suffering and we feel bad for it, I felt devastated sounds when that happened to to my patient, but I really do in my heart of hearts believe it wasn’t my fault. And I do think perhaps I shouldn’t have been so heavy handed, maybe. I was using rotary instruments for a canine and maybe some extrusion of the debris or dentin on debris could have happened. Exacerbating that inflammation. I put my hand up there that could, that could have been it. But in those scenarios, I think the lesson is, let’s not be too hard on ourselves. Let’s promote anti inflammatories. Let’s warn them that this could happen. And they can then self manage and not expected. But if it happens, they’re not like completely in shock. And then only if justified with swellings and cellulitis. Consider antibiotics and then I guess during the treatment, the Crown down approac. Now just for any students listening, last thing we’ll ask you is just describe, make it tangible, an example of a crown down approach for a molar inside a molar root canal, for example.

[Sanj]Okay, I’m glad you asked this question because I think this is quite important from a technical point of view, but also from an antibacterial preventing a flare up. Because I think maybe majority of flare ups are due to back to stuff being pushed to the end, debris infected material. I think that’s the most common reason why. So the protocol is, you found the orifices this is when you got to time. Okay, so going back to the emergency dressing, the golden rule is just to recap the emergency dressing unless you’re going to you’ve got time to go down to full working length and confirm it. Don’t go into root canal space. Okay, that said, see your second appointment you can got the time. You booked into the root canal, you find the orifices and the only thing you’re going to do now is you’re going to confirm the orifice and we what we call the endodontist called scouting and here’s a 10 to 15 size file just to confirm that there is a patent canals there and what I mean patents, I mean patent coronal not to patency we’re talking about the end. Once you canal is there, then you go on to most people using rotary systems or reciprocating. I’ve got slight reservation about reciprocating systems, they’re not as efficient as removing debris. So if you prefer a reciprocating system, way one reciproc, or whichever one, just be careful you wash out more frequently, you clean the files more frequently, because they get clogged up because of the nature of the mechanism the way they think through its work. With rotary, you’re going to use the system in its sequence. Okay. My role is, and this is this, this goes against a lot of what the manufacturers suggest, once you’ve found the orifice, they often say ‘Get down, get a working length’. And then you go through the system. That goes against the principles of of disinfection, because you you could shove coronal bacteria, majority in necrotic teeth, majority of bacteria is at the top end. It’s not actually the apex, which I mentioned. So the last thing want to do is shove biofilm further down. So you’ve got to get rid of that. So the coronal preparation, the mid third is really important before you worry about working length, I do the majority of the preparation up to the estimated working length and knock off a quarter of that, I’ll do that blindly. Without an apex locator reading. How do I know that estimated length? I’ve got a decent pre op radiograph, and knock out a quarter, I’m safe. I know I’m gonna be well short. And I’ll go through the whole preparation sequence to that point. So that all I then got to do once I’ve prepared the canal to three quarters is confirmed the working length, I know everything’s clear, because apically, there’s gonna be no virtually no bad biofilm bacteria. And there’s less chance of me pushing any rubbish through. And also, because I’ve opened the system up, your working length determination is more predictable, it doesn’t change, because working length changes from the start of the preparation to the end, it gets shorter. So another reason if you do your working length at the beginning, by the time you’ve finished, you fled that, you prep, you’re probably going through the apex. If you keep that working length, as do the geometry in the curve canal. So I do the coronal three quarters prep without working, without worrying about the working length. And then I’ll confirm the work and then all it’s doing is finishing off. And you know you’ve disinfect every point with less risk of pushing debris through. So I think that’s really important, which goes slightly against a lot of manufacturers and some endodontic teachers teach. And I’ve stuck by that.

[Jaz]Biologically, it makes so much sense to me, I think because otherwise in practice, it’s like a race to the apex which it shouldn’t be. It should be clearing just like you said the coronal portions first to allow you to get better access to the apex. So it’s very much. I listen to your lectures Sanj. Listen. I listen to your lectures. Sanj, listen, thank you so much for for giving up this afternoon to speak to me. We’ve made two episodes out of this space you so called group functions where we are answer one key pressing theme. So we talked about extra patients. So if you haven’t listened to that one, go back and listen to that one. It was it was brilliant. And now he’s covered his post op pain and flare up at the end you covered really beautifully. Just a good description of a crown down approach for young dentists and students to really connect and even just the oldies, I know what I should probably go back to doing that rather than going straight to the apex. So Sanj, please tell us about, I know you teach at the moment with institutions, but what kind of private courses do you do? Where do you do them? Is it all in Manchester? Tell us more.

[Sanj]Yeah, so at the moment, I do, we do a good friend of mine, Ammar Al-Hourani was my post grad student. He’s now established in London. So we both run courses two and four day courses in London and Manchester, for convenience because I’m in Manchester and he comes out and I go down to London. it’s quite good, quite good fun. So we do four day courses and we’re going to be doing a longer program next year. We’ve got plans for doing a longer, summer like a diploma course next year. So we’re looking forward to that. And also do a, it’s a microsurgical course. We did our second one a few weeks ago and it’s the only, it’s a human cadaver course. It’s the only endodontic course that I’m aware of in Europe and that’s been going really well in Coventry so West Midlands we’ve got another one coming up in March I think is gonna be fully booked so that’s quite good and microsurgery is another little area of mine pet subject of mine so and a lot of people live with with interest in endo or specialists don’t come across good surgical training. So that’s something I think it’s really needs to be shared and then-

[Jaz]Any website you can recommend for us to check out these courses?

[Sanj]Now, most of the things, when once we’ve got days we wish you on social media and the usual dental forums and instant things like that. I’m very old fashioned like that. I’m getting into that or that sort of thing. But so yeah, that we put posts out we haven’t got a website as such yet so that’s that’s an ongoing thing. So should we getting any website for the practice all the courses will be there but essentially keep a lookout on social media.

[Jaz]When you do give it to me, so I’ll put it on the on the YouTube and on the podcast in the summary. Because people want to know, you know people people enjoy the content let you know identify with this educator. I like the way he thinks. I like the way he or she speaks. And so therefore, I wanna be able to connect people who want knowledge to person who can help them upskill so please do send me those links when you can. And it’s no surprise that you work with Ammar Al-Hourani . He came on as a guest actually in the podcast some time ago. And we talked about, ‘Is single point arbitration adequate?’ Is it okay for dentists to do? And you know, he gave such a lovely just like you did a very real world, very diplomatic, very sympathetic to the plight of the GDP. So hats off to both of you. I love clinicians like this who don’t have that ivory towers there has to be this way. I hate dogmatic approaches. And so Sanj and Ammar if you’re listening to this, thank you so much, guys. It’s obviously great to have you as the endo buds on this podcast. Thank you so much, Sanj.

[Sanj]Thank you as well.

Jaz’s Outro:There we have it guys. The joys of post op pain now covered by Dr. Sanj Bhandari. Sanj, thanks so much for creating these two amazing episodes. And thank you protruserati for listening all the way to the end. Now you come this far, why not answer a few questions to claim CPD for listening to this. I think of all the different memberships that you have or the online memberships. And think when was the last time you logged in? When was the last time you used it? Well, you just listened to a podcast episode and you’ve learned something, hopefully. So once you actually test your knowledge, get the CPD certificate, and actually get some reflections as well. So if you’re on the app, you can do that. Now as a premium member, you get CPD certificates, a whole lot of exclusive content. So if you haven’t already, do check it out. Otherwise, I’ll catch you same time, same place. Bye for now.

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Have you ever been planning a smile (this could be a complete denture or some veneers!) and thought ‘where do I begin’?

Planning aesthetic dentistry involves more than just the teeth. A great smile is ‘facially driven’ – where do the teeth sit in relation to the face?Today we are joined by Dr. Josh Rowley to share the four rules of planning Aesthetic Dentistry (you will love them).

https://youtu.be/2jbfK2WU1e4

The Protrusive Dental Pearl: Don’t start complex/comprehensive treatment on someone who is not sure or not motivated.

Highlights in this episode:

2:58 The Protrusive Dental Pearl – Communication Tip
14:49 Screening for the first point of contact for Orthodontic patients
16:36 Four rules of planning Aesthetic Dentistry
35:10 SureSmile Aligners
39:35 Low trim height
41:24 High trim height
44:03 Support system for Sure Smile

Check out the courses that Dr. Josh teaches through IAS Academy and SureSmile Aligners

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When you Extirpate a Hot Pulp – do you need to find ALL the canals? Do you need to file to the apex? Which is the sedative of choice?

In this episode, we’ve got specialist Endodontist Dr Sanj Bhanderi to talk us through the CORRECT way to extirpate teeth in acute pain WITHOUT wasting time or making things worse for future treatment. It’s packed full of gems for pain relief, diagnosis and isolation.

So, what is your protocol for extirpation? This episode is all about how to get the job done right and minimize discomfort for your patient.

https://youtu.be/SjYWxr1sSDc Click Here to watch this episode on YouTube. For the full notes check out the Protrusive App on iOS and Android. “I call it Ninja endodontics – get in and GET OUT – Stealth!” Dr. Sanj Bhanderi

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

2:38 Dr. Sanj’s journey to Endodontics
6:30 Emergency extirpations
8:42 Diagnosis Protocol Irreversible Pulpitis
11:57 Anaesthetic for Hot Pulps
15:33 Caries and Restoration Removal Before Extirpating?
19:16 Vital pulp therapy
21:19 Isolation Protocol
25:30 Sedative Dressing for Acute Pain
28:42 Temporary restoration of choice
31:39 Post Op Medicaments

Tune in for the Part 2 of this episode – next week we cover post-operative pain after endodontic treatment.

If you enjoyed this, you might also like my episode with another talented Endodontist, Ammar Al-Hourani, on Is Single Point Obturation Acceptable?

Click below for full episode transcript: Opening Snippet: /Jaz/ In ideal world, we'd love to remove the entire restoration. Remove any caries, access cracks but when I have 20 minutes we need to get in go for the kill. Is that okay? Can you forgive us? /Sanj/ At the end of this. This is about patient, this is about getting the patient out of pain. Okay, and you just need to get in there. I used to call it ninja endo get in there, get the job done. Get out before patient realizing it. That's my principal in endo whether it's emergency or Endo. You want to- /Jaz/ Stealthy. /Sanj/ STEALTH. Stealth. Okay? Jaz’s Introduction:What is your current protocol for EXTIRPATION? So let’s say you made a diagnosis of irreversible pulpitis. Your patient is in raging pain. And you have to squeeze in this pain relieving treatment, a extirpation probably of a lower molar or something in five minutes. What are you going to do? Well, some of you will listen to this and it will be validation and revision. And you’ll be thinking wow, I’ve been doing it right all this time, even though I thought maybe I was taking shortcuts but actually I’ve been doing it right all this time and others will be like whoa, this is so much easier compared to what I’m doing at the moment because the big hint I can give you is that you don’t even need a K file for your molar extirpation anymore after today, because I’ve got Dr. Sanj Bhanderi, specialist endodontist to talk us through what is the right way, the proper way to do an extirpation of your patient who is in pain. And there are just so many gems from pain relief, diagnosis, isolation, and what I love about Sanj in this episode, is that he’s not dogmatic. Yes, he’s a specialist endodontist and so easy for him or anyone say you must always use rubberdam. But yes, he does discuss a scenario that okay, if for whatever reason, you had to do it without rubberdam, how can you optimize the isolation? How can you reduce the saliva getting inside the tooth, so I really appreciated that about this episode. I’m sure it hope you will as well. It’s very much in tune with the real world. And lastly, we do cover his step by step what is the right and proper way to do an extirpation without wasting time and without actually making things worse for future treatment.

Main Episode:So hope you enjoy this episode. And I’ll catch you in the outro. Dr. Sanj Bhanderi. Welcome to the Protrusive Dental Podcast. How are you my friend?

[Sanj]Very well. Thank you, Jaz. Thanks for the invitation. Excited. I’ve done one of these before.

[Jaz]Well, I’m amazed it’s your first time and it’s your real hero of mine, Sanj because I remember 10 years ago, I met you at the British Endodontic Society. Can you believe it was that long ago?

[Sanj]God. 10 years? You know what? Everything’s a blur nowadays at my age. Yesterday, still seeing the same but no, thank you. It’s lovely to have, to be here. Thank you.

[Jaz]Thank you so much. And I remember your lecture even then I remember some of your lectures the BDA and probably because our paths haven’t collide. I haven’t seen you. I know you’re very active with your teaching, but our paths haven’t collided since then that much, but it’s great to have you on to talk about a very important topic, which is how to get a patient out of pain in terms of your diagnosis, irreversible pulpitis. We’re going to talk about what is the optimum and best Sanj approved way of dealing with that you wish your referring dentist would do. And the other one we’ll talk about is post op pain. But before we dive into the nitty gritty details, just please tell us, listening it’s an international audience in terms of where is it that you work? What got you into endo a bit of your background?

[Sanj]Sure. Yes, I’ve been in this game in endo anyway, for, well, dentistry, I suppose we go all the way back. It’s gonna be our 30th anniversary next year. So which is a bit frightening, so now I’m qualified in London, actually in London but I now live in Manchester enough sort of wormed my way up north to the northwest, maybe by accident, really, and just just hospital jobs initially came up, then I did my postgraduate training up here. I mean, back in those days 1995, there was no, there were only three postgraduate endodontic programs outside the hospital training pathway and that was either London or Manchester and I happen to be the right place, the right time in Manchester. I go on to the Masters quite young, actually quite early. I think it was the first one in our batch in our year and guys and I wasn’t I flying student at all. I managed to, there’s one to get an MSc and then I stayed in Manchester that time the mid 90’s I don’t know if you’re too young to remember Jaz but it was quite a good university. And it was a hot thing. I had a better student life as a post grad than I did in London. But, now, it was things were changing in Manchester the Dental School’s good I was teaching. There were not many endodontist one of the reasons I stayed up north actually because I needed a job prospects. This is before endo became really popular and I could see it in fact is by accident fell into endo it was gonna be either implants at that time there was an implant MSc and there was an endo MSC because that was one of the only endo at implant Msc in the country. I was too young I would never go on the people that got onto that were experienced practitioners and I’ve really had no chance but I, that’s where I was gonna go. Ironically, the opposite way and I ended up doing endo and it’s sort of taken off from there and I just got into Endo, the state of Manchester got job offers and I pretty much been full time endo day one from finishing the Master’s since 1997.

[Jaz]So how many days are you clinical at the moment in terms of doing your endodontics referral practice?

[Sanj]Yeah, so I’m pretty much now full, full time as in I was four days and at three days now. And I’ve got an associate Rob, Rob Jacobs, who covers me so. So I’m down to three and a half days, teaching now just in private courses up and down between London and Manchester with a couple of friends. So that keeps me out of the practice. But pretty much I’ve always been a hands-on clinician.

[Jaz]So you’re very wet fingered, very clinical, you, you’ve got a great name in the UK as the person for endo. So again, it’s a privilege to have you on. The reason I have you on is because extirpations, I speak to different colleagues, and we all kind of do it differently. So I wanna find out what is it that you recommend? And I remember asking an endodontist, some years ago, what they recommended, and I got interesting answer from the endodontist. He said that, ‘You know what, as an endodontist, I rarely get to see the emergency extirpation cases anymore, because usually by time they’ve come see me there’s a sinus tract. There’s a perio endo lesion, and they’re really complicated.’ So firstly, I’m just being nosy. How much emergency extirpation do you get? How many of those phone calls you get? How many of you actually treat in that regard?

[Sanj]In terms of the practice, you’re absolutely right there being an endodontist. We, by the time they get to us, they are non vital previously root-filled, or the dentist has had to go doing it. We get a lot of phone calls, and mainly from dentists. What do I do? How do I numb the tooth up and this sort of thing, we’ll talk about that shortly. But in that way, I’m kind of slightly lucky, although I know how to deal with it. And we have to back in the training, working in dental school, you’re in the emergency dental casualty where they call it nowadays. So you have to deal with that you have to learn pretty quickly. One of the reasons I went into endo is just okay, it’s not just about the white lines at the end of the endodontic treatment right in the beginning getting patients out of pain, immediately out of pain just until they relax and you get them back into the proper endo. That is really important. And in that way, I’m kind of shielded being in specialist practice, because it’s my general dental colleagues. They’re at the coalface and they’ve got to deal with that stuff on a Friday afternoon, just before they close patient will knocks in you know, they haven’t slept for a week and they’re anxious and nervous that never been to dentists, sometimes you got a lot to deal with, and you got to get them out of pain. And we can’t shove them off with antibiotics. It’s just not appropriate nowadays, medically legally, now you could get into well, or if something happens, so you’ve got to be able to get in there and deal with it efficiently, as painlessly as possible. And that’s a challenge because the tooth is extremely inflamed, and just stabilize everything so you can get them back in when you’ve got plenty of time we’ll get someone else to do it with whatever the protocols are. For that is important. Yeah.

[Jaz]Before we go in for the for the kill and talk about the exact protocol that you would recommend to alleviate someone out of pain. Let’s talk a little bit further for the younger audience listening, those students who are listening right now, just coming up with a diagnosis of when it is appropriate to give antibiotics? Because perhaps necrotic infected and really, it might already root-filled or whatever. And then what kind of history and clinical findings are leading you to towards a diagnosis of irreversible pulpitis that needs that intervention that wouldn’t settle with antibiotics? Can you just give a distinction between the two different types of patients?

[Sanj]Okay, so you’ve got two different situations, you’ve got the root filled or non root filled teeth, or we’re talking about the root filled tooth yet because that’s a different slightly different scenario, but on a tooth that’s either potentially vital or semi vital or partially necrotic or completely necrotic. Okay, so it starts from the disease process obviously starts at the top of the pulp typically caries, tooth fractures, bugs are going to get into that pulp. Now, sometimes patients will have very low grade symptoms and a niggle, a dull ache, maybe a bit of thermal sensitivity, and they kind of put up with it. And sometimes this pulp will die, but it’s the ones that don’t die or die painfully and they go through an acute phase what we describe as irreversible pulpitis. They’re the ones that the challenge because because the the top of the pulp, the pulp, is the most inflammed closest to the insult, could be caries or a fracture, that bit of the pulp will be difficult to anesthetise. So the whole, when you give a block typically for a lower teeth, you’ll get a block anesthesia, you’re given filtration, the anesthesia will not penetrate up the ID nerve, you won’t get into the pulp, it will get into the pulp, atypically, maybe reticular area, but it won’t get to that point which is the closest to the insult most inflamed. That’s the challenge getting from the, way I describe it to the patients, I show them the X ray, this is your tooth, that’s the top, you’ve got all refilling there we need to go from the top the occlusal surface down to that pulp chamber bit. We’re going to go down to there now a lot of its patient management is preparation. Okay, because we’ll go through the anesthetic protocol, which hopefully will work but sometimes it is not going to work. But you need to know that and you know that from the patient’s symptomology where they can walk in. You just know that as a hot pulp, there’s a chance that they’re not, you’re not gonna melt anesthetise and doesn’t matter what hit them with. There are a few things we’ll talk about how to prep that if they walked in off the street If you know there’s a pulpitis just coming in, you can, there’s a few things you can ask them to do before they come in, just to help the anesthesia process. And then when they get them in the chair, it is management’s a lot of good anesthesia, multiple techniques, different agents, and then going in carefully and managing the patient being empathetic. But up to a point, if they can’t tolerate it, or their anxiety levels too much you sometimes have to do in stages, sometimes you got to gotta go for it. And as it’s sometimes you got to be cool to be kind but in the appropriate patient. You can’t just dive in and you know, you lose a patient and it’s not nice to so you’ve got to imagine yourself in that position. But equally, you want to get them out of pain. It’s a balance. It’s a real fine balance.

[Jaz]Yeah, so just the other day I saw an acute, patient in acute pain and after getting somewhat good anesthesia, you know objective, you know, I tried with endo frost beforehand, managed to elicit a necrotic response compared to others actually. But he had recent symptoms of irreversible pulpitis. So it was probably mostly necrotic. But there’s still some element of vitality to it based on his symptoms he was presenting with. And so when I did manage to reach the pulp chamber of his lower molar. Place to file just into distal, this wasn’t bleeding. So it confirmed my diagnosis of necrotic. But I saw the white pulpal tissue. So as soon as I put my K file into the distal, he pretty much jumped out the chair so I gave the intrapulpal. And that just settled him. So it kind of leads communists and like you said, I had to be cruel to be kind for that patient. Now, what could I have done? Had I known I didn’t know who was coming in, but what kind of anesthetic supplement or advice could I’ve given on the phone as you alluded to, to help achieve better success rate of anesthesia?

[Sanj]Yeah, it’s about reducing the inflammatory stages that pulp as best you can and systemically, there’s plenty of evidence to say that loading them up with anti inflammatories, nonsteroidal so four to six of Ibuprofen with or without paracetamol, if they can’t tolerate anti inflammatories, asthma or stomach issues, Tramadol, something like that, or codeine, paracetamol, not as good as an anti inflammatory, but it’s better than nothing. That will just physiologically reduce the inflammatory stages, it doesn’t guarantee that that tiny bit of the pulp that’s inflamed will completely needs to dies. But it will definitely, there’s plenty of evidence saying it will help the anesthesia anesthetic process. In terms of the actual local anesthesia for the lower teeth or is notoriously the worst teeth, molar teeth, first second molars, those teeth are really difficult to numb. And it’s because they’ve got accessory nerve supply as well often. And for me, the baseline technique is ID, we do an ID block, I don’t mess about with intraPDLs and this sort of thing. And, you know, there’s usually to knock them, knock that nerve out and not as much as you can supplemented with buccal infiltration is of an age of this absorb as well. And for me, it’s articaine. So if my ID block, I would give lignocaine. As a start, this is an acute emergency, don’t use lignocaine off, and actually, I’ll tend to fall back on mepivacaine. We’ll come to that later on why I use preferred mepivacaine for routine Endo, but for hot teeth need, you need profound anesthesia. You don’t need longevity. But lignocaine works pretty well as an ID. I’m not a fan of giving ID blocks with articaine. But I know the evidence suggests it is very good. And it’s controversial that the risk of paraesthesia. And it may not be anything to do with the agent, it’s probably to do with the fact that’s trauma from the needle. But I’d rather not if there’s an alternative and it which works just as well. So ID lignocaine wait for that to be to work completely work. So we’re talking, the lip is completely numb. The lingual mucosa are completely numb, not even the patient alveolar thing, then articaine buccal infiltrations, it tends to absorb better through the buccal plate is pretty thick, and especially in the sixth and seventh area. And then I might give PDLs as well, or lingual underpressure I’ve got an intra paradata device called the wand, there are few other devices and now available which do the same sort of thing. They basically under high pressure with a short needle, they can deliver the anesthetic through the PDM. The theory behind that is a PDLs is almost as good as an entry onto osseous. Injustice is the other mechanism, you can drill a hole into the bone through these self drilling devices, which has a pretty good effect. I’ve never got are used to those devices, but some people swear buy them. But you need to get that profound anesthesia in there. And you just got to wait. Make sure you just make sure that the anesthetics work, don’t just dive in. And then you want to patient management.

[Jaz]Well, with the busy lives of a general dental practitioners, but juggling at getting these patients in, making the diagnosis can take in 15,20 minutes. Sometimes you take a radiograph then give them the block let’s say aren’t getting infiltration, get them set outside while you see a few more patients. I’ll see you in my lunch breaks Mrs. Smith or whatever. Then the lunch rate comes your nurse is rolling her eyes, they swap nurses and so it’s all happening in busy practice. Now, let’s say we made a diagnosis of irreversible pulpitis. And we know we need to extirpate we have given sufficient anesthesia and the patient loaded up with ibuprofen and all the stars aligned when we’re dealing with such teeth. They usually have a large MOD amalgams or something like that. Right? So my first question in terms of making a very tangible for general dentist is in ideal world we’d love to remove the entire restoration. Remove any caries, access cracks but when I’ve 20 minutes we need to get in go for the kill. Is that okay? Can you forgive us?

[Sanj]At the end of that, this is about patient this is about getting a patient out of pain. Okay, and you just need to get in there. I used to call it ninja endo get in there, get the job done. Get out before a patient realizing it. That’s my principle in endo. Whether it’s emergency or endo, you want to-

[Jaz]Stealthy.

[Sanj]Stealth, stealth okay. And the first priority is getting into the pulp. You’re releasing the ,by going into the pulp you will automatically release pressure, there’s pressure buildup, that’s the number one property of inflammation, isn’t it? Then you need to sit basically, you’re applying a sedative material to relieve the inflammation, most common and popular products steroid.

[Jaz]Before we talk about medicamento and stuff. Yeah, before we talk about the medicaments I just love to ask some real world questions like let’s say you go in you open up the pulp chamber, do you think it’s desirable for the practitioner who’s going to refer to you in the future? Should we be also removing the roof of the pulp chamber as much as possible? So let’s say that lower molar saw the other day had four canals mesio-buccal, mesial-lingual, and two distals, so four canals. And I did. I opened it all up as much as I could to visualize those four canals and it was mostly restorative material I was moving at this point at now. Is it okay, in that short appointment to just literally go in? See the pulp chamber and then proceed the medicaments? Or would you recommend to open it? Or does it depend on any factors?

[Sanj]Okay, in short, forget about the root canals. Job is getting there, relieve the pressure, open the pulp space up and apply the dressing. That’s simple. That’s all you have to do on a Friday afternoon.

[Jaz]Even like three or four millimeters in them in the middle that’s insufficient?

[Sanj]Because what then tends to happen is, so the inflamed part is the coronal pulp, where in fact just the top bit of the pulp horn, you’ll find once you’ve, in those cases, you’ve got to give an intrapulpal going back to that essentially all you doing is crashing the nerves. It doesn’t matter what agent you can use, there are water, but the pressure crushes a nerve and that inflamed pulp, you’ll often find the rest of the pulpit, okay, it might be hyperemic might be bleeding a lot, but they won’t feel that. Remove the coronal pulp if you can, if it’s not painful, and then just dress it. Don’t worry about the root canals at this stage, that’s not the priority. In fact, if you then start fishing around the root canals, you’re going to start shredding pulp tissue. And unless you get the rest of the whole pulp out, that pulp tissue that you leave behind in the apical or mid third, it’s gonna be inflamed, and then the patient just you get equals other problems. So the pain is coming from the coronal pulp, deal with that, dress it and going back to the restoration unless there’s a gaping hole underneath the MOD amalgam, or it’s clearly this care, you know, it’s just the saliva coming in. Don’t worry about the stage, you can temporarily seal that off with Cavit or Kalzinol or whatever you going to use, just close the tooth, sedate it, close it and then get them back in for to dense the teeth apart, if you have to, it’ll be easy to numb up, you can then the resolvability assessment. If it’s not, if it’s too knocked from the outside, then you just refer for an extraction or book in for an extraction. But if you’re not sure, then don’t worry about that you can assess restorability, and then treatment plan for Endo once the patient is out of pain, and they’re easy to anesthetise. So don’t miss about the pulp root canals at this stage. This is about dressing and getting them out of pain, don’t fish around root canals

[Jaz]This is going to be enlightening Sanj there’s gonna be absolutely enlightning because I know plenty of colleagues who advised me in the past and they swear by this Sanj they said, ‘You won’t get the patient out pain until you file all the way to the apex.’ Now is that a myth?

[Sanj]Largely yes, it’s a myth because-

[Jaz]Have you heard this?

[Sanj]Vital so the pain is coming from that topic. It’s not the rest of the pulp. In fact, we’ll come on to this we get tired things are slightly changing. Now the way we treat vital pulps. Okay, this is an interesting conversation where we are now and it was too early to bring this in. We were in the realms of what’s called Vital Pulp Therapy where maybe we don’t need to extirpate pulps at all or the root canal we can do the coronal pulpotomy as we used to do for kids individual teeth. Remember the Cvek pulpotomy back in the day? That concept is now coming in adult teeth, not just immature adult teeth molars for example evan in mature teeth. And this comes this is the kind of crossover between risk cariology, the caries management and restorative dentists coming in. And they’ve been doing this kind of stepwise technique and all that but I think endodontists we’ve always been, not been happy with that because if you’re not predictable, materials haven’t been appropriate. And the risk is the patient could come back in acute pain, they’ll come back with advanced disease, endo disease with the level of prognosis is low. All the pulps completely obliterate and then when you have to do the endo is a nightmare. Things are changing a little bit with the new materials but at this stage in terms of emergency management is enough just as deal with the coronal part of the pulp. The rest of the pulp often it will stay vital whether you then take the dutiful-

[Jaz]This music to everyone’s ears, Sanj. This is music.

[Sanj]So whether you then go and do new canal was, so yeah, do the full Endo. Or you don’t and you apply these new vital pulp therapies. That’s the that’s the next interesting question. Because endodontics is changing now, we didn’t prevent-odontic, like it.

[Jaz]Very good, very good. I think that’d be a whole new episode. But just to continue on the reign of the emergency management, I think what you’ve said is going to be music to the ears of all the GDPs listening who perhaps had this thought that and they’re going to spend this extra time and extra risk in opening up all the individual canals, filing all the way to the apex. So really, what I’m hearing is to get sufficient anesthesia, get in there, open up the pulp chamber, just enough to get your sedative in and we’ll talk about sedative in a moment. Now, and don’t go sticking your K file. So in fact, your nurse now knows not even to give you a K file for this emergency extirpation, which is brilliant. Would you recommend using hypochlorite? Now before we can get to that, let’s take one step back. I personally I would always use rubber dam you know, with your influence on the BES, I can’t go to BES conference and then not use rubberdam for anything like this. So I always use rubber dam but I’ve got some colleagues that were more experienced. And they say, ‘Jaz, it’s okay, because we’re killing the nerve anyway.’ The endodontic, the endo buds will sort the bugs out afterwards. So just get going put some sedative in and come out. We don’t need to irrigate and we don’t need rubber dam. What do you think on that? What is best practice? What do you want from your referring practitioners?

[Sanj]Okay, but I mean best practice is you’ve got to isolate the teeth properly, both from a safety point of view and also from microbiological point of view. Now, okay, that dentist may not be doing the endo, and it’s not their problem, it will go to the endodontist. The problem is if bugs get in their, saliva gets in there, it’ll kill the rest of the pulp. Okay, fine. The plan is to do endo, but the problem is if in reverse PYtest actually exist apart from that inflamed bit, it’s actually a sterile situation, which is where relative vital pulp therapy comes in. So you don’t want to introduce bugs there. Because either you don’t know when that patient is going to get to the endodontist. Or when they’re going to have the endo might be weeks, it might be months. And if they get an infection, and it gets into apical, then you’re into different ballgame in terms of prognosis and treatment. So isolation still is important. Now, whether you rubberdam or you compromise, depending on the clinic. And if you’re working in emergency department, and another factors, it’s easy for me to say in my ivory tower of dental school or endo practice, you have rubberdam there and then but again, good isolation, your nurses there good aspiration, open the pulp, give it an irrigation. Remember, it’s only the coronal part, you know, messing about root canals, you just need to bathe the area-

[Jaz]Hypochlorite, or Corsodyl or whatever. What do you recommend? Hypochlorite. Now, what do you think about people who, because maybe they’re not using rubberdam, then they’re using chlorhexidine 2%, maybe or-

[Sanj]It’s better than nothing, and then we’ll be using 2%, we’ll be using mouthwash, which is useless to be honest, it’s the surface.

[Jaz]It’s true,

[Sanj]It’s the same for sure, because that’s quite expensive. And most people don’t, even endodontist don’t use that one. Not many of you. Even if it’s as simple as opening the pulp chamber, you’ve got isolations, suction to stop saliva getting in there, dipping a cotton will pledge it in hypochlorite and squashing it in there. So at least is bathed, then dress and close. That’s fine. Just be quick. Everything’s efficient, you know what you’re doing. Hence, keep it simple. You don’t need endo Files. The aim is, all you need is your high speed. Ideally, rubber dam but all good isolation. You need an irrigant enough to dip into whether you’re injecting, that’s another issue, you will send some material and close.

[Jaz]But are you happy for us to use a hypochlorite and using maybe a whole syringe of hypochlorite to irrigate the superficial pulp?

[Sanj]Yeah. It’s not a problem, whether you’re going to do vital pulp through endo, it doesn’t matter. For the fuse for a minute or to 30 seconds you’re going to do it. It doesn’t make a difference. It’s not going to do anything, any damage.

[Jaz]But again, we don’t need to go into the canal. It’s just staying very superficially in the pulp chamber, right?

[Sanj]Yeah, that’s all you’re trying to do get some hemostasis if you can, if you can’t get hemostasis, the agent you’re going to use will hopefully no, no, it’ll kill the pulp off. So when you go back and there’ll be less messy next time. But it’s good to have some disinfected within there. Remember the dressing material probably also have disinfectant effects. So that’s fine. But ideally, yes, get good isolation as best you can. And for the sake of a 30 seconds or a minute, it’s not the end of the world. You know, we can be careful. Another thing you can be careful of to use hypochlorite, you don’t need much. You don’t need a syringe that’s friendo.

[Jaz]Just in a cotton pellet, as you said is a real gem right there actually.

[Sanj]Yeah, just so getting in close.

[Jaz]I really respect you, Sanj. And what I’m saying, I really respect you. Because what you’ve given is you really respected the plight of the GDP there, and you haven’t been dogmatic and I really repeat, it’s so easy for you as an endodontist saying, you know, you absolutely must be committing a cardinal sin, which we know we are if we don’t, but sometimes you only got five minutes, and you’re really 45 minutes into it, whatever. Right? So therefore, I really respect that you’ve given us guidelines in terms of best practice, but you’ve said that, okay, if we have to compromise, let’s do it in this fashion, what’s going to help us either way, so really good suction, dip your cotton pellet in hypochlorite. And those guidelines you gave, so I really respect you for considering our position sometimes. So thank you for that. Now, the last question in this segment for Emergency acute situation before we talk about post op pain is which is your sedative of choice and which is your temporary restoration of choice?

[Sanj]Sedative choice, very popular one and I still like it, if you can get hold of it as Ledermix. This is purely for a coronal pulpotomy it’s not for sticking down root canals. Okay? It’s got a steroid in it. So naturally, it’s anti inflammatory. The antibiotic component is broad spectrum that’s neither here nor there, to be honest, but it might have some effect. This is the fact that sedative, you just wanna get the patient out of pain. But you need to go back and you can’t leave other beings for long because it does its thing. It doesn’t do much after that. And if there’s any pulp beyond that, it’ll start getting inflamed, the pulp will become inflamed deeper down. So if you’re using Ledermix, it’ll keep it quiet for two to four weeks, maybe. But you need to get back in there and do the full extirpation do the full endo quickly. The alternative and it’s still the gold standard is calcium hydroxide non setting. It hasn’t got the direct anti inflammatory properties, but it’s a necrotising agent, it’s antibacterial. So kind of indirectly, it’ll disinfect the environment it’ll necrotize a pulp because it’s pretty caustic calcium hydroxide is pretty caustic stuff, it’ll fry the pulpit comes in contact with, very alkaline, and it’ll do the job. So when you go back in, you’ve then got the choice whether you do endo or go down and keep preserve the rest of the pulp. Calcium hydroxide’s fine. Nonsetting Calcium hydroxide if you can’t get hold of Ledermix. Because I know that-

[Jaz]How much do we need here? Because, you know, sometimes nurses will depending on which dentists they work, when they’ve got previous biases, sometimes give you a huge splodge of it and they give you a file because they expect you to take it all the way to the apex because that’s what they used to with a dentist they work with. Or sometimes they give you like the tiniest bit and, and a cotton pellet. And I personally me Sanj, I like to use PTFE instead of cotton nowadays, we can hear your thoughts about that. But then how do you best apply that? And then how much do you put, and how do you seal over that?

[Sanj]Okay, so what I do is once you’ve got hemostasis, or relative hemo state, if you’ve got hemostasis literally inject the, it’s like cream, Calcium hydroxide cream, into the over the pulp chamber floor, a third of the pulp chamber floor very gently. You can use PTFE. The only problem with PTFE. And I know a lot of endodontists. And everyone goes on about PTFE. The problem is, if you’ve put that into place, you’ve run into a ball you meant to roll into a ball, you squash it in it displaces the calcium hydroxide, it just squirts back out so you haven’t got the volume. So a better material and you’re right cotton wool, there’s plenty of evidence saying you shouldn’t use cotton wool, because you can’t, you often can’t see the fibers and they sometimes protrude through and you’re gonna get an infection, it’ll just penetrate through the temporary material. So better alternative I use is a sponge pellets, these sponge pellets, then either endofrost pellets or VOCO pellets, they’re better. Because it compressible, their porous. So they’ll hold the calcium hydroxide or whatever agent you’re in. And it just holds a bit of bigger volume of dressing material. Unlike probably PTFE as you push it in, you meant to displace it. And it’s good because it’s antibacterial. And when I say antibacterial it because it’s PTFE nothing, bugs don’t stick to the material, which is great as an inter appointment between root canal treatment is great for that, what postoperatively before you send back, but for the dressing, you just end up displacing it out and you want the dressing material to soothe the tooth. So-

[Jaz]Fair point.

[Sanj]In terms of material on top, it did get it depends on how when the patient’s going to come back. The options are Kalzinol traditional reinforcing zinc-oxide eugenol If you think the patient is not going to go see a dentist for a long time, either GI or IRM. IRM is my favorite, because it’s super reinforced Kalzinol. It’s rock hard, and in fact, it was designed. Do you know the history of IRM? Where it came from?

[Jaz]No, I don’t.

[Sanj]It developed this, I’m not sure this. It’s developed by the I think it was the US Navy for at least during the Vietnam War. So what they used to do is they find the material where they do a dress again is emergency dressings, get the soldiers out of pain, and they knew they wouldn’t come back for months on end. And that’s where IRM was developed. They used it there. So it’s a long term. It’s quite hard. It’s not as hard as amalgam or composite. But it’s pretty rare. It’s the other property it’s got that huge knock components it’s slightly antibacterial, which is why a lot of endodontist love it. It’s called a long term antibacterial and it sort of reflects biofilm and bacteria so IRM is great but otherwise GI capsulated bog-standard GI is hard enough or is resistant enough and is easily accessible for the endo and the choice.

[Jaz]Cavit, quite soft. Is that okay? For a short term?

[Sanj]Short term is fine. It depends on the cavity. If it’s an enclosed cavity and literally an occlusal access cavity. You need depth and bulk of Cavit. It’s not very, it’s quite it’s poor wear resistance, but it’s okay. For no more than two to three weeks. And it depends on the patient’s occlusion as well. So it’s okay, it’s okay.

[Jaz]Sure. Okay, but we do a favor Kalzinol or even more IRM and then use a GIC if appropriate as well. So that’s good. If I was just summarize because the reason I’ve done a whistlestop story of this because I also want to about post op pain, perhaps after doing rc while I’ve got this precious time. For those who don’t know, we’ve been months in the waiting to sync our diary. So I’ve got this very valuable specialist, precious time to extract everything out of your brain and distribute it to Protruserati. So just to summarize so far, guys, we need to get a profound anesthesia. We don’t need to explore in that emergency appointment to get to every single canal. We certainly don’t need to file into every single canal if you open up the pulp chamber, place a sedative like Ledermix or a non setting calcium hydroxide or foam on top, put some Kalzinol or GIC for good measure. IRM maybe if you want something longer lasting, and that should work. Do we have any data? Cause sometimes I’ve done it maybe some years getting patients calls up next day, saying I’m still in pain. But most of the time, I’d say 95% plus patients out of pain the next day because I did throw for a while do an audit the day after especially when I worked at Guy’s in the emergency department. Do we know how successful it is? Or is that not been studied?

[Sanj]The emergency dressing protocol?

[Jaz]Yes. Emergency Emergency protocol?

[Sanj]Yeah, I’m not aware of any specific studies on that. But anecdotally, from when patients can’t had the dressings done, it seems within a couple of days, most patients are out of pain once a denture has been in there. Yeah.

[Jaz]What advice would you give to your patient in terms of you know, give it a couple of days and analgesics. Let’s just finish off with what advice you’d get before we talk about post op pain.

[Sanj]Yeah, a woman is going to suddenly get get better. So give her a couple of days I could ask them to continue the ibuprofen if they can take ibuprofen or paracetamol. It was acute pain then Tramadol or something like that, and I want the olders just to in terms of just symptomatic relief, I just flattened the occlusion, get all the deflected contacts out to say there’s no, most of the pain is often on lateral percussion. So just flatten the tooth. The tooth is probably going to be indirectly restored probably anyway. So just relieve any, the tooth will be in hyper-occlusion anyway, if there’s any apical involvement as well in evidence in multiple teeth, one pulp could be vital, inflamed, the other part could be dead. So you might have also a combination of apical inflammation, you don’t really know that immediately. So just relieve the tooth out of occlusion. And then yeah, post operative anti inflammatories it should settle within a couple of days should do and tell them to go to the dentist.

[Jaz]Amazing.

[Sanj]You must, they must follow this I’ve been warn than what could happen. Because if there is, again, medical legal hat on, if you haven’t worn them this, it kicks off. They’ll say you didn’t warn them and you know it just to prevent a complaint you need to warn them put in the notes, this is the advice given if you’re not going to come back to your clinic. This needs to be done. So you just protect yourself for the future.

Jaz’s Outro:Yep, and warn them and also make an entry into notes that patient one that needs to this is not the final treatment. You know, some people just assume that, ‘Oh, I’ve got my root canal and I take a radiograph there’s no root for the material. You see, it obviously has been dressed at some point probably five years ago, whatever.’ So yeah, good point, well made. So Sanj, let’s switch gears a little bit. I recently treated a gentleman. Oh, there we have it, guys, you don’t need to find and open up every single canal. Just get in there, relieve the pressure, place your medicament. And we also talked about what kind of materials we can use afterwards, I feel like we covered a fair amount in this group function. Listen, if you are listening on the app, you’re listening or watching on the premium version of the app, just scroll down now. And then you’ll see a form, fill in a few details and answer a few questions. And you’ll get your half an hour’s worth of CPD certificate with all the aims objectives and the reflective log. So it’s like legit and future proof. And if you’re not already on app, look, you can download it for free. It’s on iOS and Android. And the benefit is you can download these episodes, videos and audios and any PDFs and save it to your device in case you have choppy connection. And it’s one of those membership programs that actually let you download all the stuff like if you’re on a membership website for dentistry, then it’s very unlikely they’ll let you download the videos on your hard drive or on your phone or your tablet. You actually download the video and audio to a device to listen in the future. And if you want CPD and exclusive premium content that I’m making all the time, then I’d really appreciate your support if you support the team protrusive and joined the premium package on a monthly subscription. And I’ll promise you, I’ll make it worth your while. Anyway. Thanks so much for listening all the way to the end, your true Protruserati and I’ll catch you same time same place on the next episode.

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Orthodontics for the mixed dentition is not well taught at Dental School – for which malocclusions should you intervene and by what age? Dr. Amanda Wilson will show you how to identify whether early or interceptive orthodontics is right for your young patients as part of their antero-posterior, vertical and transverse development.

The Protrusive Dental Pearl: Prevent misdiagnosing ectopic canines by palpating the permanent canine early (from age 10 onwards). Put your index fingers a little bit apical and a little bit distal to the lateral incisors and you should be able to feel a 5-10 millimeter bulge

Highlights of this episode:

1:58 Prevent misdiagnosing ectopic canines
8:55 Difference between Interceptive and Phase one
16:15 Phase 1 Interceptive Treatment Guidelines
20:20 Arch Expander Guidelines
24:07 Crossbite Tendency
24:57 Rapid versus Slow Expansion
27:42 Guidelines using functional appliances
28:21 Invisalign Mandibular Advancement
31:10 Deep Bite Guidelines
34:08 Q: Percentage of patients that would undergo Phase 2
36:43 Patient(Parent) Communication
39:51 Retention Protocol
43:36 My Phase One Smile PDF

Get this My Phase One Step-By-Step PDF Checklist by Dr. Amanda to get started and help you diagnose malocclusions

Check out Straight Smile Solutions for more Orthodontic Consulting and StraightSmile Solutions Orthodontic Coach for GPs for Orthodontic Educational Videos

If you enjoyed this episode, you should also check out General Dentists Doing Orthodontics

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Is flapless implant placement really a solid technique? What percentage of cases are amenable to flapless implant placement?

The cynic in me wondered if this is indeed a novel technique, or was it made mainstream to attract Dentists who seldom raise flaps?

I brought on straight-talking Implant genius Dr. Pav Khaira on today’s Group Function to discuss flapless implant placement – ‘what’s the deal?!’

https://youtu.be/679HAttBQ1c Check out this full episode on YouTube Highlights of this episode:

4:36 The Rise of Flapless Implants
7:04 Indications for Flapless implants
9:43 Immediate implant placement
13:59 Advice to Young Dentists considering implants
18:56 Implant Mentorship
24:11 Dr. Pav’s Implantology Course
27:46 From Course to Implementation

Check out The Dental Implant Podcast for information on dental implants and the Academy of Implant Excellence to learn how to place implants or upgrade your skills.

If you enjoyed this episode, you will also like ‘Can I Probe This Implant?’

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As a Dentist, the first years are always the hardest. You have to adjust to unfamiliar situations and people constantly. A newbie’s nerves can lead to self-doubt and hesitation whilst navigating this steep learning curve. I brought on recently qualified Dr. Saeed Cheraghi to guide you through the first few years of the ‘University of Life’.

https://youtu.be/PXt3hvsV9LI Check out this full episode on YouTube “You come out of Dental school thinking you know things and then you go into the real world and you realize you actually don’t know that much at all!” Dr. Saeed Cheraghi

Highlights of this episode:

8:31 Indirect Dentistry experience
10:15 Challenges in terms of treatment phasing
12:17 Level of support being a newbie dentist
15:03 Dental training
18:07 Overcoming lack of experience
30:34 Worrying about litigations
35:05 Importance of Health
39:59 Lesson from experience

This episode is not eligible for CPD but you can check out other CPD-verified episodes on our Protrusive App on a web browser or you download the iOS App or the Android App.

This episode is brought to you by Enlighten Smiles, a premium brand of teeth whitening. They also run the Mini Smile Makeover Course – a composite course I really recommend.

If you liked this episode, you will love How to Win at Life and Succeed in Dentistry – Emotional Intelligence

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My story of coming to the UK as a refugee from Afghanistan aged 6 and my journey in to Dentistry. I share some tough times and what drives me today. I explained why I think Dentistry was mis-sold to many of us as a 9-5 job (HA!) and my top books and influences.

I’m delighted to be a guest on the Soft Bites Podcast. The hosts, Manuela and Jorge, have both been guests on the Protrusive Dental Podcast in the past.

https://www.youtube.com/watch?v=pznVMyEDwTE

Highlights of this episode:

4:48 My Story: Refugee 1996
7:17 Life adversities
17:13 Importance of going through difficult moments
22:31 Podcasting Journey
27:38 Practicing a positive mindset
31:51 Importance of education and information
35:36 Good communication skills
45:38 Balance between the professional and personal life
55:25 Core values in life
59:30 Future goals for The Protrusive Dental Podcast and clinical dentistry

Dr. Mahmoud Ibrahim and I are launching an occlusion course called OBAB (Occlusion Basics And Beyond). This course is o help you design and execute restorations from a single tooth to anterior aesthetic cases to full mouth rehab.

Also, sign up for our monthly occlusion tip for you to get the kind of clinical content that we are preparing with OBAB

If you loved this, be sure to watch Dentistry is STRESSFUL – this Podcast will help you

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Preserve bone, be kinder to the tissues – but NOT necessarily at the expense of time. A great insight in to Atraumatic Extractions from Dr Diyari. Some say that ALL extractions should be atraumatic, and therefore this is a ‘made-up’ term by implant bods. By clarifying some misconceptions today, Dr. Diyari Abdah gives us an inside look at WHY and HOW atraumatic extractions can be efficient and effective.

https://youtu.be/gS7h0L69hJ4 Check out this full episode on YouTube Protrusive Dental Pearl: Life Advice: “Never take advice from anyone who you wouldn’t switch places with”

This episode is brought to you by Enlighten Smiles which is a premium brand of teeth whitening that guarantees B1 shade. If you want to know more about teeth whitening and get better results for your patients, do check out their webinar, Enlighten Online Training.

Highlights of this episode:

1:28 Protrusive Dental Pearl: Life Advice
12:08 Atraumatic Extractions
15:02 Additional skill set and tools to achieve atraumatic extractions
24:24 Atraumatic Extractions Protocol
27:19 Literature regarding Piezosurgery
33:01 Collagen Plug

Check out these studies regarding Piezosurgery:

Clinical-Success-Bone-Surgery-with-Ultrasonic-DevicesDownload Essentials-in-Piezosurgery-Clinical-Advantages-in-DentistryDownload Learn more about Implant Dentistry with Dr. Diyari’s The Most Accelerated Practical and Comprehensive Dental Implant Course with ADDITIONAL 10% off (including the Early Bird pricing)

If you enjoyed this episode, check out Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth

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Half way in to a tricky extraction you hear a voice…”Maybe now is a time to raise a flap?”

You ignore this voice and keep sweating with the luxator in hand, because it has been far too long since you raised a flap and you dread the nurse’s reaction.

If this is you, then we got you. I brought on Consultant Oral Surgeon Dr. Sami Stagnell to share his tips and pearls in Oral Surgery, specifically WHEN and HOW to raise cleaner flaps, as well as what types of flaps to consider for each situation and when NOT to consider extending beyond an envelope flap.

https://youtu.be/cx6HvrZtjcw Check out this full episode on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Protrusive Dental Pearl: Nice and Clean Extraction Sites – Use the spoon end of Mitchell’s trimmer to clean the surgical site for 30 secs to 2 minutes.

Highlights of this episode:

1:27 Protrusive Dental Pearl: Nice and Clean Extraction Sites
13:43 How to gain confidence in raising a flap
21:51 Envelope Flaps
30:09 Guidelines regarding relieving incisions
37:32 Raising a nice clean flap
41:45 Guidelines in lifting the papilla
44:56 Blades – 15 vs 15C vs 12 blade

Improve your Oral Surgery Sectioning with this speed-increasing electric handpiece at Incidental Limited. And get 5% OFF their entire products with the code ‘onions‘!

Check out the Oral Surgery Course that Dr. Sami Stagnell will be launching in 2023.

If you enjoyed this episode, check out Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth

Click below for full episode transcript: Opening Snippet: /Sami/ So the first word you said was purposeful. And that is it like you're doing everything with direction and purpose and meaning. You're doing it for a reason. So get your blade down to bone, to hard tissue, be confident in where you're putting that blade and know where you are, raise the papillae first. So I tend to sort of raise the outer edges and round the margins because those are the bits that tear. And those the bits that you then don't want to sort of have to try and repair if they don't want it. /Jaz/ What instrument are you using to raise the papilla and beyond?

Jaz’s Introduction

Hello, Protruserati. I’m Jaz Gulati and welcome back to another episode of The Protrusive Dental Podcast. This time, Oral Surgery specifically how to raise cleaner flaps and the principles of raising flaps in oral surgery, for exodontia. I’m joined today by Dr. Sami Staggnell. I know you will love his humor, and his humility. He’s a really humble guy. He’s a consultant oral surgeon, but he’s so down to earth. So I know you’ll enjoy all the tips and pearls he’ll share with you. The main themes that we’ll cover in this episode are like, when should we raise a flap like I’ve been in the past struggling with a difficult extraction, I’m thinking, it is now the best time to raise the flag? Or should I just keep going? Should I keep luxating, elevating and maybe the truth will come out? Or should I really start getting my handpiece in and start raising a flap, I mean, nowadays, I’m raising less and less flaps, I mean, I probably section 80 to 90% of all molars, and I do it flapless. So it’s something that I’m having to do less and less. But obviously, for third molars, I’m raising flaps. And so I had lots to learn from Sami as well, in terms of how to make my own flaps cleaner and nicer. We’re going to revise the different types of flaps and when to consider an envelope and when to extend beyond an envelope. And also, we talked a little about blades, are all blades build equally? Are there any that you should be avoiding? It was a surprise that he taught me today, which I’ll be sharing with you as well.

The Protrusive Dental Pearl, it only has to be oral surgery related. So one way I feel I have zero evidence for this maybe it exists, but I haven’t read it, is how to reduce dry sockets. I was taught by this oral surgeon in Singapore, a very simple thing, like I think most oral surgeons do this and they pass this on to us when they will make learning from them as students. And I guess we fall into bad habits and we don’t do it, is once you’ve removed the tooth, do you actually clean the site, even if you haven’t raised the flap? And so something like Mitchell’s trimmer, you know that spoon end of Mitchell’s trimmer? My nurse knows, Zoe knows that after an extraction, I’ll always ask for it. So when we started working together a few years ago, she was surprised at how every time I was doing the extraction, I was asking for Mitchell’s trimmer. And then now she knows it’s part of the kit when I do an extraction. So every time I take a tooth out whether I’m raising a flap or not, I’ll use a spoon end of a Mitchell’s trimmer, and scrape, scrape, scrape. What am I scraping? I’m scraping the adjacent papilla you know there’s plaque there, right? That’s causing inflammation, that’s not a optimal healing environment, I’m going to scrape the inside of the socket, I’m gonna get rid of any potential debris, any granulation tissue, I’m just giving it a good clean for, you know, 30 seconds to two minutes if I find that it was one I had a section and then maybe there could be some bits of amalgam in there, you never know. So make your surgical sites clean and nice using something like a spoon end of a Mitchell’s trimmer. And using this, I’ve had like two or three dry sockets the whole year. So now it’s August and eight months, I’ve had three dry sockets, so it’s not like I’m immune to them. But I do feel since I started doing this a few years ago, I get less and less. So now let’s join the real expert in oral surgery, which is Dr. Sami Stagnell. I’ll catch you in the outro.

Main Interview:

[Jaz]

Sami Stagnell, welcome to The Protrusive Dental Podcast. How are you my friend?

[Sami]

I’m very good, Jaz. Thanks for having me, man.

[Jaz]

I’m so buzzing for this. Oral surgery is always a popular topic when it comes to Protruserati, we had some great ones in the past. And we’re gonna delve deeper into flaps. But before we get into that, tell us a little about yourself. Where are you in your training pathway? What kind of work really, what part of oral surgery that you love to do? What’s your niche within that?

[Sami]

Yeah, for sure. Training is a long term thing, isn’t it? But as far as training goes, I’m a specialist now. So I got through specialty training about five, six years ago. I’m also a consultant. So I work at Eastern hospital two days a week, the rest of the time I manage things between general practice. So doing IMS type work, so specialty referral and through the NHS as well as balancing private referrals as well. And then subspecialty interest in implantology. So I spent most of the last 10 years building that as my niche. So traditionally a lot of oral surgeons would sort of just put implants where the bone is, but I have a background with a Master’s, restorative masters and a few other bits and pieces up my sleeve. So yeah, a few tricks to sort of help make me a sort of better implantology. But that’s effectively the sort of the general day to day so yeah, it’s quite good fun mixing it up general oral surgery and implantology

[Jaz]

Do you restore your implant as well?

[Sami]

Yeah, I still do. Absolutely. And I think I’ve always, I’ve never given an up totally. I’ve got a prosthodontist who I absolutely love, and she’s amazing. She makes me look good in so many ways. But I definitely think you’d have to keep your hand in and I know, Pynadath George, who’s sort of been on your podcast before. He’s one of those people who inspires me in so many ways and I do look up to him a lot. And he’s a polymath, and I sort of, I’ve always been comfortable in that zone and I think until in the last few years, took a while for people to get okay with people being polymaths and I think as an oral surgeon as someone who does the surgical side you’ve got to understand the restorative and the the outcome orientated aspect of it because otherwise it’s moot. It’s completely lost, I think.

[Jaz]

It raises an interesting point. I mean, firstly, I respect so much from an oral surgery background, that you respect the fact that is restoratively driven. That’s amazing. That’s the way it should be. But when it comes to Implantology, as a non specialty, there is no specialty of implantology, there’s no specialist in implantologist, really, it’s a made up term. When we have people with perio background claiming that okay, you know, we are the drill experts in implants, then you have the restorative folks, prosthodontic folk and the oral surgery, how can you get it and even GDPs who do implants, I guess what I’m trying to ask is how can we be more integrated in our approach, when all these different sub specialties are dabbling in implants?

[Sami]

You have hit the nail on the head with that question. I am totally on board with how that question gets asked. Because I think it’s asked often by the wrong people in the wrong circumstances it’s often asked is how can we control implantology? And it tends to be like you say, specialty specific people who are asking that question rather than people ask them holistically. And one of my other sort of sideline jobs is I’m a council member on the College of General Dentistry and we rent things like the training standards and implant dentistry that are due for review. And it’s a question we constantly ask ourselves, how do we improve that? How do we change? How people approach implantology because when I got into this about 12 years ago, when I placed my first implants as a undergrad, I was quite lucky over to do that as part of my sort of general upcoming as a dentist. You know, I got taught by a prosthodontist, who’s daughter now is also a prosthodontist, as well, who I work with on the younger itI and

[Sami]

Must be Emily Abraham?

[Sami]

It was yes. Well spotted. Yes.

[Jaz]

Another Sheffield alumni.

[Sami]

Yes, Sheffield. Absolutely, though, the Sheffield group. So I think it’s one of the few things in dentistry, that means you actually makes you have to be raise your game and everything. I think implantology doesn’t give you any leeway. Like you can choose other specialty areas. And even just if you’re just doing basic Oral Surgery minor or surgery, you can get away with sort of understanding, is the teacher restorative, is it not? You can tread lightly around the edges and sort of get vaguely whether or not it is or isn’t. But implantology, the deeper you get, the more your knowledge base has to grow, the wider your sort of scope for it has to be. And I think there are lots of people claiming stake in it. But in the UK, we’re the only country in Europe that has specialties in the way that we do almost there’s not as many specialties as many other European countries. And I’ll be corrected on that if I got that wrong. But if you go to someone like Germany, people orthodontics and surgery, you go to Austria, so I spent a year doing ITL fellowship in Austria. And there’s no specialties, it’s simply an oral surgeon by virtue of the fact that you work in the oral surgery department. So when I was out there for a year, all the faculty were mixed on one floor, so everyone had their offices that we shared with prosthodontists, perio guys, the was the president for the European Federation of Perio was in the office opposite view, which was amazing. So I spend a lot of time with those guys raising my perio game. So I do connective tissue grafts, I’ll sort of assess phenotypes, I think about the current conditions and things because that was so important. And what they brought to the table was crucial. And I watched these teams, everyone handed off to everyone, everyone knew where their cutoff was. And everyone knew, right, this isn’t for me. Now I’ve got a handle on. And it just meant that no, but there wasn’t infighting, and it’s somewhere I really want to get us in the UK because I think there is so much to be learned from that sort of background, from that way of thinking. And that’s much more open and collaborative approach to it. And then the only people that are going to benefit other patients. And then when they were not going to run out of work, we still place relatively few implants as a country. So there’s loads of work to be gleaned. We just need to approach it the right way, I think.

[Jaz]

Thanks for explaining that. But did I catch you right that you placed your first, technically you place your first implant as an as an undergrad?

[Sami]

Yeah, I was a fifth year. So Neoss was running an undergraduate program in King’s at the time, because I think the founders of Neoss were partly related to King’s. So when I was a fourth year, there was sort of an option out there to sort of get involved in implants. Now, I’ll take this story back even further. And I try not to bore your listeners. But a lot of people asked me when I sort of got into dentistry what I wanted to do Dentistry, I wanted to do it from a young age, no family or anything. I just my dentist didn’t hurt me. I went to the doctor for jobs, but my dentist was always nice. And then when I did work experience, I ended up doing my work experience with Andrew Darwin, who is sort of one of the gods

[Jaz]

Oh, my goodness

[Sami]

In anhtology. So 16 year old me on Harley Street has no clue about oral surgery, has no clue about dentistry. It’s just been told all the standard Spiel stuff that you get at the UCaaS sort of forms and all the rest of it. And I’ve walked in and I spent a week with these guys, and it blew my mind, absolutely blew my mind and I sort of knew that oral surgery of some kind. I was like, if this is dentistry This is then I’m in you know, sign me up now because I’m all on. And by the time I then got to 40 I sort of, I was toying with the idea of do I maybe do medicine as well and maxfax and I think you know, at that stage of your career, you sort you’re flooded with ambition and enthusiasm and you sort of you haven’t had enough clarity, have seen enough things yet to make good decisions. But this opportunity came up to, you know, who wants to try and do implants. And because it wasn’t really a mainstay thing in dentistry, even like 15 years ago, it was happening, but it wasn’t sort of something that undergrads were really talking about. Most people were trying to busy fill their quotas with composites and root canals, let alone trying to get anything else done. And I sort of me being something I struggle with saying no to things. So I was like, yes, struggling. So I then had to go to Prof Abraham, who sort of would work up the case with me, and I had to present him do all of that other stuff. So my finals case process, I placed two implants. And it was one of the nurses working in King’s at the time, it was her dad, I got to do the implants on so yeah, so it was already

[Sami]

That is so cool. You talked about quotas. And you know, when dentists are trying to do their one quota for that molar root canal, you went ahead and place two implants. I love that. And I think it’s so important to appreciate everyone’s origin story. And I repeat this theme time and time again, with every guest, I might spend a few minutes finding out how you fell in to where you are in the world at the moment in your journey. And I think it’s so relevant that, hey, you had that experience with Andrew Darwin in Harley Street, you met some people who took you under their wing to help you go above and beyond to help you as an undergrad. And you showed that interest. And then that spiraled into where you are today. So amazing, I hope people find some value from that journey and can can model it and look up to it. So don’t be, undergrad all over the world, don’t be upset that you didn’t place an implant. That’s the norm. But appreciate that When opportunity comes knocking, take it where you can. And if you already have an interest from before, then then go with it. So I’m glad you shared that.

[Sami]

I’ll add to that, if you don’t mind. Like I think you know, I was listening to a podcast really recently that was talking, you know, some people talking about luck. Luck is simply preparedness for when opportunity arises. Like you’ve just said, that opportunity comes you jump on board. And I think at the early stages of career, you’ve got to take those steps, you’ve got to take those leaps. And you’ve got to put in the mileage because all of a sudden, one day, kids come along, mortgage comes along, the world approaches you in a different way. And you may not have the energy and the enthusiasm. But if you can be inspired by what you’re doing, it makes a heck of a difference. And you’ll sort of find the drive. And often it’s motivation comes from seeing the results. And it’s simply being able to dedicate the time and the discipline to dedicate yourself to some of the ventures to begin with and understanding patients in those early formative years. I think so many people want to jump into implants, and I see young people come to it all the time. And hopefully this segues on to what we’re gonna talk about today. But people come and go, I want to do implants. Okay, great. How many surgical did you do? They’re like none. I’m like, Oh, my. Okay, no, no, no, do not pass go and like so what years have you done? Have you done any surgical? Have you spent any time in the hospital? No, but I’m on an implant MSc and I’m like, The only people winning here are the universities like they are the ones taking money. And I’m not, that’s not a go at the universities because the universities have phenomenal teachers but you’re not you haven’t seen enough composites fail. You haven’t managed enough patients, who didn’t enjoy their perio treatment, you haven’t screwed up making immediate dentures like you haven’t done enough of the stuff that will make you good at the rest of it later down the line. So take inspiration, but be patient. And that’s a really tricky balance, especially in today’s Go, go go sort of lifestyle.

[Jaz]

Sami, that is real talk right there. And I love the way this podcast started because it was very warm and fuzzy and uplifting and the story and now we just hit them hard with a real talk. I love that. Let’s because people now are getting little bit nervous because we’re into the podcast now. And we haven’t mentioned the word ‘mucoperiosteal’ yet so there we are, we mentioned it now. So let’s move on. Let’s talk about flaps, my friend. So the first question I have for you really is I am not afraid anymore to raise a flap like go back four or five years ago maybe then the thought of raising a flap was very much like okay, it’s been half an hour, the tooth’s not budging. I look at my nurse, I’m sweating and like okay, get me the blade. And then that means to her, okay, there’s no, I’m not having a lunch today, basically. So that was the kind of sort of background. A lot of dentists are like that okay, I’ve run out of options here. And I don’t want to refer in the middle of an extraction. So let me remember what they taught me in fourth year of undergrad and try and pull up some sort of flap and drill some bone and figure it out. Now whilst I had better mentors and stuff, and now I’m very happy to Section teeth and that for me, and we’ve covered this before as well, sectioning teeth, for me was so important in getting higher success rate and confidence and now things don’t faze me as much and having those failures behind me, those painful faces behind me that taught me valuable lessons. And even when I was at Guy’s hospital doing an oral surgery post, I saw an upper canine humble a consultant, Oral Surgeon. So that showed to me that actually, sometimes when you have these patchy areas, the way explain it to me you have these patchy areas of ankylosis and you can’t predict that sometimes and those are just gonna be really difficult. So don’t you know don’t be too upset if you can’t get it out because chances are if you’re struggling, most people would struggle

[Sami]

You won’t ever know. And I remember seeing this as an NHS as well. Watching a maxfax consultant who I absolutely like, put on a pedestal. And I watched him walk into an EMT theater where they were doing a cancer operation to take out some pre molars and he spent 45 minutes doing it. I’ve watched as a registrar, one of the like, the greatest surgeons I’ve ever worked with who’s at cleft maxillofacial surgery, he made everything look easy. And, you know, we walked away after an hour and a half doing four wisdom teeth, and he just turned to me was like, Well, that was like glass bottles in a concrete bed. I was like, Yeah, and I was assisting, I wasn’t even doing it. And I was sweating. And it’s totally that this having respect for the foundation, I think. But it’s the tightrope between fear and respect. And a lot of that, and the difference is experience. The difference is simply putting yourself out there, but most people, they don’t see it as a means to an end with oral surgery, they don’t see a means to an end with surgical extractions. You’re doing you know, when you started doing verti preps, and you might do crown lengthening, you’ve got an outcome because you’ve got a bigger thing that comes after all of that, you’ve got something else that supersedes it. Whereas in oral surgery is just getting the tooth out and I say just, but actually, you know, the thing that causes most fear and problems for most patients, most of their bad experiences are root canals and bad extractions. So surely, if the PRA, ever the PR exercise needed to be had in dentistry, it’s about good root canals and good extractions. You know, people come in and like the other dentist had any on my chest, I’m not that agile for one. And secondly, I don’t know, a single person teaching that technique, the sort of amount the patient style of removal of tooth. And, but when I speak to most people, and then especially on the implant courses that I teach on, where are people getting hung up on with raising flaps with approaching these is they don’t think far enough ahead. So the biggest start of stumbling block is often planning for the unexpected. So I have a plan A, but I have B, C, and D, hopefully in the background somewhere, that means that we’re not going to get stuck somewhere, we’re not going to come unstuck. And if we do, I’ve talked the patient through it, I’m not keeping it from the patient either. And I think again, it was a medical legal lecture, I went to the British Association of Oral Surgery conference a few years back, and there was a barrister talking, he was like, people need to stop getting worried about owning risk, because it’s not your risk to own, it’s for patients don’t. So if a tooth is risky, if there is a three that’s going to be ankylotic and different, difficult. I just talk people through my experience, I will normally tell people look, this is how I expect it to go. These are some of the things that can happen, the 30 seconds of telling people that tends to mean that you’re just sharing your experience. And if it happens, then they just look at you like you’re sort of you had your crystal ball on you could tell the future. And if it doesn’t, then they just think you’re good anyway. So you know, telling them after it’s just an excuse, that was always the way it was told to me, you know, just for warn. I think a friend of mine, Richard Moore, who runs an oral surgery podcast, he just did one on complications as well, which is worth a listen to for any of your listeners as well. And Judith, his colleague, I forgot his surname now who is a friend and colleague of his as well trained Richard initially used the phrase forearm is forewarned, and I think that is such an important that hope I got that away, right. That is such an important phrase. But I think listeners will hopefully get it that you can make assessments but people don’t treatment plan with oral surgery, so they just in their head go the tooth going to come out. But they don’t think about the anatomy, they don’t think about if I’m going to raise a flap where I’m gonna have to put it, do I have all the kit ready, I get the nurses to get stuff out at the start of a session. Because the nurse, 10 quick turnarounds, between getting things up, because you can adlib for 20 seconds, we’re just gonna get some more kit out, we’re just gonna make this a little bit quicker, we’re going to try and speed things up because it’s not playing ball. So I want to make sure that we go the right way with this as quickly as possible, versus trying to talk holiday plans for 20 minutes with whilst the nurse remembers which where water tubing goes in and the like. And all you do is sweat more and feel worse and then just that hiatus ruins your momentum. But it’s that’s the experience factor. And I think the more people do it, the more comfortable they get raising a flap and I think you’ll see that now like you say you’ve raised a lot of flaps, you’ve done a lot of these now. So you start, I put luxator on to tooth and I’ll tell straightaway whether or not I’m going to bother trying to just continue luxating or not, I’ll sort of use feel and in the same way that you’re sort of apply a certain tactility and experience to cram perhaps or looking at aesthetics and assessing whether they’re right or not. And actually now we’re going to do something different, but people aren’t used using that experience, and then it becomes a vicious circle. The more you avoid it, the less likely you are to do it. And you just keep going and then 10 years down the line you refer everything out and it’s actually it’s not that’s not a practice bill.

[Jaz]

Hey guys, this is Jaz again, just interfering with this important message about extractions and how to make them easier. We did a few episodes previously talking about speed increasing handpieces, electric handpieces and how I love them to Section molars without raising flaps, it reduces your risk of surgical emphysema because the bur itself is not driven by air. So if you’re looking to get a handpiece whether it’s the normal straight one and you want to use it for restorative and for extractions, or if you’re going to get that angled one, which is primarily for awkward extractions, but you can also use it restoratively, then check no other place than Incidental Limited. So incidentalltd.co.uk has got all these hand pieces. And if you use the code ‘onions’, that’s ‘onions’ with the plural, you can get 5% off and the crazy thing is a speed increasing handpiece is just 360 pounds that includes VAT. Screw all the companies that don’t quote with that. Okay, so iIncidental Limited run by Chris, one of the good guys, they always quote with VAT. So it’s 360 pounds, including VAT everything, and you get a speed increasing handpiece, there’s no reason why in 2022, your practice should not own a couple of these in every surgery. So check it out, go to incidentalltd.co.uk use onions to get 5% off on their entire stock, you know, stock up on rubberdam, wedges, tor VMs anything you need, but it expires on 30th of September. So buy before then pass it on to your practice manager or whoever does ordering at your practice to do a bulk order to take advantage of this time sensitive discount. Anyway, back to Dr. Sami.

[Jaz]

You’re so right. And I love those communication gems you shared. I love the humor there. And in case you are multitasking and you missed it, the whole glass bottles and the concrete. I love that. What a great analogy, what a great visualizations about some of the trickiest teeth that we’ve had to remove. So yeah, I mean, I am not so worried anymore. So just reflecting back on my journey in evolution in oral surgery as a GDP. But when I, even when I am raising a flap, quite often my go to flap is an envelope flap. So if you don’t mind, Sami just explaining to those maybe younger grads, what an envelope flap is. And I just want to know, in your practice, when you are raising as part of your let’s say, Plan A, you’re going to do a flapless maybe and then plan B if you need to raise a flap you will do this kind of flap, what percentage of times are you ending up doing? So we’re talking non wisdom teeth here, we’re talking anything but wisdom teeth, What percentage of times would you just raise an envelope flap?

[Sami]

Yeah, so I think envelope flaps are the way so those watching the video, I’m gonna apologize for telling my back and those listening, I’m just gonna tell you that and I’m drawing some badly drawn teeth at the moment and a broken root. And so, you know, assume typically this is sort of in that sort of four or five region or sort of the lateral that sort of breaks off, you know, after post core crowns tooth. Envelope flap is just what we traditionally typically called the single sided flap. So it’s that first incision, where you sort of use your blade to gently sort of trace the outline of usually the adjacent teeth, you can take it crestally, so sort of if you’re looking from it, top down, and, you know, the incision is in the midline, along the crest. And I often think that it’s quite useful putting fingers either side. So if you’re holding the buccal and palatal or the lingual and the labial, you get a feel for where your distance is. So you can place your blade in the right place. And often, a lot of people look like a sushi chefs, when they’re sort of doing this the way they’re sort of trying to sort of filet things and you’re like, Well, hang on. No, no, no, no, just raise the flap. And it’s almost I think it comes from this tentative nature of wanting to do it properly. But all you do is traumatize the flap. Unless you’re a periodontist raising a split thickness, flap, go to bone, go down to firm contact, be is sincere and sort of direct with the movements that you’re making. Because..

[Jaz]

Be purposeful

[Sami]

Yeah, that’s it perfect word. And then that’s it. Because if you’re not, all you’re doing is traumatizing tissues, the more trauma there is the more bleeding, bruising, swelling, soreness, discomfort people are going to get later. So that all forms part of what you’re doing. But typically, for most procedures, I think probably for 60 to 80% of stuff an envelope works. Because often you can get enough reflection. And the other thing with raising flaps is you want to start and give yourself enough leeway because a lot of people will do flap, and then go, right I was taught two sided at dental school or whatever it is. And like they’ll do their flap. Now something else breaks or now you have to take away more bone. Now, you know, for example, if this had a big perio defect on that tooth and the tooth in front, whatever, all of a sudden, you’ve now put your flap on compromised that area that’s never going to support it when you put your…

[Jaz]

Your relieving incision

[Sami]

hen you put periosteum Well, you do a couple of things. One is you damaged tissues around adjacent teeth. And I think again, in an era of aesthetics, if you’ve got nicely done crowns, you know, this is why I get my prosthodontist provisional crowns on anything that we’re operating around for months before we get to the final things. So we can connect with tissue graft to do whatever it is that we need to do to make things look nice because if those margins are going to change at all, and I’m responsible for that change, the last thing you want to do is in on really nice looking crown and the same for some of the older population. You already have great margins and already fed up with that, but don’t want to go and replace some of the stuff. Why make that situation worse for them. So often you can maintain those flap margins quite nicely reposition that replace things to where they are, because that’s it, you’re starting with the money, this all has to go back to where it was when you started, if you’ve got solid bone, and is this concept of a periosteal cuff. Maxfax guys used to talk to me a lot about this, and they never understood it until they had loads of infections. And they often try and give themselves like a 5 to 10 mil cuff of margin. In some cases, I think that’s too much. And you’re probably encroaching on their anatomy. And actually, I think we can be a bit more minimally invasive of the concept stands. And again, it comes from autogenous, grafting and Frank Zastrow, who took the quarry bone split technique a little bit further, he talks about this, and I think it’s because you get this periosteal attachment to bone natural will stick to natural, you will get that and here is the Hemi desmosomes or behavior that you want to sort of reconnect to tissues, you’re not going to get that if it’s on the mind, but more so again, it comes back to the planning, if that’s going to break or I’m going to need to take away more bone and then all of a sudden I’m in a difficult situation, start minimal, give yourself freedom to extend but no way you’re going to take it to. And I think that’s

[Jaz]

So it’s a perfect good thing to start with an envelope and just follow the adjacent gingival margins, you know buccally usually, and then as and when your plan changes, you may then need to put a relieving incision make it a two sided three sided as appropriate. But as you said, 60 to 80% time when you are raising a flap and just out of interest, what percentage of your referral cases for like in an upper first molar or lower pre molar, some tricky extractions that you might get, What percentage of times I even raising a flap?

[Sami]

Very few. Because sort of failed extraction. But often like people have done the same thing, again and again, you can always predictably do. People look at you like you’re 30 When you sort of tell them, Did you put your applicator here? Did it then break like this? Did you then look at the fast handpiece in the long diamond. And people look at you like were you in the room. And you’re like No, but people do these things predictably. And often it’s because of the fear takes over. So the bad behaviors creep in. And then like no one will know if I just picked up the fast handpiece. Or I’ll just you know, I’ll just dribble some water from the three in one and the acrylic bur, we’ll see if that works. And might, because people cut corners because they haven’t set up, they haven’t got themselves ready or prepared. They didn’t anticipate it would break. And no one is perfect. Stuff still goes wrong on me. But it’s how you carry yourself in it. And I think you know that candor of being able to say to a patient, look, this isn’t going how we expected it to be. Hold fire, we’re going to reset and we’re going to restart. And we’ll come back to and often just having the authority about yourself and the confidence to say it’s not going right. So what I’m going to do is this. And you talk about referring and often like I think people are either afraid to refer because they think that we sit in our ivory towers as consultants just casting in Shame on those who send in? No, we don’t, because we’ve all been there. But there are some things we know that are avoidable. And often I think you get the fear stories, then people come in and go oh, my dentist said I needed to be asleep for this. And it probably didn’t. If you the dentist just lead with actually I’m not confident or comfortable doing this. I’m going to end and I say to patients my backup because I say to patients And I said to my colleagues all the time that being a GDP is probably the hardest job and it ends up on my doorstep. It’s only going one place in the bin. So I got a really easy job. Because I only do one thing. Being a GDP is probably one of the hardest jobs you can do hands down, I think. So if you turn around and say to your patients that your GP isn’t going to try and manage your dodgy ticker, are they going to send you to a cardiologist, I’m not going to manage this too, because actually, it’s outside my skill set. And you may need someone who can manage it, if it goes wrong. Most people are fine with that, and they will respect you for it. So don’t feel bad to say that to people. But I think it’s their sort of when people skirt around the subject. But in terms of, you know, again, I say this to the juniors who come through training. And I don’t say it to sound arrogant, but the difference between me and one of the juniors is 10,000 teeth, because I’ve spent the last 10 years you know, 5 to 10 years doing it. So in that time, I’ve amassed enough screw ups. You know, Michael Jordan talks about his failures quite openly, like he made, he missed several 1000 shots, he screwed up a number of games, it’s the same thing for me, I’ve done the mistakes enough times to know how it feels often when those broken teeth end up in my chair if I put a luxator on it. I have a sense of fear that other people won’t do in the same way that you will look at a splint Jaz and know whether it’s badly adjusted probably without even putting articulating paper. Because you’ve seen enough of that and you’ve done enough for them and that’s all that it comes down to in the same way that some people will be great and GDP is great with Invisalign. They’ll look at a case and straight off the bat go no you need fixed. Go see this guy and that’s just experience. That’s all it comes down to. But again, I go back to the point, if you do avoid it, you’ll never get that experience but for most stuff, you can avoid it. And then again, like if you’re going to add in throw in distal relieving through the motor, you know, chuck it further back, chuck the distal relieving incision.

[Jaz]

Let’s just make really tangible for those listening in case they’ve forgotten exactly what we have on the board at the moment. So we’ve got, let’s say, we’ve got a canine, premolar root, second premolar, and molar and then the first molar is broken, it’s subgingival we’re going to be raising an envelope flap and now somebody’s going to suggest it. Okay, when might we need to extend that to a relieving incision?

[Sami]

Yes, I’ll put the relieving incision distally always to start with, because I think in the lower arch, it’s less of a problem, scarring is less of a problem. Because people you know, nobody has a high lower lip line, you know, very few people show off gingiva in the bottom to be honest, then you end up with recession problems. So, again, most people have thin phenotypes anteriorly, around lower central incisors. So that’s always going to be a tougher place to manage those. So, you know, stick those distal relieving incisions in there rather than mesial ones. And often, again, the longer that envelope, the initial envelopes, if you’re taking a one, two up to two and a half units, then you’ve got enough, you don’t always need to take a papilla. And I think that’s one of the things that most people are sort of fallible for. So you know, I’ll sort of drawing the papilla on my shonky drawing, yeah. But for those listening

[Jaz]

Just to make it clear, I mean, you’d start, I’ll usually start off with the envelope first and see where you go. You then would add the relieving as and when required?

[Sami]

Yeah, totally. That’s all it is, like, you know, see what you can see, if you can’t see enough, what are you going to need to see more? And if that’s going to fail? Or what are the light again? So going back to the idea that if I can’t see at this stage, where am I going to get caught out? And where am I going to need? What am I going to need to see? So say, around lower premolars, you may well need to see them in terms of if you’re really getting down that low, hopefully not. But if you need to see it and protect it, then you know, it means you’re relieving incision may be a benefit just past the canine. So you avoid the anteriors you can you know you can include that, you can avoid the papilla. So the sort of sparing type flap, so you basically imagined an oblique incision, next to sort of one of these lower incisors, sort of angling the blade at almost like a 45 degree angle down to the bone at the level of the papilla. So you sort of leave the papilla intact, because between the two and the three, and then you can take the rest of that incision down and that will often spare because it’ll have blood supply from the labial aspect as well.

[Jaz]

So that’s one principle, don’t cut in the middle of a pillar, either either include the entire pillar, or would you say it’s okay to stop short of the pillar?

[Sami]

I think you can stop short of it. Because often like and you’ll see this, this has come more from the perio guys than anything else. So say you’re around the tooth, say imagine you’re on that lower four or five spaces again. So you’re sort of round the three in and then you’ll include the papilla, and then as you just compose the ability to then go to the midline of the tooth. And then when you’re sort of because again, you’re thinking forward to when you’re going to repair that as well like how am I going to put that back together? So do I have the right sutures for this? Am I going to be able to reconnect keratinized tissue to create nice tissue mucogingival junction to mucogingival Junction, use anatomical landmarks and make sure you safeguard those anatomical landmarks because again, it’s all starting with the end in mind. So you thinking forwards to what am I going to send this patient away with? And what am I going to have to deal with later when they come back? If they need a new crown? If they’re going to have, what’s the next stage? If it’s just having a tooth out, you know, are they going to walk away with scars or deficits around crown margins those things?

[Jaz]

Well, I think the reason I mentioned some of those points there is just to give some principles and foundations to dentists who are revisiting refreshing Oral Surgery flaps and I think what this podcast can’t be because you really need to be go to a proper courses. Okay, this is a two side, this is a three side, this is how you raise it. That’s wasn’t the plan. But the plan for just a main message I guess we want to send is a mistake that I would have made many years ago is okay, I’m gonna raise a flap now the flight or flight responses is inside me. Again, the whole sweating, find the blade 20 minutes are talking holidays, the blade comes, you’re gonna miss lunch, and then automatically you go for okay, I was, the only flap I remember from dental school is a three sided flap. So let me just go and raise a three sided flap. And that’s a common mistake that GDPs might still be making nowadays. And I just want to save everyone for everyone from that. Maybe start with an envelope first. Get some training, get some refresher course under your belt, start with an envelope first and then see if you need to extend it and I think some of those foundations you covered well, good there anything else want to add to that before we talk about how to make the flap cleaner?

[Sami]

Yeah, I think the two things that I add into what you just said are Yes, go on courses, get some mentoring and I think mentoring is becoming something that we’re shying less and less away from we’ve got more and more comfort with getting someone else on board to come and give us a hand and watch us do some cases. And you know I know some absolute you know pillars in the industry who will still get their mates and they’ll still pick up the phone to and you know, I have no qualms over going next door and speaking someone’s I’m still a new consultant in the grand scheme of things, I’m still very junior in my career. And just because I have the name badge doesn’t mean they know everything. And at some point, I have to be able to go, you know what, it’s not safe. Actually, I want to just sense check what I’m doing. And that’s, you know, that’s consciously incompetent. And that’s the safest you can probably be because you know, your boundaries, you know what your standards are, don’t be afraid, I think to go and ask for help, get some mentoring. And if you say to your patients, look, you’re a bit more complex, I want to bring in a colleague who can help me I’m sort of training up to make sure that I’m better at these cases, again, very few people mind because you’re open and honest. And if they don’t like it, then we’ll find them refer them anyway. So save yourself the headache, and because they’re probably not the patients you want to try and manage when it goes wrong anyway. And the other thing is instrumentation people go cheap, you know, people will spend 1000s on the weirdest stuff, like apps, like, they’ll buy a scanner that they use twice, or something like that, you know, and then then I’m not really buying to digital, but it’s the same thing at surgery, people won’t spend two, three grand on a decent surgical deck, you know, again, if you’re going to get into implants, you do those other things that will pay dividends. Same goes for things like Piezo, yeah, I use my Piezo for more than just taking teeth out, I do it for all the implantology work that I do as well. And so it’s got multiple uses, and blog rabbits in my line of work, it’s great. I’m not saying go out and buy a Piezo, but they’re a great addition. But a good surgical day. Good hand pieces that work that are going to get looked after that are gonna get oil. And then again, you don’t need the hue, you know, the top of the line, finest, you know, hand instruments, but you can get really decent sort of German made ones for not very much money. And again, like Hu-Friedy, Zepf, devemed, like there’s some great lines out there that, yeah, they’re a bit more of a premium, but they don’t fall apart. I’ve used cheap and cheerful and that stuff last minute. And by the time you’ve bought it for the eighth time, you spent what you would have. And actually you would have had something that worked much nicer fell better on your hands didn’t constantly like lose grip, didn’t lose teeth, didn’t drop Needles, Scissors that cut, you know, stuff like that was just like, again, because you’re there hacking away. It’s like you’re trying to start a campfire. Just it again, it’s the small things that just make the whole thing miserable. It’s marginal gains, but from a different viewpoint, I think.

[Jaz]

Brilliant. Now, when we come to raising a clean flap, any top tips that you can give that okay, we’re gonna be raising either two sided or maybe an envelope flap. We don’t want messy flaps, it looks like a dog’s dinner, it looks like a facial trauma injury. Any tips I can give on raising a nice clean flap, full thickness mucoperiosteal.

[Sami]

So the first word you said was purposeful. And that is it like you’re doing everything with direction and purpose and meaning. You’re doing it for a reason. So get your blade down to bone, to hard tissue, be confident in where you’re putting that blade and know where you are, raise the papillae first. So I tend to sort of raise the outer edges and round the margins because those are the bits that tear. And those the bits that you then don’t want to sort of have to try and repair if they don’t want it

[Jaz]

What instrument are you using to raise the papilla and beyond?

[Sami]

So often enough of the very least, the Mitchell’s trimmer does wonders. But it’s something that if you don’t have one of those sort of medium sized excavator works, because actually that the shape of that will get right under the papillae, you can put them in contact with a bone just peel up edges ever so slowly, and that works really nicely as well. Or a curette is a sort of more spoon like version of an excavator, isn’t it. Again, you can get dedicated papilla elevators, things like that. And those are, again, reduce for instruments. General Medical has a really big range. And I’ll pick up the general medical guys because they’re very good for the substance. And the so you can use any range of things. And again, like typically the ones that are fine, and we’ll have it sort of like a sharp or fine point on them that you can get between the teeth, you can sort of really put that sort of arrow head type almost configuration in underneath the papilla, just try and gently sort of like flick it up and flick it open. And then as you sort of work your way down the flap, you sort of the width of the instrument can get wider because as you get into the meat of the flap, what you’re potentially doing is tearing, if you’ve got a very small fine instrument from that you’re putting a lot of pressure through a very large space, because the periosteum will give eventually and so then you can sort of key help that your flaps and things and so again, that’s more repair work that you don’t want to sort of do unnecessarily so, and keeping these instruments in contact with bone, not on the flap because so Pynadath George again is great at this. We’ve had long conversations about it. I think you talked about it in the local aesthetic podcasts he did with you. So listeners can rewind to that one. But he talks about hydrodissection. And giving yourself enough time for

[Jaz]

Man, that’s changed our practice in terms of when I’m doing with wisdom teeth, I love that so much.

[Sami]

But it’s so i And again, like, when I’ve got many trainees with me, they sort of look at me really funny when I sort of walk in numb up, and then go and make coffee. And then I was he gone. And because like, I’m going back to rethink and look at the scans and look at the x rays and replan make sure that I’m happy in my head with everything. But I’m letting the local get to work, because it’ll take 10 minutes for the adrenaline to get to work and to create that vasodilation and give you that sort of cleaner field that you need for them to be comfortable. And then you can come back and redeliver more anesthetic. In that time, the team will prep the patient, get them ready. So when I walk in and scrub in, I just get started. And actually it saves time, because again, it’s small talk that you don’t really need to make with them. And it can feel almost awkward. And if they’ve been given that time to go numb when you get started, they’re properly numb. And they have a bit of time to forget. And sometimes I’ll do it. If I’m dealing with sedation, it’s like numb them as I’m as they’re sort of getting started as they give the first bolus of the dazzle and so tends to be a very patchy haze. And then the anesthetist will get them really comfortable. So by the time I come back again, they’re properly sedated, we’re good to go. So yeah, using good local and good local technique is a big part of it. And that helps with the cleanness of the flap because I definitely think you can see a difference. And we’ve seen it, you see it across oral surgery. Now is so vascular, but whether it’s orthognathic or otherwise good time for your local to work makes a huge difference with how you can then handle flaps.

[Jaz]

The right instrumentation, being purposeful, keeping your instrument on the bone, like you said and correct LA techniques is a good summary of that. But it’s want to just hone in on one point we’ll go to next question, the intrument. Let’s say we’re going to use a medium size excavator, can you just guide the dentists who may be visualizing this, if we liken that excavator to a spoon, that spoon is now going on to papilla, are you using the outside of the spoon? Are you using the inside of the spoon when you’re actually lifting up the papilla? So I curbside or the? The convex side or the concave side?

[Sami]

So I’ll often use the convex side against bone when I’m lifting the papilla first, because you’re almost trying to scoop under it, you’re trying to sort of gently lift and flick it forward, and then spin it around and get a toe, or there’s sort of a tip of that spin down onto bone and sort of gently sort of tunneling. And what I tend to find as well as most people will stick into one area of lifting that flap. And that’s when they get tears and things because the rest of the flaps not mobilizing. So sometimes it’s worth going around to other areas of the flap and seeing what will start to raise and what will start to move because as you start to get more mobility in the flap, you’ll get more of it raise. And I’ll often use tissue forceps. So the same as you would be doing for when you’re suturing. I’ll use those to sort of hold up leading into the flap, again, it’s about control. So making sure that you’ve got control over where that flap’s going. And as you sort of hold it, and you gently apply some pressure and pull, you can get your elevator down onto that bone and squirrel in underneath it. And that will again help to sort of push up to raise it. So you gently working your way around it and taking some time. And I think people underestimate, you know, again, it’s knowing where your patients there. So some of the perio patients, if we’re doing sort of clearances and then coming back to them for full arch work or whatever. Some of those patients have got such inflamed tissues that by the time it all heals, it’s really scarred up. It’s really tethered. It’s very rare. And again, even in the ones that are sort of you look at the ones who have been wearing dentures for years and flabby ridges, similar sort of stuff, these are sort of quite traumatized tissues. So sometimes it can be quite hard. So don’t underestimate how difficult that can be to raise the flap because no tooth extractions necessarily the same. And that will sort of have an implication what’s underneath and again, it goes you know, if you’re raising a flap and you’ve say you’re raising the flap, and there was a socket there, you know, I talked about putting your blade down quite decisively. But often what scares people is they put the blade and suddenly it drops into where the socket was. But again, that’s where it you know, I mentioned earlier on putting your fingers either side, or where the pallet is in, say that buccal bone is. Knowing where that midpoint is okay, fine, you’re going to be safe, but it’s okay to go to bone and to use again, you can use a caret to try and scoop something out. There’s Danny Boozer from Bern, he talks often about you know, if you’re doing an early placement with an implant, for example, you’re raising that flap, that’s tissues really immature. So taking that out of the socket moving it bucally, he calls it the free gingival flap, because you know you’re not taking it from anywhere else, you’ve got that tissue and it adds to the bulk buccally as well. So use that tissue if you can, if you need to.

[Jaz]

Brilliant. And the last thing I want to cover through the wrap up is, talk us about it, I mean, I think we can do a whole another episode on suturing that kind of stuff, but that’s we’re just focused on armamentarium, the blade. Is there just the one for GDP? Is it just a 15? And can you just talk about 15C versus 15 Normal? And and How about one more thing, which I actually people have asked me for is, you know that I usually call it the putty knife, but it’s actually a blue sterile blade that comes in a packaging. I use it for my putties. But the first time I worked in this practice

[Sami]

Do you mean the 12? Like a sickle?

[Jaz]

No, that’s what I use for composite. I mean, an actual, it’s actually 15 blade on a plastic handle, right? It’s sterilized, got an expiry date on it. But first time I was reblading for this practice, the nurse handed me this, I’m like, No, I want it on a metal blade. And I want the blade open from a package and stuck on. Now and that got me thinking Hang on a minute it. Am I just being very old school? Are dentists actually using this disposable blade, which I use for putties? Is that acceptable? I don’t know.

[Sami]

I use them. Because again, not everywhere has them. And it’s, I think it’s being versatile. And again, sometimes like, I’ll be honest, they’re not the most comfortable. I prefer round handled blades. And unlike a certain feel to like the pen type ones, I find that the feedback is much better. And I can be more dexterous with them, I can sort of change the angles in a nicer way. I don’t shy away from them. I think if it just gets you going and doing it again, then great. They don’t make 15C thing

[Jaz]

Sure, No one’s ever taught me to use that. I was just unsure. And I don’t want to do the wrong thing. So you know, already. You’re raising a flap you wanna do it well, so I was like, no, no, get me the proper surgical kit out. Let me use the blade I’m used to using but it’s good to hear, have that reassurance that if you have that pre-sterilized number 15, Blue, that’s usually the one I use light blue in color. You can use that right?

[Sami]

Yeah, you can definitely I mean, there’s the you know, the people will use them in a&e will use them all over. Like, it’s not wrong to use it. But again, like, you know, to go out and buy a nice scalpel handle will set you bet like 30 to 50 quid. You know, I know people who spend more on coffee in a month, you know, I just think there’s that, you know, if that makes your life easier to just buy one. And then you can use any blade you want as well, because they’re all universal, sort of, like, sort of fittings. So just, you know, there’s no, you can shortcut it. And if you want to get used to get out of this, so what and some practices if you work in lots of practices, and some might have different things. But again, if you’re moving around working lots of practices, you might want to start investing in your own kit anyway. So I think, yeah, the scalpel blades, 15 C is my preference, because I think it’s a fine blade, it’s the same shape as a 15, just a smaller width. So it has a smaller cutting to the length on it. And the smaller tip, so it’s just shrunk down 15. And I prefer those, I feel like you are in a much more finer way you’re managing the flap and a much finer way and raising that nicer. So that’s my preference. I started using, I’ve now gotten forgotten the number whether it’s at 11 or 12. I think 11 is the sharp pointy one. And 12 is this sort of curved, sickle one whatever I’ve got.

[Jaz]

Super curved

[Sami]

Yeah, and they’re quite useful. Because again, if you start getting into like implantology, and you’re doing lingual flaps to sort of raise for bone grafting, you can’t get in there otherwise. And same for things like taking connective tissue from the tuberosity sometimes are quite useful on the palate, if you ever do things like ectopic canines and flaps there. So it’s worth having a pack like I seem to collect packets of sort of blades and things and then you can get into Microblading sorts of stuff. But again, that’s more sort of adventurous. I think 15 C will cover you for the vast majority of stuff. And I think that that’s totally okay, just get started with that.

[Jaz]

Well, I learned something new today that you can use that blue blade, and I will apologize to my nurse when I get there from an afternoon shift of it as the first thing I do. So thanks so much for sharing that with me. And honestly, you gave so many communication gems. You’re very funny. I enjoy your humor today. Please tell us where we can follow you on Instagram. You mentioned about implant courses. Please tell us about your involvement with that. Tell us how we can reach out with you.

[Sami]

Yeah, thanks so much. And like you said, the armamentarium side, I think we could keep going to I’ll hold you to this and I’ll invite myself back. We’ll do another one if you want. But in terms of reaching out, you can follow me on Instagram @mr_ oral_surgery. So Mr. Oral Surgery And I’m on Twitter as well @samistagnell and also you can heckle me there and on LinkedIn as well. And as for courses, I am in the midst of setting up some new oral surgery courses, I’m going to be doing them with a few colleagues of mine. And we’re looking at developing, mentoring network because everything we’ve talked about today is sort of the real struggle. And you can go and implant courses. But the feedback that I’ve had from a lot of this senior guys the big names in implantology is that most people aren’t doing the basics. So for me my tagline you heard it here first is you know being better at basics. That’s what I want people to be. I want people to get the simple stuff, right and then progress and then grow and elevate themselves from there. But just come back like you said before, touch base, mentor, refresh. You can do that umpteen times and you’ll never sort of tired from it. And again, learning it from a few different people which is why we want we’re building this mentor network because we appreciate the fact that there are more than one way to skin the cow or there’s more than one way to elevate molar. So I think you want to hear it from a few different people and find what works in your hand. So you get comfortable with that. As for implant courses at the moment, predominantly, I’m teaching on the Paul Tipton year one course, which is really good. So definitely recommend that. And I contribute to a few others here and there. So if you follow me online, you’re sort of

[Jaz]

definitely well, I’ll put the link to to follow you on Instagram and LinkedIn. But also, if we need to know when you have any links, so you can send to me, Sami I’m gonna stick them in the show notes, so people can just quickly click on, that’d be great. I really enjoyed our chat today. And I think we’ve got what we wanted out because it’s unrealistic to explain through a podcast format all the different types of flap, but I think people will walk away just thinking bit more about the plan for oral surgery. The fact that knows even just learning you as an oral surgeon, the percentage of time that you actually using a flap and when using flap, what’s the main go to flap, I think that’s going to hold a lot of value for a lot of people. And then just little nuances about blade, which I discovered today. Thank you so much for that. And the communication stuff you shared today was really valuable. Thanks so much for your time today.

[Sami]

That’s a real pleasure. I think my absolute takeaway is going to be just plan, you plan for everything else. Don’t stop planning in this plan, the complications, plan your approach, plan your escape, and those are things that are going to sort of make things more comfortable, because when it happens, it’s not a complete unknown. So there’s definitely but Jaz, thanks so much for having me on. I’ve really enjoyed it. It’s been really good chatting.

[Jaz]

It’s been really fun. Thank you.

Jaz’s Outro:

Well, there we have it guys, you can use that blue blade after all, and I shouldn’t have corrected my nurse. So there we

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My worst nightmare: a patient complaint.

We share with you a story of triumph as one of our colleagues SUCCESSFULLY defended a complaint. We reflect on the lessons learned and how to manage complaints (including the emotional side).

Dr. Gulshan Murgai spoke about a long and arduous case that was resolved in his favor, demonstrating that he has patience and determination in spades. We will also discuss the importance of attending risk management lectures and how to deal with this nasty situation you might face with unhappy patients.

https://youtu.be/v342FiEete0 Check out this full episode on YouTubeHighlights of this episode:

The scenario that led to the patient’s complaint 8:41
Insurance-based scheme 16:40
Patient’s Complaint 19:07
Legal narrative 22:08
Dealing litigation emotionally 31:29
Emotional help for dentists 34:45
Importance of risk management courses 38:32
Lessons from the case 41:27

Head over to Confidental for Emotional Support for dentists in distress.

Connect with Dr Gulshan Murgai

If you enjoyed this episode, you will also love 10 Habits of Highly Successful (and Most Valued) Dentists

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Being a dental student is tough – you’re learning a clinical and surgical discipline alongside all the challenges of relationships, studying and social interactions. In this episode with Dr. Lincoln Harris, we talked about three key themes relevant for dental students: overcoming fear, leveling up your skills, and being able to cope with failures.

https://youtu.be/sl3CcLJYQUk Check out this full episode on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

“You only get confident once you DO the thing that you’re afraid of” Dr. Lincoln Harris.

Highlights of this episode:

Students pursuing growth vs Students enjoying uni life 12:07
Overcoming Fear 16:44
Coping with Failure 26:01
Discovery throughout Dental Career 31:36

For Dental Students who want to have a head start in their Dental Career, join us LIVE on Friday 30th of September with Dr. Lincoln Harris. Register Now!

For Dentists who want to see Lincoln Harris LIVE in London for a full-day keynote lecture: From Class 1 Composites to Complicated crown preps. Email or DM us on Insta for a super special student rate.

Check out Ripe Global, one of the biggest groups in Dentistry with 80,000+ members!

If you enjoyed this episode, then do check out this 5 Lessons from Dr. Lincoln Harris

Click below for full episode transcript: Opening Snippet: The reason that failures hurt so much when you're a new grad is because you always think it's your fault. And you think it's your fault because you're no good.

Jaz’s Introduction:

This episode is specifically for dental students. So if you’re a dental student, keep listening. If you’re a dentist, I think you’ll actually still gain a lot from the latter parts of this episode. Who doesn’t love listening to Lincoln Harris after all, but if you’re a dentist and you haven’t checked out some of the big episodes, we’ve had this year, like Basil Mizrahi on Shell Crowns, we’ve had Ed McClaren on Ceramics, and of course, the other Lincoln Harris episode on Retraction Cords, do check those out, if you haven’t already. They’re huge. But if you’re listening today, about three things we wish you’d known as a dental student who wants to improve, who wants to no longer be scared, and who wants to be able to cope with failures, then this is the episode for you.

Thanks so much for listening wherever you’re listening from guys. My name is Jaz Gulati. I’m the chief Protruserati and I’ve got Lincoln Harris, again, to talk about all those things I just mentioned, essentially about all the things that are all emotions I had as a student, so I want to help you guys out. So just to give you a bit more information about the three main things we’re discussing today is upskilling as a student, because what frustrations I had was that, as a student, you are just learning the basics. If you can just get the very, very, very basics correct, then the rest you can build on. I was really hungry as a student, I really wanted my composites to look nicer. I really wanted to know more about occlusion. And I just felt as though I didn’t have the access now. Now in this world we live in in 2022, with Instagram and etc. The education is everywhere. It’s actually amazing. We had such little to learn from when it comes to the big bad world of internet, when we were students, you guys, you students have got so much at your disposal. It’s actually amazing. But it’s also a little bit confusing and it can be a bit scary as well seeing all this dentistry on social media. And you can’t even take a bloody impression. And I know I’ve been there, right. So it’s one of those tricky things, which poses its own unique challenges. I mean, I think you’re in a far better position than I was, as student. I think it’s great that you can see what’s out there. It’s great that you can pick up tips from all these educators posting great stuff, great cases online for you to learn from. But at the same time, don’t forget that you’ve got your whole career and to enjoy your Uni time.

So you talk a little about how I felt at that time, and how I want to do the course and my dental tutor at the time discouraged me from doing it. I’ll talk a little about that. Then we talked about overcoming the fear. Like I used to be really scared of giving ID blocks. I used to be scared of Crown preps for sure that just scares me the most. In fact, specifically with Crown preps, the thing that scared me the most was breaking the contacts. That was the most scary thing I could do during crown preps and then coping with failure. Like as a dental student, it’s funny actually, one of my mentors, Michael Melkers taught me is that one of the things we don’t get to experience as a dental student is failure in a way because you don’t get to recall your patients. So you don’t see those failures, the kind of failures you get are instant ones, ie failed extractions, failed temporaries, etc, etc. But you don’t get to see the real hard hitting failures a few years later. So it’s interesting when we talk about failure, but I suppose as young dentists, when you have failures, it really can cripple you. So Lincoln does a fantastic job of covering this.

Now Linc is actually coming to London, 30th of September, and the 1st of October. Now 30th of September is an evening lecture just for you guys, students, whether you’re in Bart’s, King’s, or if you’re anywhere in the UK, or Europe, and you want to come to the free event on the Friday night, I’m gonna put on some pizza for you guys, then come on over. It’s an evening lecture, the way you can book that is if you go to protrusive.co.uk/students, it will take you to a blog post for this episode. And then I’ll put a link awakened by the ticket for nothing. It’s a free ticket, by the way, for the Friday evening. So you can come and join us and Linc will be there to talk about from graduation to a great career, what are the important things that are going to define your career in the future and how to maximize your time now. And then on the Saturday, it’s a huge event, there’ll be dentists coming from all over the country. And guess what, guys, you guys can come free. Now the Friday night is open to all students, the Saturday event priorities being given to fourth year and fifth year students because it’s just more clinically relevant for you guys. And so Ripe Global are sponsoring your ticket. What you need to do is get in touch, DM me, your student president should have already emailed you, all of this but if they haven’t just DM me on Insta @protrusivedental, and we’ll send you a linked typeform to fill in. And then that will eventually confirm your place so you can come on the Saturday. It’s a full day lecture at the Guys campus in London. Come and join us for both if you can. We get to see you guys and meet you and it’d be nicer for you guys to see what Lincoln has shared with you on the day as well. So I look forward to seeing some of you then. But anyway, let’s join Linc and talk about all these important things, all the struggles as students and how to overcome them.

Main Interview:

[Jaz]

Lincoln Harris, welcome again to the Protrusive Dental Podcast. How are you my friend?

[Lincoln]

Very good. And thank you for having me. It’s an absolute pleasure to be on your podcast again, so.

[Jaz]

Linc, you absolutely blew everyone’s mind on episode 54. If you haven’t, if you guys haven’t listened to Episode 54 yet, five lessons with Lincoln. I love that theme because it was five lessons that I’d learned from you. But I wanted the whole world of dentistry to know and that was a huge hit. It’s probably up there in the top 10 episodes actually They have all time. So it’s a Masters of anyone. Linc, we were just having a chat briefly about education going forward, the one of the things you’re doing with Ripe Global. For the few people who listen who don’t know, you are, I don’t know, as anyone who doesn’t. But please, may perhaps some of the dental students coming through discovering this big world of dentistry. Who are you? And what do you stand for?

[Lincoln]

I’m a general dentist, and I work in a very small village in Australia, so and that isolation in that village has actually really shaped my entire career, it has forced me to learn more complex procedures, because I don’t have specialists nearby. In fact, I have an orthodontist, and no other permanent specialists of any sort within two hours drive. And so forcing me to learn sort of, I guess, more comprehensive and advanced procedures purely because my patients didn’t always want to travel two or three hours every time they needed to have something done. And then that led to teaching and teaching led to learning things on the internet, because it’s so far for me to go anywhere. And that has led to what we do now. So Ripe Global was really founded on the idea of giving people open access to really high level education. And to this day, we are the leading company in the world to deliver cloud hands on training of any sort, in any field, we were the leading provider of cloud education. So that’s where I am in a nutshell.

[Jaz]

That’s absolutely mind blowing. And for those who do know, Lincoln will realize that the way you answer that was extremely humble. I mean, you are the best in my opinion, and not just my opinion, pretty much most of the Dentists I know, you ask them, ‘Okay, who’s number 1 dentist in the world? Linc, whether you like it or not, like to hear this or not, they will say you, okay? And I certainly do. So you are someone I’ve loved enjoyed learning from over the years, your philosophies and how you make things tangible, your diagrams that you share on the Ripe Global Facebook group, it’s completely transformed how we learn and when, in fact, actually, next week, I’m doing a talk about social media and dentistry. And one of the first things I’m gonna talk about is how social media has enabled dentists from all over the world, every corner, to be able to learn from mentors that are remote, and our journey of learning has really expedited. And I’m gonna mention, the very first exposure I had was from your group that you set up showing full protocol photos, that for me change the game from before and after, to full protocol. And that was absolutely massive

[Lincoln]

We started that because at the time, there was lots of before and after pictures, and what people had learned is that if you showed the preps of your case, then you got criticized for prepping teeth. And so that if you just showed that before and the after, and you didn’t show the preps, then you didn’t get criticized. So all over the world, people were hiding their preps, and people would give them a lot of praise going, ‘Yes, lovely case. Lovely case.’ But it just wasn’t realistic. And so we were kind of all in denial that often to get a particular result that we really like you have to prep the teeth. And so and that’s really, I mean, that whole discussion about touching the tooth or not touching the tooth is actually people frame it as a clinical or a scientific discussion is actually a political one. It’s dental politics. And so more or less, you have like, you know, the left and right of actual politics and within dentistry, you have the left and the right of like enamel politics, really. So there’s another podcast for you. Enamel politics. We’ll cover that one next.

[Jaz]

I love it. Well, that absolutely shaped my career so far. All the course have been on yours and what you guys do with Ripe Global and I’m proud to be one of the educators make some videos for Ripe Global, it’s a great community. If you guys if you haven’t checked out Ripe Global, check it out. It’s such a fantastic platform, what you guys are doing now with making learning accessible through the new model, the hands on model, but remotely just briefly describe that because that is very clever, what you guys doing very much pioneering dentistry before we get to three things we wish we knew as a dental student.

[Lincoln]

So we actually, for a long time I’ve been passionate about education ever since I wanted to go to dental school. And there was doubt about whether my family could actually afford that. And so access to education is baked into me because there was a period of my life where I wasn’t sure whether I could afford to escape my life with education or not. And so, you know, that obviously, as you know, I’ve been teaching in one form or another since 2006. So this is my third evolution of education, you could call it so I started out at like luxury conferences, which were silly. And then I went into procedural training in a traditional sense. And now here we are, and but what’s interesting is that my brother has been at the forefront of technological advances in communication for all of his career, and he spent a lot of time trying to help some of the biggest companies in Asia Pacific, learn to be collaborative, so learn to use technology to enhance communication where people can just communicate all the time. And he spent a lot of time with universities trying to convince them to be build immersive collaborative education. Education where the students talk, and the students and the educators talk. And it all happens all the time. In 2020, I thought, Okay, let’s start a new company where we make education far more accessible. So we will use the power of the Internet to make education more accessible. And we bet we still had a traditional model that was like videos online. And then we would build training facilities, you know, in the UK, and Europe and the United States and wherever, and we got investors to help us do this. And then, in the middle of COVID, my brother said, we’re taking the education closer to the student, but we need to take the education right into their office. And so then we basically worked out how do we build this. And so we’ve built simulation kits. And we have built a platform and we connect the two together. And we can teach hands on education while you are in your office, so you don’t need to travel. And the thing that’s really interesting is that the students, the dentists who were training, they learned faster, and it’s not a little bit, they learn to 50 to 70% faster when we train them on Crown preps when they’re using their own equipment in their office on our cloud platform on a live class, but it’s a lot on cloud than they do if they’re in a similar app. So it’s amazing, because pretty much if you have the internet, you can join our hands on class and get ultimately very intensive education that you know, and our students that their careers, their offices are going crazy. It’s an amazing way to learn. And just if we’re like really calculating about it, cost is about 70% less than traditional education because the biggest single cost with education is closing your office, and they almost never need to close their office. So that’s amazing.

[Jaz]

The two reflections on that is A) You can do it anywhere with an internet connection, reminded me of an Instagram post you made of you know, someone on the beach during a prep, we don’t know they’re on the beach until they zoom out. And that was awesome. I love that and how fast they’re learning. Well, we have proof because on the Ripe Global Group, we’ve got the first cohorts of the fellowship. I mean, amazing. Let’s name, Stephanie, her I mean, wow, the development we’ve seen from her from Piatt, from Brett, from all these guys on the fellowship and just seeing that the quality of Dentistry you producing is really inspiring. So on the topic of development, the first question I have for you is just rewinding to when I was a student, I was a fourth year student. And I remember how awful my composite looked like even then I kind of knew that okay, this you know, my lower molar composite looks nothing like a little molar. So I approached one of my tutors, and I said, Listen, I see this leaflet here, there is a composite course happening. There’s nothing really there for students. But for dentists first few years qualified, it’s a reduced rate of 185 pounds, should I go? I think might be a good investment for me to make as a student, I didn’t have much money, but I knew I wanted to develop. And my tutor said to me, ‘Listen, you’re a student go drink some beers, go enjoy, you can do this stuff when you’re qualified.’ And I look back and I resent that because I could have had a head start, I feel. So what do you think about that? Do you think my mindset was right that I should have perhaps pursued some education, because I really wanted it. And I really, really want to improve my composites. And that was the only way I knew how because my tutors. The proof was there, my composites wasn’t helping me to the degree I wanted, or should students just be chilling out enjoying their uni life while while they have it.

[Lincoln]

I don’t Far be it from me to tell the university student what they should do during university. But if you are interested in attending further education while you’re at dental school do so. In fact, we have quite a few students who do because so you have to remember that universities do a terrific job with the constraints that they have. And they have quite a few they have a lot of regulation, they have a lot of government demands on them. And they have a captive audience and a captive audience sounds great. But what that means that they have to teach the dental students who are enthusiastic, but they also have to teach the ones who are like limping over the line with their total least amount of effort possible. And so whereas when you teach, when I teach, the only people who turn up are people who are motivated enough to like do something voluntarily above what they have to and this is very different. So if you’re a person who wants to learn more at dental school, go ahead. I have, I actually have an American dental student who has signed up for my full two year fellowship before he has graduated, because he says I’ve only done like a handful of Crown prep, so I don’t feel confident and I’m about to be released into the real world. He has a very good theoretical grounding, and like a theoretical understanding how to do it, but it doesn’t have a technical, like, I’m 100% confident that I can drive my hand around something. And so he has done that. And we’re actually working on programs like that, you know, for new grads to make education very affordable. So obviously, I can’t talk about that yet. So that’s still coming, but that is definitely possible. And I think more and more dental students are realizing and we’re getting contacted from a lot of them saying ‘Hi, we want to finish our degree and then we want to go into high level education, post degree.’ And you go well, what can we teach the dental schools. Dental schools are teaching you to a regulated standard. And that means a lot of making like a lot of paperwork to prove that you have met some type of standard. And that’s, it’s a difficult job. I don’t have to do it so thankful for that. And I, you know, it’s easy to criticize them with skills, but they have to take the great unwashed and turn them into dentists. And then I get them after they’ve done their job. And they’ve done the hard yards. And then from there, I’m putting icing on top. So what can we teach from there? I mean, we can then go into things with a much more enthusiasm and specificity if you like, these are real world problems. Not the theory. But how do you actually do it? Like the theory of class two composites doesn’t help you when your rubber dam clamp has gone ping. And while you’re waiting for it to land on the other side of the room, you’re watching the blood well up from the gingiva that was inflamed. And you’re wondering how you’re ever going to restore this subgingival class two, you know, that the theory of that is not really well covered, and the actual practical, how do you do it? And then even more, so, how do you feel? But that’s not covered. How do you feel when this is happening? You’re feeling like really stressed. So how does that? How do you manage that stress and emotion?

[Jaz]

I’m so glad you mentioned the stress and emotion, what I heard from that was that perhaps if I went back in time, I should have pursued what I really wanted. I was really keen I was executing, I should have pursued pursued what I wanted. And then of course, all these emotions took off when things aren’t going well and the daily struggles and when you’re a newbie, gosh, I mean that those emotions are heightened like you know my routine days now. I can only wish my days now, as I kind of coast sometimes your crown prep. I remember when I was scared of Crown preps. So my next question is about fear. Fear to prep, fear to extract, fear to give a something you talked about giving a palatal injection, giving an ID block. I’ve been through those phases, and eventually you lose that fear. So what advice do you have? Or lessons do you have to give to Dental students who are feeling that fear? How can they overcome the fear that is procedural?

[Lincoln]

So there is more or less the whole process of teaching is an exercise in fear management, because mostly what is holding us back it’s actually fear. And I need to stop at this point and point out that I also am afraid. So I’m afraid of different things now to what I was when I was a new graduate. So I’m not afraid of doing an injection or class two. But I was when I graduated, I was very, you know, like, I can’t remember how long it took it might have taken 10 years before I could just do local anesthetic willy nilly without being concerned about the fact that I had to do this nasty thing to the patient. But beyond that, there are some things that you can do. Now, in Ripe Global, we have spent a lot of time not only on the technology platform and the simulation kits and the collaborative communication between all the students and giving them a community that safe that they can help each other through their journeys. But we have also put a huge amount of effort into innovating and how to teach the way that most people teach is not necessarily the most effective way to be taught. And so if you look at that, why doesn’t it work? It doesn’t work, because it doesn’t take into account a thing called human factors. Now human factors is the effect of how you feel on your ability to perform. So if we look at that, what things affect how you perform? Obviously, we know that if we’re tired, we can’t perform as well as if we are not tired. We know that if we are stressed, you know, we know that stress makes us perform worse. And we know that fear makes us problem. So all of these things affect how we perform. And so you can do things about that the first one you can do is you can have the right type of training. And I’m not talking about theoretical training, I’m talking about training, that builds your skill that will actually make a huge difference to your fear. So like to give you an example, most courses that teach you how to do a crown prep, you do like occlusal reduction in the morning, and then you do mesial and distal cuts in the afternoon. And by the time you finish the day you have done one crown. Now almost none of us have eight hours to do a crown. We mostly have like 30 minutes, one hour, an hour and a half. And so we don’t do that. When we do our crown prep training, we do 17 in one day, we don’t stop for lunch. We stopped for like 10 minutes, because that’s what real dentistry is like. So we it’s not a simulation if it’s nothing like the real thing. So simulated training exercises can be significantly helpful to reducing your fear because you need to have the ability to do a procedure far in excess of what’s required so that when you are stressed you can still do it. So like if you can only just do a crown prep, when you’re relaxed, you won’t be able to do it under stress. That’s just because your stress levels, stress levels reduce your performance by up to 85%. So you need to have like this massive reserve of skill and competence. So that when you are stressed, when your ability to reduce, you can still do it. And so the one is the right type of training. Now most people don’t focus on human factors training. In fact, I think almost no one does, we do, because we’ve done the research into it. And so one is this highly intense simulation training, that helps a lot. The second thing is, there’s a whole bunch of mental things that you can do to help keep your mind clear while you do a procedure. One is the boxes, which you will have heard me talk about a lot of times. And I won’t go into that, but only doing your procedure in small chunks. And so a lot of the ability, like people focus on the theory far too much. And actually, our controlling our mental state, and having ourselves trained to a skill level far in excess of what we need is the way that you reduce stress. And that’s, you know, we’ve built a whole program around helping people get past this. And also you have to support people emotionally through confronting their fears. So you can’t just go okay, here I’ve taught you now go like, then they get to the first page and go, I’m afraid, which is normal. And you have to have that support. That is normal to feel afraid. And you’re not going to feel confident until you do it. Like people think there’s some secret to feeling confident before you do something that you’re afraid of but there isn’t. The confidence will only ever come after so yeah, that’s it. It is what it is.

[Jaz]

I think we’ll all, I think everyone listening, all the students, young dentists listening will take satisfaction, I guess, or there’ll be a little bit happy to know that you’ve been through the fear, I have it, we all have had it at some stage, whether it’s the first ID block or whatever. And I think the key lessons from what you shared there were, for example, an ID block, it really helped me to revise the anatomy again, and then get opportunities to practice it. So opportunities whereby I could get away with the buccal infiltration. Actually just do the ID block with some support might be a good way to go. or less, like you said about repetition. So if you’re a student, because I’m gonna probably get really tangible with students here, yes, watch all the videos in , log on to Ripe Global, see the preps on the forum and whatnot on the Facebook groups, but then find that dedicated couple of hours of space in the mannequin head room as a student and just prep prep, prep, prep prep, and get that muscle memory going. Don’t worry, I mean, yet, obviously do the theory. But try and get some sort of hand skills going to get used to prepping and prepping. And then on the day when you’re performing, it’s going to help you a lot and having that confidence that ‘Okay, I’ve just prep 17 of these yesterday.’

[Lincoln]

Yeah, like. So I think a very important thing is to literally sit down. So when I say that I’m still afraid. The things that I’m afraid of are different, but don’t think that I have less, I feel afraid less often like building a company with investors is scary. Trying to develop a new way of education is scary. All these things are scary trying to move at the same time as all that building my office from a one dentist office to a three dentist office whilst I was doing the other thing that is scary, like literally, you know, at times terrified to the point where I can hardly copem, okay? So it’s not like the fear goes away unless you no longer progress. So if you are progressing, you will be afraid that is just a fact of life. But a good exercise to do is to sit down and go what am I afraid of? Don’t skirt around the side of the issue and go Well, no, I’m not afraid of anything. But then you actually are. Like literally sit down and go, ‘I’m afraid to do injections. Well, I’m get stressed about crown preps or whatever, root canals, okay? I mean, it took me 15 years before root canals felt easy. So you write down those things that you’re afraid of and then conquer them. That is the only way otherwise, it’s like the boogeyman under your bed. Okay, you’re lying there in bed and you go, maybe there’s a boogeyman under my bed. Now, you can do one of two things at this point, you can hop out of bed and look under the bed and you will conquer the boogeyman because you’ll see he’s not there, kay? Or you get too afraid to look, because he might bite me when I look under there. And so you lie there all night awake. And while you’re lying there, the boogeyman gets bigger and scarier and has bigger teeth and longer claws and by the time you wake up in the morning, okay, he is like the most scary thing ever. And so, and then daylight comes and he goes away. And so your fears about dentistry are the same, if you avoid them because you’re afraid they get bigger. So don’t avoid them, right? Like the problem is that sometimes we don’t realize we’re afraid and we’re subconsciously avoiding them. So like conquer those fears. Write them down, because I can absolutely guarantee you. Your confidence is only ever found on the other side of that fear. You never get confident first, and then the fear goes away. You only get confident once you do the thing that you’re afraid of. That is a universal human trait that you are only confident like, how am I not scared to public speak? Was I born this way? No, I was terrified. My knees used to shake. And now I’ve done it. And now I’m not scared. So the confidence was on the other side of the fear. I had to do the thing until the fear went away.

[Jaz]

On my public admission here, students, anyone listening, dentists, I am afraid still of Cobalt Chrome dentures, I just have done so few of them in my career, my demographics. So that’s my fear. I’m putting it out there. I’ve made it public. And guess what, I’ve got a fit next week. And I’m looking forward to it. So that’s I’m gonna get around it. And I had like a one hour mentoring session with one of my prosthodontic colleagues guiding me through it. Even though I’ve been qualified some years now. I still had that fear of something that you know, you think a denture is a denture but depends on how much exposure you got. I lost my fear of extractions a good while ago, since I got improved at sectioning and elevating, that was a big game changer. Loads of great tips that Linc shared on just general improving your extraction technique as well. So do check those out. Next theme is failure, how to be comfortable in your own skin with failure. And I’ll give you an example, which is not quite a failure on my part. Literally two weeks ago, I saw a gentleman root canal of his upper right canine everything was done. Yeah, it was necrotic, little bit infected. Everything was procedurally fantastic, use all the best stuff, rubberdam, hypochlorite. And then, a few days later, he’s in absolute agony. He has been taken to hospital, he’s had blood tests and whatnot. They can’t find any sepsis. But they find his inflammatory markers really high. He is just an agony. The hospital staff don’t know what to do. His because you’ve got some learning disabilities as moms on my case, his mom’s on the hospital’s case. And I was worried, I was generally worried for him because he was suffering so much that he was in a maxillofacial department hospital. But for me, even though the procedure was in success, it kinda was a failure, that he had so much post operative discomfort. And to this day, I get sleepless nights sometimes, and that kind of stuff, something like that one of your patients suffering because something you did, even though I would have done it the same way 100 times, there was nothing I could change about that. It’s just Sod’s law I think I generally think that after, I’ve speak on some endodontics, as well for, for clarification, it still bugs me to this day. And I guess when I was, you know, 5, 10 years ago, even the simple thing like a composite, crown coming loose that I done or something like that, it’d be like, Oh, my God, I’m getting major anxiety here. So when you experience some sort of failure, how can you cope with that? Because when you’re younger, and you don’t, you’ve had very few failures, because done very little dentistry, they really hit you much harder.

[Lincoln]

The reason that failures hurts so much when you’re a new grad is because you always think it’s your fault. And you think it’s your fault, because you’re no good. Now, I’m going to confess that I probably get the same number of failures in a month now, as I did when I was a new graduate, miss a few reasons for that. One is that the cases I do are much more difficult. I push the limits of dentistry probably a bit more because the cases are difficult. And also because the volume of cases I do is much greater. And the number of cases I have that are 20 years old is also much crisis. So just like pure statistics is going to bite me so but I get stressed now because I know I’ve done a good job and that sometimes just things happen.

[Jaz]

It’s a bit like that root canal I told you about, you know, if that happened to me, when I was just a dental student, or one or two years qualified, I would have completely been like, ‘Oh my god, what have I done that was all me.’ Apologizing profusely to the patient. I was still apologetic. ‘I’m sorry, this happened to you.’ But in my own skin, I was comfortable. That ‘Hey, you know, this wasn’t my fault. It’s one of those things.’ So you know, I definitely agree with that.

[Lincoln]

Look, there’s a lot of people also, like the last thing they do to you, just before you graduate is tell you that you’re going to get sued. Like usually like the people come from the Protection Society or whatever. And they go, right. Now, let me tell you about a person. He did a perfect filling, but they got sued and went to jail. Like this is like the last bit of advice you ever get as you graduate in almost every country. And it’s like, it’s so unnecessary, because the first thing is that almost no one gets sued in their first few years. Like me, it probably happened somewhere in the world. But the indemnity, there’s a reason why you get charged less for professional indemnity in your first two years than in your later years, because your first two years are the lowest risk for any sort of claim or complaint or anything like this of any of the years of your life because you’re not going to do anything complicated that’s going to be a massive problem. Like I mean, the chance of you putting a implant and then having it fall into their sinus and then you have to do surgery to get it out of the sinus in your first two years is vanishingly small, like because you’re probably not going to do implants in your first two years. And the first, the chance of you doing like some massive smile makeover and then they go to another dentist who throws you under a bus is also quite small because you’re generally not going to be trained to do this. So the fear of being reported for a crime against dental humanity is quite low in your first two years, so it’s probably more than unhelpful to have those lectures just before you graduate. Second thing I would say is that things just go wrong. Like, go home and try and bake 100 cakes in a row, and have all 100 workout, it’s impossible. Like, it’s just the law, it’s just the bell curve. The bell curve doesn’t allow everything to be perfect all the time. If you select 100 Random humans off the street, what’s the chance that several of them are going to have some sort of quite complicated disease? Very high. So it’s just statistics. Yes, your do a crown and it’ll fall off. I mean, I did a crown three months ago, and the patient had sensitivity, I had to cut the crown off and put a temporary on and then like, it wasn’t my fault, it was just the tooth. So that’s why failures will hit you really hard in your early career because you actually doubt that you’re any good and you doubt that you’re, you always think it’s your fault.

[Jaz]

That’s the crux of it. I totally agree.

[Lincoln]

And sometimes it is your fault. But like, you will continue to make the mistakes through life, I still make mistakes, it’s just that like, it’s not the same mistakes, it’s just different ones, you know, like I have a patient at the moment where I probably should have pulled their teeth out and done implants. But I decided after doing a course on saving teeth that I should save the teeth, and now it’s just so hard. I’ve done so much work to save these teeth. I’d be finished, if I’d done implants, I’d be finished six months ago,

[Jaz]

I can actually think of a very similar case right now. Anyway, Linc you’ve covered these main themes, I’ve got limited time with you today, we’re gonna bring you back on to discuss all the difficult stressful things that we do in dentistry, subgingival dentistry, difficult isolation, how to see difficult patients, we’re going to cover that theme as well. But if you can just give us one more lesson you want to give to a dental student that’s going to help them to want, to make perhaps make a realization make a discovery that’s going to help them throughout their career.

[Lincoln]

Okay, the number one thing I would say to dental students, and this is not a negative thing. So don’t think of it like that. Dentistry is much more difficult than you think. And the reason this is important to understand as a dental student is because when you’re a dental student or a new grad, you think that dentistry is difficult because you’re not good. Because you’re not good enough, you’re not trained, your skills are not good enough, you don’t know enough. And if only you knew all these things, dentistry would become less difficult. And I can tell you that after doing many, many courses, and hundreds and or even 1000s of repetitions, that I’ve come to the realization that dentistry is a surgical specialty, as difficult as ophthalmology, but unlike an ophthalmologist, we are not trained to competence when we’re released. So if we’re an ophthalmologist, we will be trained for about another six years after we have graduated as a dentist before we’re allowed to enter private practice. So dentistry is a surgical specialty. And but unlike every other surgical specialty, we are released, basically with the most basic training we’re not. Yeah, so it’s very difficult. And so when you go out and you’re going by ‘Oh boy, this is hard.’ It’s not because there’s anything wrong with you, you’ve just chosen a really difficult thing to do for your career, and it will get easier, it actually won’t get easier, it will get routine. Routine is the word you use for when something starts to feel easier, even though it’s technically very difficult. So that, you know, the rough timeline for myself. It was two years after I graduated before I could use a dental mirror without my hands still going the wrong way. It was probably five years before, I didn’t feel an urge to see what patients were in the book tomorrow so I can mentally prepare myself for them. 10 years before I could roll into work, knowing that I could just cope with whatever the day threw at me. And at 15 years, I woke up one day and I said, I think I’m actually good at this now. But that’s how hard it is. It took me 15 years before I felt good at it. So you know it is a very difficult technical profession because it is a surgical specialization, which is not recognized as one by most of the population.

[Jaz]

Amazing. It is not a race. Take time. So great to hear those numbers from you and your own story of that. I think everyone needs to hear that. Don’t worry if you feel like you’re really struggling because it’s super, super difficult. When we talk next time, when you come on the podcast, we talk about those really tricky daily conundrums, you know, not Instagram dentistry. What happens behind the scenes of the Instagram dentistry is what I want to talk to you about. So I look forward to bringing you on for that. Linc, as always a pleasure to have you on. I look forward to speaking to you again. Now, Linc really special thing that I know you’re doing is you’re coming to the UK, you come to London, you’re really speaking to dental students so I’m really excited for you to come and speak to dental students. I’m gonna make it very clear on my social media and the email list protrusive.co.uk/emails when I sign up about how to get involved and meet Lincoln live and we’ll put on some drinks and stuff and a few lectures, followed by a full day course as well which students will be invited to which is absolutely crazy. What are you going to talk about on that Friday evening?

[Lincoln]

So the Friday night when I talked to dental students, I’m going to talk about your career. The title is from class one composite to first class career and, and the stages and some of the things you’re going to have to battle to get through and make a great career. And you can make a very good career in Dentistry, there’s no doubt about that. It is not easy. And there is, it takes courage, because it’s pretty scary. But that’s what I’m going to talk about is how do we go from our, because it’s very, you know, to some extent, it can be a bit dispiriting when you graduate, because you graduate, and you sit there and you look at the tooth, you’ve just treated and you go, that looks rubbish. And then you open Instagram, and you see, like a tooth that looked like a nuclear holocaust. Okay, you know, it looks like a nuclear wasteland. And then the dentist has sprinkled fairy dust on it. And it now has all of its fissures, and it has tertiary anatomy on the composite and all of this stuff. And you look at it and get that like I don’t even, I can’t even comprehend how that is possible. And so that can sometimes be a little bit hard, like a little bit depressing. And so, and then like, even from a financial point of view, you’re a dental student, like you’ve just graduated, you don’t have any money, you’re got a terrible job, usually, your first job is going to be your worst job. And your boss has probably signed you up on some abusive contract. That’s usually what happens to new grads, because of the only people who fall for it. You know, like everything kind of, you know, you graduated with all this optimism, you’re gonna go into this great profession, and you’re gonna be like rolling in money. And then next thing, you’ve got a terrible job, you’re doing a million checkups a day, and you get all of the cases that the boss doesn’t want to treat. And then the boss rolls in, in his like, you know, Porsche GT3, that was just got back from racing, and your car has broken down and you have a repair bill. But the reality can be pretty hard when you graduate, and so it can seem an impossible chasm to cross. So what I’m talking about is how you cross that chasm. And it’s a pretty simple process. It’s not easy, but it’s simple. And why the chasm is not as big as it looks, it looks a lot bigger than it really is. And it’s not as big as it looks. And there’s reasons why it looks so big to it. So I’ll be talking about you know, basically how we start as a baby dentist, where basically we graduate with optimism, suddenly everything’s a bit rubbish. And then how do we get to a place where life is actually pretty good in a sensible way, and the sorts of thing the challenges that we will encounter and most of those challenges up in our head, not anywhere else.

[Jaz]

I love it. I love the theme and I think it’d be a great event to involving for dental students in the day after I’m a tease everyone a little bit more about that another time. But Linc, thanks so much for getting time I know you gotta go in the numb up the patient and then do the complex restorative dentistry whatever you’re doing. I look forward to seeing the case unripe. Thanks so much, Linc.

[Lincoln]

No worries thank you so much. Absolute pleasure to be here. Thank you.

Jaz’s Outro:

There we have it guys hope you found some value from that. Look if you’re dental student, let’s share the love, right? Send it to another student who hasn’t heard of Protrusive before and hasn’t found this episode. You’re going to help your colleagues and hopefully some of you can join us in London. So remember, go to protrusive.co.uk/students find the link, there’s two links there, one for you to book for the Friday night for free. And Saturday. You can also come free if you’re fourth and fifth year BDS. And I will sponsor your ticket. And you can learn from one of the best dentists in the world which Lincoln Harris so we’ll see you in London. But if you can’t make it then thanks for listening to this episode all the way to the end. I really appreciate it and if it’s the first time listening to the Protrusive Podcast, check out some other ones. I mean, some episodes may be a little bit too advanced for a student but there are some other fundamental episodes which I know you can gain so much from. So if you enjoyed it follow @protrusivedental, say hello, I like connecting with my listeners and watchers, and I hope to catch you in another episode soon. Thanks so much

View Details

We have switched roles! In this episode Jaz gets interviewed by Dr. Devang Patel on The Ultimate Dentist Podcast. The focus here is bigger picture stuff: trying to improve your clinical skills, finding your niche, dealing with imposter syndrome, burnout and the need for FOCUS!

https://youtu.be/ituRPR_UNWE Check out this full episode on YouTube“Gain some self-awareness, figure out what your strengths are, and play to your strengths in your life, in your relationships, in your career, and everything!” Dr. Jaz Gulati

Highlights of this episode:

3:34 Motivation and Challenges in doing Dentistry
7:17 Niching down in Dentistry
11:55 Becoming more focused on the path you chose
16:35 Journey in implementing what you learned in clinical practice
17:38 Protrusive Dental Podcast Journey
21:51 Dealing burnout in Dentistry
25:26 Future Plans
29:41 Criteria on CPD Courses
31:33 Lesson learned on the journey
36:50 Golden tips for the new dentists
42:16 Improving your Dentistry

Want to expand your horizon with TMD and Splints? Check out SplintCourse for a comprehensive online course.

If you enjoyed this episode, do check out Adhesive Full Mouth Rehabs in 11 Appointments with Dr. Devang Patel

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Sub-Gingival dentistry: the dark, scary, bloody world you don’t see as much on Instagram. Straight talking Dr Lincoln Harris will help you choose the right retraction cord protocols to reduce your stress during subgingival caries removal and crown/onlay preparations.

https://youtu.be/RyOIO61wfpE Check out this full episode on YouTubeJoin us to see Lincoln Harris LIVE in London for a full-day keynote lecture: From Class 1 Composites to Complicated crown preps.

Protrusive Dental Pearl: When inverting/tucking in the rubber dam, instruct your DA to blow air continuously at your flat plastic instrument as it works around the sulcus. This will effectively and efficiently tuck/invert the rubberdam for a better seal (and sexier photos!)

Highlights of this episode:

3:33 Protrusive pearl regarding inverting/tucking the rubber dam
6:40 Deep Subgingival Caries cases
11:44 Deep Subgingival Caries Protocol
22:44 Which Retraction Cords to Use
25:10 Retraction cord protocol on Silicone Impression
30:50 Retraction cord protocol on Digital Scanners
31:48 Teflon as Retractor
35:53 Isolation of Class V restorations
42:02 Place of rubberdam on class V restorations

Check out Ripe Global, one of the biggest groups in Dentistry with 80,000+ members!

As a bonus, check this one-page summary of this episode

Head over to protrusive.link under the Infographics Tab for the other one-page infographics summary of the past episodes

If you enjoyed this episode, then do check out this 5 Lessons from Dr. Lincoln Harris and also this Rubber Dam Isolation by Dr. Harmeet Grewal

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When is Botox an appropriate option for the management of Temporomandibular Disorders? Knowing this will help you make better referrals, or even consider Botox as a management strategy. Dr. Sheila Li guides us on the use of Botox/Toxins for TMD pain management. We discuss indications, protocols and regulatory requirements (which surprised me!) – as well as learning if these patients will now require Botox indefinitely…?

https://youtu.be/QJyxF0EGwsM Check out this full episode on YouTubeProtrusive Dental Pearl: How do you routinely check the masseters and the temporalis at your new patient examination? As a restorative dentist, the most important thing I want to know (and what will influence the occlusal risk for my patient) is the size of the masseters. Start palpating and feeling for the size of the masseters to understand how much force these patients can generate! If you want to learn more, join the Facebook Group: Protrusive Dental Community because I’ll be doing a little blog post on that about the significance of masseter size on Occlusal risk.

Highlights of this episode:

2:50 Checking Masseters and Temporalis
13:34 Dr. Sheila’s journey in managing TMD pain patients
16:13 Ideal case selection for Botox regarding TMD
21:15 Botox as a standalone vs Botox as an adjunct to splint therapy
24:26 Patient communication about the frequency of Botox treatment
26:39 Place of Botox for myofascial pain patients
30:01 Additional indemnity for GDPs in doing Botox
33:31 Functional Perspective of Botox
34:47 Success rates in using Botox for TMD pain management
39:53 Experience of having Botox
41:55 Long-term side effects of Botox

Learn more about Botox with Dr. Sheila Li on her functional toxin course just for dentists to treat functional elements!

Want to level up occlusal appliance therapy and TMD management? Check out SplintCourse for a comprehensive online course.

If you enjoyed this episode, do check out TMD Full Exam with ‘The TMJ Doc’ Dr. Priya Mistry

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Being ‘Mum’ is the hardest (and most rewarding) job in the world. What are the unique challenges of Parenthood for Dentists? I’m thrilled to be sharing this non-clinical episode with you about work-life ‘balance’, especially if you’re thinking of starting a family one day (or just want to reminisce about real-world challenges facing young Dentists that are parents). Even if you’re not a parent, I think it will help you in your career and personal life. Dr. Hardeep Basi and I also discuss why Women in Dentistry sometimes do not get the recognition they deserve.

https://youtu.be/FRP3vUQQdQI Check out this full episode on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

Dr. Hardeep’s Journey 6:33
The ‘complaint’ that changed Dr. Hardeep’s perspective in life 13:01
Motherhood affecting career progression 19:34
Parenthood and Dentistry 28:14
Female (Mothers) Support Group (Lead Her) 33:57
Work-Life Quality 38:20
Worrying about the Future 52:51

Check out the Support Group LEAD HER that Dr. Hardeep established to support females especially mothers in having the work-life quality they deserved!

If you enjoyed this episode, you will also like Being Unstoppable with Ferhan Ahmed

Click below for full episode transcript: Opening Snippet: There are so so many challenges. I could spend an entire day talking about this and I made a list of about 25 unique challenges to particularly mothers in dentistry and things that I've experienced.

Jaz’s Introduction:

Hello, Protruserati. I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. This is an interference cast which is a non clinical interruption. For those who are listening, I don’t know if I sound different. For those who are watching, you’ll notice this crack on ceiling and my room looks very different. And where’s my background gone? Hi, I’m recording in my sister’s old bedroom in my parents place because Hardeep, our guest today who is a just a fantastic person. She’s a shining light in dentistry, she’s blossoming into this amazing voice for females in dentistry. And I brought her on to talk about parenthood in dentistry. It was so difficult to plan this date that it actually worked out that I’m recording not in my usual studio. So do excuse the acoustics and the video if it’s a bit different.

For those of you that know me parenthood is something that’s really important to me in my life. And I’m so happy to be sharing this episode with you guys. Even if you’re not a parent, and you never want to be a parent, I think there’s so much you can gain about our discussions at work life balance, like Hardeep maybe changed my thinking about it not being balance. It’s about work-life quality. So we discussed that towards the end. We talk about family planning and how especially for females and mothers to be, this could really change your career trajectory. And we kind of touched a little bit on why, perhaps, in dentistry, women in dentistry sometimes not get the spotlight they truly deserve especially when you look at the lecture circuit, there are many more male dentists on the lecture circuit despite there being more females in dentistry up and coming than males.

So motherhood may have something to do with that. The challenges, unique challenges like being mum is the most difficult job ever. I remember Lakshmi. Lakshmi kind of got the I know you’re listening to this. You’re one of the loyal Protruserati and you came to our live splint course day and we just talked about being mum and being a practice owner and how it poses such unique challenges. Now one thing I discussed in this episode with Hardeep is I have been like the broodiness guy ever, for the longest time, like it was a dream come true when I became a father. So this was an episode I was really looking forward to recording. And I think dentistry does pose some unique challenges. And some of the challenges that Hardeep talks about, like wow, her being three months into becoming a mother and having to go back to work to see a patient while her child who’s breastfed was being getting express milk upstairs by a nurse because this is the reality of women in dentistry. And I’ve seen that in the practice of our work where the dentists will come back from maternity leave to see, squeeze this private patient in for orthodontics. Like you know, if you’re in the middle of orthodontics, and you need to go on maternity leave, that becomes a little bit messy. So we tackle these really real world themes. And as a parent as a father in dentistry, with all the things I do clinical and non clinical. It’s a real challenge I do and I know Hardeep tries not to bring her work home with her. I feel as though me and probably you listening and watching to this and the Protruserati, you probably take your work home with you, you’re doing ClinCheck, you’re doing treatment plan that is, you’re doing courses, online courses, webinars, etc.

So it becomes really challenging to find that, probably I say work-life balance, but work-life quality, because that’s the main change in thinking that we explore in this episode. So I really hope you gain so much from this journey that me and Hardeep explore as well the unique challenges that parenthood poses to us as dentists. And so listen, and I’ll catch you in the outro.

Main Interview:

[Jaz]

Hardeep Basi, welcome to the Protrusive Dental Podcast. How are you?

[Hardeep]

I’m very well, thanks, Jaz. I’m excited. I’m excited to be here.

[Jaz]

I’m super excited. And, you know, I don’t know if you believe me or not, but I’m being deadly serious here. I have never been this pumped and exciting. I was telling my wife as well for an episode of Protrusive before even though I do so much clinical, this specific nonclinical episode, which is very close to my heart. I’m going to talk all about that today. Parenthood is such a beautiful, beautiful topic. And I remember sharing an Instagram story. Not too long ago. It was actually in March and then that’s just a testament to how a busy lady you are Hardeep, you’re so difficult to tie down. I’m so glad I finally got you on this Friday morning. I’m actually recording right now in my sister’s old bedroom in my parents place. You see a nice little crack in the Loft ceiling here. You see all this red and pink decor. It’s not me, it’s not my usual place. So I’m making an exception for you to make this happen because this is long overdue. Anyway, back to the story. I shared a story on Instagram, saying, Hey, I’m recording on Hardeep and someone message, who, whose name I now forget because it’s so long ago. And he said, wow Hardeep, I was in hospital placement when she did MaxFax something. Did you do MaxFax?

[Hardeep]

Yes, I did. That’s right.

[Jaz]

So he message me, he said ‘She was one of the sweetest people I ever met. She was very popular with the nurses. She wants to bring in food.’ I don’t know that you’re, Is that something you’re famous for?

[Hardeep]

Oh, yeah. Well, I used to bring in like sort of leftover dinner from the night before. I used to bring it on my mom’s curries and not feel guilty about eating them in the staff room? No, but I did share with others. Yes, yes.

[Jaz]

Amazing. Well, you had this reputation. And he said that he was really looking forward to this episode. So sorry, buddy. It was in March, and I’m not gonna go through my Instagram all the way to March. So thanks so much. And for that. And so you know, I’m really pumped for this. And just to give everyone a bit of context, Hardeep, I know, because her dad is the person whose practice I did my first ever work experience that when I was like 15, or 16. And then your brother and I were worried or at school, and I used to see him through dental school events as well. So and then I met Simran as well. So a real true family of dentistry. But for those who haven’t got the complete picture here, just tell us a little about yourself, Hardeep, what you do at the moment? And I always want to extrapolate the journey. Everyone’s journey, how has your journey been? You’re now in in Scotland, you’re a mother of one, tie into your personal life. But just tell us a bit about your professional journey.

[Hardeep]

Yeah, sure. First of all, thank you. Good morning to everyone and Jaz, what a gracious introduction. And I’m so, so delighted and honored to be invited onto your incredible podcast platform. You know, the fact that we’re here today, after arranging I think, somewhat three times is a huge achievement in itself. And so it’s all about getting the timing right. So Hartaaj started to nursery and I’m now able to fully focus on enjoying and having fun in this conversation with you. And yes, you know, you’re well connected to the, to our family, you know, I think for me, the journey has been, you know, people would think that I’ve come from a family of dentists, it’s been quite smooth and quite easy. And it’s quite the contrary, you know, obviously, I came into dentistry before I came into parenthood. So I’m coming into dentistry for me, it was a challenge in itself. And Jaz, you know, of my dad, he’s incredibly inspiring. He’s a humble gentleman, is a great educator, a mentor and a supportive

[Jaz]

Very much it’s very truly he is

[Hardeep]

Yes, so many colleagues in the profession. And I’m very, very lucky to have had parents who encouraged me to go down any path that I wanted to, and they would always insist that being a girl, I should never limit my dreams. And I’m always eternally grateful for that. And growing up, my dad devoted a significant amount of time to building the family dental practice, which was incidentally just down the road from our home. And I really enjoyed going to the dentist as a young girl and it wasn’t far for a start, you know, it’s swivel around on the chair in the surgery or at reception watching and listening and learning all the time. And, you know, built rapport and relationships with all the staff and the patients are like, and you know, on the odd occasion, I would sit the reception desk and cover it. And what really strike me though, while I was there was that I was inspired by how many female dentists are working in the practice, who had children as well. And taking all that into context with working alongside my dad and looking at what the dynamics of the practice were that he was building an inclusive practice of males and females, I set my sights on following in his footsteps and studying to be a dentist. And the journey to becoming a dentist in itself was challenging. And during my school years, I suffered a lot with bullying and harassment actually, and debilitating migraine attacks, which would incapacitate me for weeks. But this didn’t stop me, I kept focused on my education. And I achieved the grades that I needed to to get into dentistry. And I graduated in 2012, at the age of 24. And you know, being a young woman from humble beginnings in Hounslow to living independently that far from my family was really tough initially. But you know, I got my head down, and I graduated with distinction and finals. And I had a few academic prizes at graduation. And the reason I share that with you is because I worked so diligently and I was so focused on my career aspirations as a young, independent woman, that my desire to put that energy, effort and time and hard work was almost ingrained in my DNA. And don’t get me wrong. I did. I pursued hobbies at university. I was socializing with my peers and I was that girl who went out on a social night and I would still make that 9am lecture the following day. But yeah, in my mind,

[Jaz]

I can vouch for that from our meetings at BDSA.

[Hardeep]

And yeah, that stage in my life, I’d set my, I’d imagine this was my lifelong career, you know, clinical dentistry. And you know, university was a great place. You know, I when I met you at the conferences and things, you know, we made amazing friendships. And while I was at uni, I met Manreek, who was studying medicine at Edinburgh. And so, you know, university time was really the opportunity where, you know, I had a few part time jobs, I was studying really hard. And I was playing hard as well. So that’s when the juggling act sort of began. And then to explain a little bit more about my journey. When I left university, I entered the realm of clinical practice, I was still an energetic, ambitious, mature, although my siblings, my big two might disagree there. But my focus was channeled on attending courses, conferences, volunteering, networking, and just continuing to learn as much as I possibly could. And I’m glad I did that, then because looking back now as a mom, it’s quite different to be able to seek those opportunities and have those networking opportunities and be out and about. And after completing my VT year training in Edinburgh, I returned to London where I spent two years doing core trading posts at King’s College London and Queen Mary where I did oral surgery and maxfax in general duties. And, you know, I look back at that time in life. And I’m always grateful for the inspiring consultants, the peers from whom I learnt so so much from in those early years. And during those years, I sat my MFTs exams. And I was maintaining a long distance relationship with Manreek, but we made it work and then we married in 2015. And I settled into married life and I moved to Scotland. And, you know, obviously a new town, no friends,

[Jaz]

That’s why you’ve got this Scottish twang. Now I can definitely hear it. I mean, at record, you sound very different to the Hardeep I once knew.

[Hardeep]

You know, when I first started university, I was like, Girl from London with the Posh English accent. And then now I’m like, you know, so hybrid, there’s a wee bit of a twang. Yeah, you’re right. Jaz, there’s a wee bit of an accent comes through. But yeah, it was difficult, you know, because I was new town, no friends or finding a new job. And but you know, I had incredible support from my in laws, my family that I settled in with up here. And life was different, but it was so so pleasant Jaz. And I landed a job in general dental practice, which was fortunately, in comparison to my SHO jobs. The commute was only 15 minutes. And this was ideal, you know, for me. And yeah, clinical practice was going really, really well. And I was building my self esteem and confidence until one day I got a patient complaint. And I don’t know about you Jaz. Have you had a complaint?

[Jaz]

I mean, I’ve had my fair share of near misses, but hasn’t been so bad. So are you happy to share just a little bit of about how that affected you? What happened?

[Hardeep]

Yes, absolutely. I think it’s really important to be open and sort of transparent about these because, there is a stigma attached about talking about things that don’t go so well in clinical practice, you know, and I’m more than happy to share that, you know, the mental trauma of going through that tough time. You know, it took a real negative emotional, mental, physical impact on me. And it was actually a turning point in my clinical career where it made me question whether I really wanted to continue with clinical dentistry. And I know to some that might sound really irrational, but it was a thought that crossed my mind. And, you know,

[Jaz]

I don’t think so Hardeep, I don’t think so at all. I don’t think that’s irrational at all. Like even all the near misses I have, even like the restorative failures that I get that don’t lead to any complaints and the patient’s very understanding, right, and I bring the patient in and fix it even just the other day, I was a bit ambitious with the Zirconia Resin bonded bridge, and I wasn’t happy with the connector with but I still fit it. And then the pontic snapped off. And so, you know, that still has a potential to give me a sleepless night. And then I still, you know, despite how passionate I am, I still have those thoughts like, oh, man, I hate these failures. Is this really what I want to do? So everyone gets those thoughts, especially when they experienced failure, or I guess heightened even more so when you have something as stressful as a patient complaint. So I don’t think it’s irrational at all. I think it’s very much normal to have those thoughts.

[Hardeep]

Yeah. And Jaz the sort of difficult part of it was that I didn’t feel fully supported. Yes, we have our indemnity, but it was an experience that I know so many of us feel like we go through alone. And for me, fortunately, the complaint was resolved amicably. Right. And it wasn’t as significant but the fear of that litigation, the fact that it was going to allow it to destroy my drive and my determination and passion because of one negative interaction over all the positive patient interactions I’d had up until that point And so, you know, it was really, really tough. And then to compound on top of that I had a horrific car accident in June 2017. And without going into detail, I was so lucky that I survived because my car was written off. And, you know, I suppose up until this point, the experiences I had made me reflect on life, about, you know, up until this point, I’ve been so focused on a career, that what did I want out of life that I wanted to live fearlessly? And I wanted to live it fully in my potential, because you just never know how short it is. And, you know, Dentistry was my life. But you know, as a young married woman with that passion for the profession, but these are life events that were happening to me made me question whether it was really for me, and I was overcome with anxiety. But you know what, there was a reason for this all happening to me, and life was happening for me at this point, it was a realization, it was a time where I knew there was a deeper purpose in me, and I had a desire that I wanted to start a family. And, you know, my faith has always been a solid anchor, you know, my self belief. And I started reading around a lot of personal development, listening to podcasts, rebuilding my energy and my focus and surrounding myself with supportive positive people, so that I could really unleash that potential in me. And, you know, Jaz, things happen according to the divine timing. I really, truly believe that. And after my brother’s epic wedding festivities in India, we went to Amritsar and we went to the Golden Temple. And there I prayed so deeply for a child. And six weeks later, I found out I was pregnant. And it was just the most incredible moment in my life. And the sheer joy of becoming a mother filled my heart with so much excitement. You know, I thought, you know, getting into dentistry and

[Jaz]

Is that something that you always wanted to do? Were you always a broody? Because I can tell you now, like, I don’t know, or is a man allowed to be broody? Is that the right term for a man but I’ve always wanted to be a father. So for me, though, all those comments you said there about how it made you feel and stuff like when I saw those two lines on my wife’s test, like, I’ve got a photo of me, like, almost like just so emotional, and charged and happy and stuff. And it’s been the best thing that’s ever happened in my life. And I’m sure you can talk about that. But also talk about the challenges and how it affects our profession stuff. But yeah, I definitely share your sentiments.

[Hardeep]

Yeah, absolutely, Jaz, you know, like, I grew up in a big family, I had lots of surrounded by lots of cousins, you know. And so, having a family of my own one day was definitely an aspiration. But the timing of it, you know, it’s always something that culturally and socially conditioned, were thought to believe that things need to happen at a certain age, and you know, all that sort of stuff. But, you know, for me, I was at the age of 30. And it for me, it didn’t matter about the age, it mattered just about the stage of life that I was at, and I was ready to take on this new challenge. And, you know, I thought the journey of getting into dentistry, my career was challenging, I was in for a real treat, when it takes eight years to get into some sort of stability in the dental career. And it takes nine months to become a mother, you know, through that whole journey of pregnancy. But fast forwarding all of that, and when our baby boy arrived, it was

[Jaz]

Hardeep, I just gonna stop you there one more, because I just want to pick on two small aspects that was gonna so in case anyone in case you missed it, when you were listening, guys, one little thing, which you know, might be missing passing is that you said how you did so many courses early on. And then you did actually touch on the fact that actually now as a mother, you couldn’t imagine doing that. And I feel the same that I’m so glad I did so much of my education on the front end, so that now I choose quality over quantity, whereas before it was, like, get quality and lots of quantity to see what’s out there in the real world dentistry to expose myself. And as a parent, I definitely as now a learner, avid learner as an educator now as well, finding the time that’s why I do a lot of my stuff online because I can make more time for my son. So that’s a thing just worth mentioning to anyone listening that okay, if you’re a position where you’re not thinking about children, but you might like to have a family one day, then how is your career gonna kind of map out and then on a similar vein, my main question for you now is before taking the plunge into motherhood before family planning, did you and I don’t know if you’ve spoken to other mothers in dentistry, Were you nervous about how this might affect your career progression? Because one of the themes I want to, it was actually last question was asked you is we see so many people at the top of field who are male, we see so many lectures, I look at conference programs, male, male, male male, you see one female. And I feel as though a lot of the high positions in dentistry are occupied unfavorably or to bias towards male. And I feel as though perhaps this has all got something to do with it. So, how do you feel? How did you feel the time about this would affect your careers? That’s something that you thought about?

[Hardeep]

Yeah, I mean, absolutely, Jaz. You know, I think this advice would have been really helpful while I was at university, you know, to give people that advice at an earlier age, you know, things will happen when they happen for you And when you decide that you’d like to do things, but I think going on courses and pursuing your career aspirations, do that as early on as you can, while it’s all fresh in your knowledge, and you’re building on a good foundation from University. And I think coming out of university, I realized when I went into the real world of clinical dentistry, how much I didn’t know. And so yeah, I would absolutely advocate for doing things now, and not procrastinating on those choices. And family planning is really important as well, you know, I didn’t have those sort of conversations with people earlier on I just, for me, it was a turning point in my life where I had to go through such adversity and such challenge and then decide, actually, I was so tunnel vision focused on dentistry, but I lost sight of other things. And Hartaaj wasn’t actually, it wasn’t actually planned in that way. You know, as to right, I’m at this stage in my career, you know, now’s the right time, it was other things that made that gave me that realization. And I think for me, you know, it’s quite interesting because I was having this conversation with Manreek the other day, and he said, and I said, I think I’d been on more courses before I had Hartaaj. And he actually looked at me and said, No, I think it’s the other way around, I think you’ve been on more courses since you had him. And I thought, Well, maybe it’s to get a break from both of you then. And, you know, it’s different, there’s a lot of shifts that happen, Jaz, you know, when you become a mother, and I can talk from that perspective, you know, I have this wonderful life changing experience of becoming a mum to Hartaaj, who’s now three, even though I do introduce him as 3 going on 13. And it’s the greatest thing, but it’s also the hardest thing being a mum, because there is this, there’s this shift in your identity. And, you know, the amount of learning that happens when, you know, a child is born, but so too, is a mother or in your case, as well as a father. And so for me, the sort of key challenges that I had, when I came into motherhood. And also, you know, in keeping in line with my sort of career aspirations was that when I returned back to work, after nine months, so I took nine months of maternity leave, I was so anxious Jaz, I was stressed, I had this fear of letting go, this separation anxiety, when I would drop him to nursery, we would be bawling our eyes out, you know, that I’ve spent nine months with him, he’s been in my arms, he’s been spending a lot of time with me, there is that sort of emotional connection that you have and that attachment. And then to sort of hand him over to somebody else who effectively is a stranger, you know, you don’t know the nursery staff, you know, you know they’re there to take care of your child, but you don’t know them. They’re not like a family member. They’re not you. And I think for me, it was just all the emotions, I didn’t know what I was feeling, I didn’t know that this was normal, I and I became overwhelmed with the emotion of that sort of unhealthy attachment. So separation anxiety, is a very real emotional feeling. And for me to kind of come through that, you know, to grow through that, because, you know, it was there for a long time, you know, Hartaaj cried for every single day for 18 months before he turned a corner and actually had a smile on his face going into nursery. And, you know, for me, it was about managing, getting the help and support to help manage those feelings, that it was valid to feel that way. And it was an accepted part of being a mother or a parent, and leaving your child in the hands of someone else while you know you go to work. So, you know, it’s it’s very normal to feel that. And I think it’s really important to acknowledge it, to know that you’re not alone in feeling it and that you can get the help and support you need to manage that feeling. And so, that’s the beauty of it is that you go through that, to know that you become stronger. And then now you know it’s wonderful, dropping him off to nursery, going off to work, grabbing a coffee from the drive thru on the way and listening to a podcast, you know, just enjoying that time without feeling guilty. About that’s really what it means to me.

[Jaz]

You know what that reminds me of? I just thought, I have to it to mention this as a book called, you probably familiar with it. The Seven Habits of Highly Effective People by Stephen Covey. Very highly referenced, you’ve probably read it, I imagine,

[Hardeep]

Yes, I have read it.

[Jaz]

One of the first chapters talk about what it is that you channel your focus to. So we have many dentists who are very much focused on their careers, their everything in their life is about my identity is a dentist Now, if that gets taken away from them, then their life is over. That’s it. And then on the other end, you have people who are spouse centered, or children centered, so everything in their life revolves around their children. And then, you know, when they’re 18, or whatever, they felt the mess, and suddenly their life has no meaning anymore. And so what Stephen Covey argues is that we shouldn’t be centered around any of those things. We should be values centered, so I’m always having this discussion, my wife, I’m saying to Sim, Look, I know we love Ishaan, he’s the world to us. But you know, everything in our world shouldn’t revolve around just him. He’s very important part of our life, but it should be revolve around our values. And he is very much part of that. But he is not the sole thing. And there’s something that I think is worth mentioning, would you say?

[Hardeep]

Absolutely, Jaz couldn’t agree more. And I think, you know, the conversation about knowing what matters to you as a person first and foremost, you know, I think a lot of the time what happens is that, and coming into motherhood, before that, my responsibility was me and my career. And then he came along, and obviously, you’ve got your relationship as well. And it’s about your value system and quality of time in life, you know, how do you choose, as a family to spend time together to make that time that devoted, you know, no distraction time together, and also then be able to manage your work commitments and pursue your career aspirations? Because somebody like me, has realized that they are, you know, passionate about dentistry and specifically leadership in dentistry. And, you know, you’re absolutely right, it comes down to your why, you know, why are you doing these things? You know, what are the barriers,

[Jaz]

So it’s essentially to children, our children, anyone listening, who’s a parent or wanting to become a parent, we love our children. But I think the message here is, our children probably shouldn’t become our why because then you’re attaching your entire center of everything to an individual person. And you know, if you had an argument, that person when they’re a bit older, and that’s it, your whole world turned upside down. It should be very much centered around you and your values. That’s essentially the book says, Would you agree with that?

[Hardeep]

Absolutely. Yes, you come first, as selfish as that can sound to some people, it is absolutely necessary to set out why you’re, you know, absolutely Jaz, you know, what matters to you as a person? What do you value in your life? And of course, we value relationships, family, work. But you know, as part of all of that as well, Are you giving yourself enough time to look after you, wholeheartedly? Are you filling your cup with a lot of self care? And self care isn’t, you know, that sort of all around the sort of fluffy stuff. It’s really unraveling your thoughts, your processes, your, it’s messy, it’s hard work, you know, it’s understanding the barriers that are keeping you stuck from unleashing your full potential. So absolutely, first and foremost, you need to tap into, what it is that matters to you? What do you value in life?

[Jaz]

I’m gonna switch it up. I’m gonna just talk about very specifically in our niche in dentistry, what do you think are the unique challenges that we have? Very much the meat of this episode? Like, you know, fine, you know, a lawyer could be discussing with another lawyer about the unique challenges that lawyers have with being parents. So what do you think are the unique challenges that that dentists might have? As a role as a, you know, wearing the hat of a dentist, but also wearing the hat of a parent? Can you can you think of any I’ve got one to share with you, but anything that you’ve experienced as a mother especially?

[Hardeep]

Yeah, I think, Jaz, for me, I’ve kind of alluded on it, but coming back from maternity leave, back into dentistry as a mom with a new sort of, you know, role and responsibility. For me, it was the lack of support when I came back. And, you know, it was quite sad to just see that, you know, you’re just expected to throw yourself back into it, with no sort of additional support. And, you know, there were so many changes that happened, because, you know, I was full time before I had Hartaaj, and then I came back and I was part time, I had to obviously reconsider my working hours and my working patterns. You know, there are so so many challenges. I could spend an entire day talking about this. And I made a list of about 25 unique challenges to particularly mothers in dentistry and things that I’ve experienced. I remember

[Jaz]

Just go for it, real amount, just to spend a little bit of time just to go for it. Let’s hear it.

[Hardeep]

Yeah. You know, I remember Jaz. I had a few sort of ortho patients before I went on maternity leave, right. And I still remember, he was only three months old, and I had to go back into practice. These were private patients. I had to go back into practice while I was breastfeeding, and sort of look after these patients and that stress, you know, luckily, I had, you know, a really nice supportive team at work. You know, I remember one of the nurses holding, you know, Hartaaj upstairs in the staff room and giving him sort of express breast milk. And I’m downstairs in the clinic treating this, you know, this patient. And, yeah, that in itself was a huge challenge. Like, how did I do that? You know, taking him with me to practice.

[Jaz]

Oh, my goodness

[Hardeep]

All a lot going on. And I think it’s just so overlooked. And, you know, then you have the guilt, the feelings of guilt, you know, are you coming back to work too soon? Putting your child in nursery, what’s too early? What’s too late? You know, you’ve got to think about your working hours. Your, you know, especially in the evening, if you’ve got no childcare, how late can you work? You know, your career progression, you’ve taken a break from clinical dentistry, when you return and you’ve got this feelings of being good enough, but your clinical work, you’ve got, you know, the impostor syndrome in dentistry.

[Jaz]

I get those thoughts when I’ve been on like, a one week off holiday, and I come back, and I feel okay, oh, my goodness, I’m so rusty in my decision making in my precision, I can only imagine after a maternity leave, and whatnot. Absolutely.

[Hardeep]

It’s crazy. And, you know, a lot of people do sort of just dismiss it as when you go back, you’re just all come back to you. But it takes time Jaz, and you need people around you, you need to be able to speak to people and share these concerns and struggles with them, you know, you’re coming back to work, you’ve got broken sleep, and I’m sure you experienced that too as a father, you know, if you’re sharing that sort of responsibility, looking after your child, you’re coming back to work not fully alert. And you know, then you’ve got this sort of mad rush in the mornings dropping the children to nursery or school or what have you. And have you had breakfast, you know, have you eaten something? Have you fulfilled your basic needs? You know, it’s and then you’ve got the element of, you know, if your child is sick, you know, you’ve got to leave work, you know, what’s the contingency? What are the measures for this? that consideration

[Jaz]

I just want to talk about that. So my wife works in community, I’m in private practice, so she’s salaried, I’m not and therefore, if Ishaan’s sick, then it’s going to be her. And it’s always unfair. It’s always unfair on her and the trust that it has to be her. Because I’m the one who’s private and you know, why does it work like that? It just, it is just makes sense. Right? The person who’s salaried takes at least a day off, it’s just the way it works out. But you know, lots of women in private practice A) The whole maternity pay situation is something we may touch on, that’s very complex, but B) you know, if your child is sick, you know, there’s no replacement for Mum. Mum is mum. That’s why I think motherhood poses such unique challenges to tell, challenge in a good way that you know, it’s such a beautiful challenge that you embrace. But Mom is mom and motherhood is a, mother is the most difficult hat to wear as a dentist. And that just highlights some of the issues like what if your child is sick?

[Hardeep]

Yeah, you’re absolutely right. You know, they have this strong desire, you know, ‘when I’m sick, when I’m ill, I want Mum’, you know, that’s how I want to be around. And it’s that phase of, you know, that sort of attachment that happens and you can’t just, you know, working you’re busy NHS practice with all those sort of considerations, you know, rebooking patients and things like that, it’s tough going to get your head around. And you know, when you finish your nine to five job, you’ve then got your five to nine job, you know, your dinner, the dishes, the bedtime routines, all of that. So it’s really hard going and I think, that can’t be overlooked or underestimated by, you know, there needs to be more support for mums returning back to work. And I feel like that is one of the biggest challenges, you know, that sort of holding somebody’s hand and saying, Look, I’m here with you, I hear you, how can I help you. And that is something that I’m so passionate about, which is one of the reasons why I started which was back then the dental motherhood, and is now the ‘Lead Her’. And we’ll talk about that in a little bit but..

[Jaz]

I’ll just bring that into actually, because I’ve seen so much of your stuff on Instagram and how passionate you are about this. So just tell us because you are essentially fulfilling the role that you wish you had in those stages where you felt maybe isolated that you felt you need support, you want to be that support to amplify the voice of females in dentistry, which is a beautiful thing to aim for. And also motherhood being part of that as well. So tell us a little bit more about ‘Lead Her’ What beautiful name.

[Hardeep]

Yeah, thank you, Jaz. So yeah, originally it was the dental motherhood. And the reason for that starting under that umbrella term was because on the back of as you say, you know, my struggles, my anxiety, returning to work, first time mom, and also passionate about dentistry and my career aspirations in that field. So I set the group up to really provide an online community a space so I created that space which was never there. And to bring together a community where we can have connection, we can have collaboration, and we can really share quite transparently and quite often honestly and anonymously if you wish, your struggles and provide that support network, which I think is so important, just to know that you have a platform to share, and to get support is so pivotal. And I think, you know, once I did the dental motherhood, and it started to gain some traction, I then decided what, you know, why am I restricting this to just dentistry? You know, there’ll be, and this also came on the back of my clinical leadership fellow post that I did that, you know, I was with medical professionals, and mothers and pharmacy fellows who were mothers, and, you know, I decided, you know, let me broaden this out, let me expand it so that more women can come in. And you know, it’s not just for mums, it’s for any female out there in any field. You know, it’s about empowering, supporting, sharing knowledge and information, because I’ve been through those tough times. And if I can be there to support in any measure or capacity, then I will do that. And it’s growing. It’s a growing community. And it’s lovely, it’s a wonderful feeling. And we have so many exciting things going on in that group. Slow and steady, because obviously, I’m trying to find that, you know, time to be able to do it. But yeah, it’s brilliant. It’s really, really amazing.

[Jaz]

How, how do we connect? How do we connect with that? What’s the first step like, you know, you’ve inspired someone listening today and she would like to come on and connect with you and learn more about how to empower herself as a female in dentistry or beyond, because this podcast has got more more reach now, how is the best way for them to connect?

[Hardeep]

So it’s through Facebook, so it’s a Facebook group called Lead Her so it’s lead dot her, and you can join the Facebook group, and there are, the community is growing, there are ideas that I’m coming up with, as time goes on, you know, we’re going to be starting a book club, which is very exciting. And that will be a great way to learn and to get to know each other. And then I have organized retreats, which are luxury retreats for women to come away from their sort of comfort zone and experience new surroundings, with new people, and, you know, epic experiences and activities. And on those retreats, there is learning there are leadership masterclasses, where I impart some of the knowledge and wisdom that I have, and tools and strategies and techniques that have really helped me to grow into being confident, feeling empowered, and feeling happier in life in being a dentist and a mom. So, you know, it’s a great community, and I would love as many to come in and join because I think there’s real value in that

[Jaz]

And I love your social media, Hardeep, it’s such a positive voice in dentistry. And you’re such a wonderful leader in what you’re doing in the moment. And I wish you all the best success with this So ladies, if you’re listening in particular, it for lead her is resonating with you, I think you should with every every female listening to this, you should definitely reach out, check out what they’re all the ideas that Hardeep has, and it’s only gonna grow you as a person. So thanks so much for sharing that I just want to bring you on to highlight and put a spotlight on lead her which I again, I can’t get over how awesome the name is, I can’t believe you own that. That’s amazing. Tell us about your work life balance as it is now. In the stage of life, you know,Hartaaj is three, my son also, Ishaan’s gonna be three next week. So tell us about your struggles, your goals, who would work life balance? Is it elusive? Does it exist?

[Hardeep]

I love this. You know, I love this topic. And I could spend a good few days talking about this and I do share quite powerful information about this on the Lead her retreats. And you know what Jaz, the word ‘balance, right, recently, I had some conversations with some colleagues about this and friends in dentistry who coincidentally are mothers but also that aren’t. And we debated the word balance, because balance is sort of defined as a stable mental, emotional and psychological state. And what we were thinking was, you know, a better word, a better term to use is quality. Quality over balance, because balance implies that everything is in a controlled state and certain state and the equilibrium, but the reality is we live in uncertain times, and adversity and things are changing all the time. So the idea of achieving balance almost seems quite unrealistic. So what we feel is that and what I feel particularly as well is looking at the quality of personal and professional life, knowing that that quality will vary from day to day, it will be different in your health and your sickness and under different circumstances. But as long as you’re giving your best, and that will be different day to day. The quality can improve and as long as you’re focused on being better, and being kind to yourself along the way. You know, for me that that’s what it stands for. And, and you know, I’ll share my perspective terms and these are just my personal thoughts they will be different to you know, my parents and friends alike. But your quality of life, work life is different for each and every one of us. And for me, it comes down to again, what we already touched on is my why and my values, you know, why do I do things the way I do? What do I enjoy doing? What lights me up? What is my purpose here, and you know, becoming a first time mom, it was a tough ride, I had no one, give me a manual, give me some advice or anything like that, you know, my mom did impart some great wisdom with me. And having raised four children herself, you know, I saw how she did it. But it is a roller coaster of emotions. And, you know, with me having experienced burnout, overwhelm, anxiety, guilt imposter, I can relate to how many of my female colleagues, and especially working moms feel because I’ve been there. But I’ve come out the other end with now a solid toolkit that I can tap into whenever I need. And we need our quality of personal and professional life to be a daily practice like that self care has to be disciplined daily practice at home and at work. And I’ll focus, you know, for the benefit this podcast, I want to focus on the positive reflections, because I’ve grown massively, just in this last year, there’s been a huge amount of self awareness. And unraveling and unpacking all the messy thoughts and things that are going on and gaining a deeper understanding of standing of my values, my needs, my aspirations to live happily, in both my career and at home. And for me, it needs to be achievable. And it needs to be about taking the time to reflect on how you want to lead in your life, you know, taking control of the choices that you can make. And for me, it’s about optimizing your mental and physical health and well being every single day both at work and at home. And it does come down to how you use your time to really focus on how you spend it, because it’s the most valuable asset we have, it keeps going. And it’s the currency, we have to get what we want out of our one life, our one conscious life. So for me that a good quality work life balance is about being happy. It’s about being healthy, it’s about leading life on your terms. And, you know, even when things get tough, they do get tough, but you have tools to help you thrive not just survive. And so for me, it’s about prioritizing, it’s about my primary focus to make it to have that sort of good quality life is personal health. And there’s no substitute for health, you know, positive healthy habits that you can do at work and I don’t know if you’ve read the book, Atomic Habits by James Clear, but you know, your habits

[Jaz]

Audio book are my way through at the moment.

[Hardeep]

Yeah, it’s a fantastic book, right. And he, you know, he talks quite about it being that, you know, these habits that we have in our personal life and our professional life need to be obviously need to be attractive, they need to be easy, and they need to be satisfying. And so for me, I prioritize things like sleep, you know, it’s a necessity, you know, worry thrives on a tired mind. So, I do some meditate, I do some meditations before bed, I do some light gentle exercises, and you know, we try and distract, take away all the electronic devices, at least an hour before bed. For me also a good quality of life and hygiene,

[Jaz]

Sleep hygiene

[Hardeep]

Sleep hygiene, exactly. And doing that sort of daily physical exercise as well, you know, making time in at home and at work to do some daily physical exercise. So I have a personal health coach who educates me on good dietary habits, you know, taking supplements, I have vitamin D sitting on my desk, discussing nutritional needs, and he has actually given me a tailored need a lot. Where, you know, he’s given me really, really, you know, a bespoke fitness plan where 5 to 10 minute bursts of physical activity such as squats, squats, and lunges between patients is enough, you know, we don’t, as working mums, I don’t have an hour that I can spend in the gym. But I have 5-10 minutes between patients that I can do some squats and lunges or 5-10 minutes at home between, you know, while the kettles boiling or whatever I’m doing to do that regular sort of physical exercise. And, you know, I think he’s also you know, at lunchtime, I always go for a walk, whatever the weather, it’s so refreshing to get away from those four walls. And, you know, I can’t emphasize that enough and I’m trying to get people at work now to come and join me on these walks because often the default is let’s go into the staff room and you know, chat about cases or patients or you know, whatnot, but actually getting outside in fresh air is great for that quality of life. And also, you know, Jaz, having time for your relationships, you know, you can get so consumed with work or home and kind of lose track of your relationships. So I schedule, Manreek and I schedule some time to go for a breakfast date or a dinner date. And we’ll do that while Hartaaj is in nursery on a Tuesday morning. So having that sort of communication and enjoy

[Jaz]

Even in couples, who are friends of ours who don’t have children. And then I know that, for example, a couple of friends of mine, who were both doctors, no children, and they just tell me how difficult it is to see each other, like they both are busy GPs, and then have very active lives in terms of sports and stuff. And then they have to make time for each other is difficult. And it becomes even more difficult as a parent. So you have to do life design, you have to design your life, to actually put that in the diary as a recurring event, which as lame as it sounds like you’re so so sad that in, you know, in 2022, we have to diarize time with your other half, but you do in a way, otherwise, you just leave it to chance. And then other things take priority to have that dedicated space, where you’re going to give yourself to someone else for that time and their undivided attention and to nurture that relationship is so important.

[Hardeep]

Absolutely. And you know what they also, you know, for example, Hartaaj gets to spend quality time with his grandparents, you know, for an afternoon a week, and sometimes more. So it’s great while you’re, you need to consolidate and build on those relationships that you have, otherwise they do challenges do come in between that. And in terms of work commitments, you know, I keep my clinical commitments, I work three days a week, I’ve now dropped to two at the moment. And while I’m currently on this Leadership Fellow, which is half my working week, and you know, my full clinic days coincide with the days that Hartaaj has full time in nursery. So you have to sort of work around your personal circumstances and you know, Manreek’s working four days a week, and then he has a Tuesday off with Hartaaj. So he’s got his day with him and his commitment with him in the afternoon. So there’s lots of things that come into play. And obviously, for me, out of my working hours, I’ve dedicate time for leadership, coaching, developing lead her organizing retreats, I’m constantly reading books on self improvement and leadership. And you know, all of it is learning, you’re gonna make mistakes along the way. And sometimes I feel like, Oh, I haven’t spent enough time with, you know, Hartaaj or I haven’t spent enough time with Manreek, even though we did have a breakfast date, whatever it was, you know, or I missed out on family dinners, you know, things like that. It does happen. But it’s all learning at the end of the day, and it all comes down to your boundaries, you know, at work and at home. You know, I try not to bring work home, I consciously decide at work, there is no such thing as procrastination, if I do my notes, and I don’t try, I don’t try to have any sort of access at home to do any clinical notes. I don’t do it, we don’t I don’t do it. I do what I can, if I have to add another 5-10 minutes on to the day, I’ll do it. Of course, sometimes, realistically, some things do need to come home, like I’m doing some Invisalign planning case planning at home, or, you know, whatever it is, but I also learned to say no to things, you know, what am I saying Yes, to all the time that I should be saying no to, and realizing that I can’t do everything, and I can’t please everybody that I’ve got a level of autonomy, and I need to make decisions, you know, it might be at home deciding No, I’m not going to do the ironing today, because, you know, I want to play with Hartaaj for a couple of hours. Or no, I’m not gonna go tonight, we’re gonna get a takeaway, because, you know, I want to, you know, spend time doing some work, you know, it’s whatever really suits you. But it’s that ability to create those boundaries. And if you don’t, it can be quite disruptive to your day to day living. And I think, you know, it’s about being organized and having some structure, but also, you know, being quite spontaneous and picking out time to just, you know, have fun and go on a little adventure outside and just, you know, switch off and not everything needs to be so regimental and routined, you know, apart from obviously, when I’m organizing to go on courses and conferences, that also requires some, you know, structure, but it’s really important Jaz, I think, to get a good quality of life, both in a personal and professional sense. You need to have support. And I think that’s, we’re very grateful that we have family close by and friends that we ask for help. And there’s no, you know, I’m so so grateful for that. And there is no, you know, as cliche as it sounds, you do become the average of the people that you spend the most amount of time around. So it’s really about deciding what kind of life you will carefully selecting the people who will help you live that life, right, both in your personal and professional circles, and learning from each other. And I think also for me, what’s really important is that I spend time with positive people because energy’s really important to me and their personality characteristics rub off on me, you know, you start to grow together. And with Hartaaj as a mom, that quality time that I focused with him, I removed distractions, I silenced notifications, I sit with him. And I asked him what you’d like to do. And I think just giving that dedicated time to build that attention, connection and love, the present is more powerful than anything, you know, we sing songs together, we read, we draw, we color, we snuggle up and watch a movie, we’ll go outside and kick the football around, whatever it is. But, you know, as they say,

[Jaz]

I’m very much the same, it’s all about undivided, it’s quality, you know, in your quantity is great. And we can have it when you have a week off and you spend X time together. But when that, you know, when he’s gone to nursery, I’ve come to work come home, it’s about everything has to go, it’s all about Ishaan for that one hour and to really fulfill my role as a father and I get so much enjoyment and fulfillment and energy from that base about at that point, if I’m not replying on Instagram, whatnot, is because I’m busy and with Ishaan, and there is a place to that if I’m constantly multitasking, and I’m giving some of my time to Ishaan and some my time to Instagram or whatever, it’s just not going to work. So I definitely agree with that.

[Hardeep]

Absolutely. And I think also, well, you mentioned, you know, disconnecting from social media, because it can be, you know, really overwhelming, you know, all these sort of messages and replies and things that you’ve got. And people do generally post and I aren’t guilty of this, I post a lot of positive good stuff, right. And I do also share struggles and, you know, mistakes along the way, because it’s an important platform for learning. But I think it’s so important to be able to decide I’m going to switch off. And also if it’s not playing with him or doing things with him, I like to have time for me, I like to be alone, you know, and have some time to really ground myself go and do things that fulfill me whatever that might be. You know, whether it’s booking a massage, or going away on a retreat with some other incredible women, you know, I think we really, really need to give ourselves that, to have a good quality of life, which I think between personal life, your home life and work life, you are in control of that quality. And, you know, I try to live in the moment, in the present

[Jaz]

A huge learning point from this podcast for me Hardeep is I’m removing the word balance now it’s no longer work life balance. It’s work life quality, I really as lasting sentiment, that’s such a wonderful thing that you shared. And definitely, I agree so much with that. And yeah, balance, I agree, there’s no such thing as balance, it’s impossible to achieve, I think, I think you always one or the other, and then things just bounce out. But it’s all about quality, focus on quality. So that is something that resonated very much with me.

[Hardeep]

And Jaz also, you know, like, I think we just really need to a lot of us worry about tomorrow, five years, and worrying about tomorrow really robs you of the joy of today. So it’s about being present, you know, it’s okay to plan for the future. But to live there, you know, live in the present moment, enjoy the precious time that we have now. Make it a value. And I think that is so so important to really understand that and I think, you know, you really can have it as a female leader in our profession if you want it if that’s what you desire. And, you know, if you choose to believe I think dentistry is a great profession for women with families and without, you know, do pleats fall as I’m performing my course they do, but the show must go on and I keep showing up, I keep learning and I keep being inspired. And then it’s my duty as well to share it and support others along the way you know, each one teach one and you know when you make it to that point when you’re there at that point in your journey, it’s your duty to look back and help the person behind you and I firmly believe that and yeah, so we need to focus on

[Jaz]

I definitely think you’ve helped a lot of people who listened and watched today. I’ve gained so much I think this episode is an essential like listen or watch for anyone in dentistry, whether you have a family or not, but especially if you are female I think the things you covered with lead her and things you’re doing I want this to reach every single female dentists I want everyone who’s thinking about children the future of family planning to to listen to this episode, I think we’ve covered so much ground and I’ve had a really lovely time and I knew there was a reason I was looking forward to this and you have absolutely lived up and they exceeded that expectation. Hardeep, thank you so much for making time for this and finally made it happen. And I’m gonna get one to I’m gonna put the link to your Facebook group or just instructions how to find it, you know, down below on the show notes so everyone can find that. And yeah, I mean, I really appreciate you making time for this.

[Hardeep]

Thank you so much Jaz. It has been an absolute privilege and an honor and you know, I’ve got while I’m on this platform, I’d like to share a little bit about the retreat that’s coming up if anyone is interested in coming and joining us. So the Lead Her retreat is in September on the date of the 23rd to the 25th of September. So it’s a Friday to a Sunday. And it’s really there for you to have quality time and space out for you away from your family in a stunning luxury resort in Scotland. And it’s a really unique opportunity to enjoy epic experiences, and connect with other amazing, amazing, wonderful women. And it will allow you to relax and recharge and learn really, really powerful leadership skills that you can employ into your personal and professional life. And if you’re interested, get in touch with me through the lead her Facebook group. Alternatively, in Jaz can share some contact information about me, I’d be happy for you to reach out by email or text. So yeah, it’s an experience.

[Jaz]

I’m really upset, Hardeep

[Hardeep]

You want to come, Jaz?

[Jaz]

Really? Well, no, it well, I you know, I just checked the dates. And we’re away in Turkey that week. And I really wanted Sim to go, I really wanted to Sim to because you know what, she used to work so hard. And I love everything you’re doing, I want her to be part of what you’re doing. And she recently she wants to talk about on social media. But she got, she finished her first year as a master’s in peds at Eastman she got a distinction. And she’s done really well. And I want her to mix with the positive minded females like you because sometimes he lacks that self confidence. And I think some you’re capable of doing wonderful things, and you are the injection of positivity she needs. And so September, she can’t make it. But the next retreat, I’m all well, I’m going to make sure I pack send her post first class to you to change her life.

[Hardeep]

Amazing Jaz or listen, you know, there’ll be plenty of these opportunities. But yes, no, you know, I would love love, love to spend time with Sim, she’s a fantastic woman. And absolutely, it’s about inspiring, empowering each other and lifting each other up. Because there is greatness within each and every one of us. And we just need to recognize our potential and be around that support network that drives you to be the best you can. So thank you so so much for giving me access to your incredible platform. And Jaz you inspire me every single day, every single day.

[Jaz]

Thank you. The feeling is very much mutual, Hardeep. Thanks so much. And I’m indebted to your family, your father, your brother, all these people in my life growing up in my journey of dentistry, you are important parts of it. And so so thanks for and I just want to say, Waheguru Ji Ka Khalsa, Waheguru Ji Ki Fateh. Thanks so much, Hardeeep for coming on once again.

[Hardeep]

My pleasure. Thank you.

Jaz’s Outro:

Well, there we have it guys, thank you so much for listening all the way to the end. Do reach out to Harddep on her platforms. In the show notes on protrusive.co.uk, I’ll put all the links, the brochure for her retreat and how to connect with Hardeep. If you enjoy this episode, would you consider leaving a review on your platform wherever you’re listening, whether it’s Spotify, Apple, whether on YouTube, comment below if that’s the case, a review would go a long way in making me see who’s listening who’s watching out there. As always, I really appreciate you being a true fan and listening all the way to the end. Thank you so much.

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Let’s demystify what is often considered an ‘advanced’ Restorative technique: Shell crowns. My guest Dr. Basil Mizrahi is known for Comprehensive Dentistry and teaches Dentists the art of perfect provisionals- we go from A to Z of Shell Crown, how to reline them and cover all the nitty gritty details of this useful technique.

https://youtu.be/6-a3XGBKZWM Check out this full episode on YouTubeProtrusive Dental Pearl: Preventing Bisacryl Temporary Crowns from cracking: Hollow out the inside of the temporary crown (just enough space for the cement) and therefore create the space for the temporary cement to flow and exit, preventing cracking of the temporary crown. Check out @Dental.Story IG page

“You should become familiar with acrylic before shell crowns” Dr. Basil Mizrahi

Highlights of this episode:

Preventing Bisacryl Temporary Crowns from cracking 5:35
Temporary Crowns 12:08
What is a Shell Crown? 13:59
Technician role in creating Shell Crowns 15:22
Acrylic Shells vs Bis-acryl Temporaries 20:07
‘Relining’ an Acrylic Temporary Shell 21:20
Using Bisacryl instead of Acrylic inside a Shell 24:14
Relining Acrylic Shell with Fresh Acrylic 25:00
Use of Vaseline? 35:41
‘Fit Checker’ for shell crowns 38:26
Anterior vs Posterior relining 39:23
Shell Crowns vs Lab Made Acrylic Crowns 40:19
Shade decisions in relining the shells 42:47
How to Remove shell crowns 44:08
Polishing after relining 45:59
Multiple Shells at increased OVD 46:49

Head over to protrusive.link for the one-page summary of this episode and for the other summarized infographics of the past episodes

To learn more about it, check out Dr. Basil’s Courses and other wonderful stuff on his website!

If you enjoyed this episode, be sure to check out the Adhesive Full Mouth Rehabs in 11 Appointments (Part 1)

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Listen to that voice inside your head! We all get those clues and a bad feeling in your gut when you see a red flag patient. The challenge is being receptive to this feeling and acting upon it tactfully. I share 2 examples of encounters where I either ignored the alarm bells, and 1 scenario recently where I avoided a disaster.

https://youtu.be/UBvJxhgzQp0 Check out this full episode on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Highlights of this episode:

1:34 ‘Alarm Bells Scenarios’
2:20 Case No. 1 (Extraction on a 78-year-old patient)
7:47 Case No.2 (Heat Burn on Patient’s inner cheek/lip)
9:20 Warning Signs

If you loved this episode, you will like 12 Rules for Dentistry

Click below for full episode transcript: Opening Snippet: Hello, Protruserati. I'm Jaz Gulati and welcome to one of my ramblings, okay? We're gonna do this as an interference cast. And I'm gonna teach you a few lessons that I've learned before, I guess I've learned them in very traumatic ways.

Jaz’s Introduction:

You know, when you make mistake and think, Wow, I never want to make this mistake ever again. And then you want to share it with everyone so that it helps others too. So the theme of today’s rambling is the following. It’s about listening to that voice that we all have inside of us, during a consultation or during a patient interaction, you know, that deafening sound of alarm bells you sometimes get. And yet, for some stupid reason, you might decide to ignore it. Well, today, guys, I’m happy to report that I didn’t fall for it. I heard those bells, loud and clear. And I acted appropriately, and I dodged a bullet. Okay, let me give you the exact example. And in fact, I am going to liken this example to a really significant thing, which I picked up from a book, like one of my favorite books is Outliers by the author Malcolm Gladwell, if you haven’t read Outliers yet, please check it out. It is my all time favorite book. And I think it’s in chapter seven, where it discusses why aeroplanes fall. It’s a random divergence, I know, but hear me out. Aeroplanes fall not because, you know, the engine has an error. And that’s it. And that’s why airplanes fall and that could happen. That’s rare. Airplanes actually fall, when they do fall, when there’s an issue, a big problems do happen in aviation when lots of little things, lots of minor things that all happen at once. And they usually surrounding communication, and teamwork so it’s accumulation of all those minor errors that would result in it. So for example, the pilot was hung over, right? That’s one thing, right? And then the pilot was working with a co-pilot, and they’ve never worked together before, okay? And the guy who was supposed to do the final checks on the aircraft vehicle, had COVID or something, and he couldn’t come into work that day. And therefore, all of those little things combined and bad weather that day, is the reason that the airplane fell not because of one big error, it’s accumulation of little errors.

Main Episode:

[Jaz]

So what lessons can we learn in dentistry? Well, think of those little errors lining up in your patient in front of you. So let me give an example. I saw a 78 year old patient today who was referred to me for some surgical extractions, okay? Age doesn’t bother me too much. Yes, we know sometimes it can be more difficult to extract and we need to take care, but it’s a medical history that really bothered me. So let me tell you the accumulation of minor errors. So error number one, there was no up to date medical history, it was last filled-in in 2019, okay? So I was like, oh, god dammit, why is this patient referred to me without a medical history? Error number two, he comes in and I get an update of medical history from him. And he conveniently has forgotten his sort of long list of medications and he’s going by memory, okay, that’s another little alarm bell that I’m hearing in my head. Error number three is that he was taking Apixaban, which is an anticoagulant, so it’s a blood thinner. So that is, you know, for someone who’s doing surgical extractions of upper canines, and I’ll show you the X ray of these upper canines, long roots, but really mushy crowns, subgingival dentistry, I was planning, you know, based on a radiograph I was planning already to raise a flap and remove some bone because I was anticipating a difficult extraction. So he’s on Apixaban. And error number four is that he wasn’t instructed to miss his morning dose. So the usual way I would manage someone who’s on Apixaban, is that what we would instruct them if it’s safe to do so to skip their morning dose and see them first thing in the morning, so he had his morning dose already so that was increasing his bleeding risk. Error number five, or complication number five is that this guy had a stent placed three months ago following a suspected heart attack, right. So that is also a real big concern, doing invasive treatment, and someone who only just three months ago, had a heart attack. Okay. Error number five or six, I’ve lost count now. The next one is that he had, believe it or not, his toes amputated around about nine months ago and he had a major bleeding complication. So why did he have his toes amputated? It’s because he’s severely diabetic. And that’s a negative cinquante of that. So that was also ringing alarm bells that this person already had some surgery before and that didn’t go so well. There were some complications with bleeding. And the final issue I had was that he was on lots of antihypertensive medicine. So his medical health, it was poor health combined with all other factors and I did not feel comfortable treating him today. And he wasn’t even in pain. It was just teeth that need to come out their , but he wasn’t in pain today. So I made the judgment call to refer to a hospital and explain to him all the things that were all the reasons and he took it really well. He he noticed that okay, this guy really cares for me, I didn’t want to do anything risky. So sometimes I’ve in the past, not weird, like extractions or whatever, sometimes are difficult extractions but taking on patients or cases or treatment plans that had all the signs there, when you look back, you can see that, hey, why did I ignore all those signs of the small errors? Why did I take this patient on when all the alarm bells were there? And sometimes you don’t listen to that voice. So it’s important to listen to that voice. And it’s a totally an acceptable thing to do to say to the patient that look, I don’t think we should proceed with this and justify why and stick to your guns, okay?

[Jaz]

Now I’m going to admit to you another mistake that I had made around about a year ago, and I’m embarrassed about it, but I want to share it with you because it was a clear example of the many small accumulations of errors that resulted in my patient’s inner cheek getting burned, and a massive, painful ulcer or a significant burn that took a long time to heal. Well, I say a long time was it was a week of me feeling really bad for the patient and the patients send me photos and it’s not nice. No, I’m really sad. And sorry that happened. In fact, she very kindly let me share the photo. So those who are watching, can see the photo now up there. That’s her cheek about two days later, in a lot of pain. That’s a nasty ulcer there. And I asked her I said can I please share this story with my colleagues so we can learn something here. So let me tell you what happened and how I burnt this patient’s inner cheek. I was doing some routine composites in the lower quadrant I think it was like lower right second premolar DO composite, right? And I’m a big fan of using rubberdam especially for lowers, the tongues in the way, anything that’s, you know, deep caries subgingival etc. I’m all rubberdam, right? But the problem that we had this day is that my usual blue, non-latex rubberdam wasn’t there. We had that horrible green rubberdam and I really don’t like working that green rubberdam. I think I was just being a little bit of a diva. Okay, so my hands up in the air. My bad that was not a reason to not use rubberdam I guess. But for me, on that day in the mood that I woke up in. I was like, No, I’m not going to use this rubberdam. This is disgusting. I don’t have my usual rubberdam. So yeah, I didn’t use rubberdam and 99% of time I do. So A) I wasn’t using rubber dam and then B) it was like stressful for me. So as someone who’s regularly using rubberdam, rubberdam reduces my stress, but now that I had no rubberdam, my stress was greatly increased. 2. It was subgingival. It was difficult dentistry. Okay, so that was stressful. Okay, 3. and this is something I really should have picked up on. The handpiece was making a funny sound. I didn’t think much of it was like, Oh, this sounds a little bit higher pitch. This doesn’t sound right. But I ignored that. And then I can’t believe I look back at now, I just felt as though the handpiece was warmer than usual, okay? Now the patient was anesthesized. And the patient didn’t feel any of this. But as I was doing her prep, the handpiece was actually burning her cheek. And then I realized that Woah, my gloves getting really hot here. Let me see what’s going on. And then once I finished my restoration at the end, I had a look at the cheek and I could see that it was a bit traumatized. And I realized what happened.

[Jaz]

So all those little error I didn’t pay attention to you know, A) I didn’t use rubber dam. So that’s a small, you know, a small error. I anesthesized the patient so the patient can give me feedback, obviously. So that’s another alignment that not an error, but another reason why it happened. I didn’t pick it up. It was difficult dentistry. The handpiece was making a funny sound, and I did feel a bit warm and I didn’t stop to think why is this handpiece warm. So naturally I felt devastated. So how did I settle this? Well, when I found out what happened? I made sure that I got I went on Amazon and I’ve got delivered a gift to a house So it wasn’t like flowers or anything. It was some Gengigel, right? So something that contains, I believe it contains hyaluronic acid. I might be wrong here but I know that Gengigel was good for soft tissue lesions. So I got some delivered as a gift to her house. I was following up daily, I recommended some benzydamine hydrochloride or aka Difflam mouthwash and all those things and she got better, and actually ended up refunding of her money as well. I just felt so bad that I refunded her money of that restoration appointment because I felt like I let her down, right? I wasn’t acting in my best interest. And so I think she was quite pleased about that. And she thought I handled it really well as well. So that’s my admission to you that I burnt my patient’s cheek, and I’m not gonna let it happen again.

[Jaz]

But it’s a time that I ignored the warning signs. But that first patient I told you about that as for today, I didn’t ignore all the warning signs. Another classic warning signs to find out things I sign off is another classic warning sign is that the patient has seen another dentist and the other dentist for whatever reason has declined to treat the patient for whatever reason. That is a massive red flag. So I remember seeing a patient who saw a dentist I don’t know which dentists but she, the patient told me that, that dentist won’t treat me without orthodontics. That dentist thinks that I can only get a good result with orthodontics. And me being me a young dentist at the time, I’m still a young dentist, but like one or two years qualified, I was thinking well, you know, I’ve been to few composite courses, I think we can do it composite. And I look back and I think you know what, I do regret not sticking to what I should have done, which was yes, I should have agreed and recommended orthodontics because the result in the end wasn’t quite as wow and I do feel it could have been better with orthodontics. So anytime a patient says that I saw dentists X and the dentist X strongly believes that I should be treated this way. And you might disagree to that Dentist and that’s okay. But take that as an alarm bell. Take that as one of the alarm bells. And if you start to see all these alarm bells, sort of accumulate all these small errors if you’d like accumulate, then that could be why the aeroplane could fall.

Jaz’s Outro:

So I hope that was useful. And it’s a reminder for you in that consultation or at that moment in time that when you get that funny feeling in your stomach, don’t ignore it, act on it. There’s no shame and picking things up before they happen, before they go wrong in the best interest of your patient, and so that you have a smoother ride throughout treatment. Hope you enjoy that little quirky, little short episode. If you enjoyed it, please do leave a review on Spotify or Apple or YouTube or wherever you watch it. It means a lot to me. Thanks so much.

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In this episode with Dr. Carlos Sanchez, we’re going to take a look at the concept of additive equilibration as a way of managing tooth wear. In other words, it’s an occlusion-based technique that involves adding composite or ceramic to achieve the ideal restorative results and we’re going to try to help you understand what that is. There are also some themes that are discussed in the same way as the Dahl technique.

https://youtu.be/TZ5FKkiscco Check out this full episode on YouTubeNeed to Read it? Check out the Full Episode Transcript below!

Protrusive dental Pearl: Keeping PTFE tape secure – a straightforward trick I found to keep the PTFE so it doesn’t get sucked away is to floss the PTFE through more distal contacts. It gives the PTFE some security and resistance to being sucked away. So it’s not going to make that horrible sound and you get to keep that PTFE in the stable place!

If you want to improve your skills and your understanding of occlusion, I’ve set up a free monthly resource for you starting this August! Just head to www.occlusion.wtf to sign up for monthly occlusion goodness.

Highlights of this episode:

2:40 Protrusive Dental Pearl – Keeping PTFE tape secure
9: 43 Fundamentals of Additive Equilibration
37:28 Journey of Additive Equilibration
44:22 Additive Equilibration workflow in generalized wear cases
1:00:37 Restoring lateral and central incisors for aesthetic reasons (after canines)
1:06:36 Anterior coupling in class two increased overjet cases

Check out CaSi 3C Instrument and all the other instruments that Dr. Carlos has made. Distributed by CosmeDent and Enlighten Smiles in the UK

Another instrument you need to check out on Dr. Carlos’ website is this Vacu-Grip. This little plastic insert that fits in your suction would hold your crown like an extra gravity.

Check this Easy Peasy technique that Dr. Jaz mentioned: The ESIPC Jig

ESIPC-JigDownloadIf you liked this episode, you will also enjoy Basics of Occlusion

Click below for full episode transcript: Opening Snippet: Hello, Protruserati, I'm Jaz Gulati and welcome back to your favorite place to grow as a dentist. In this episode, we're discussing additive equilibrations for managing tooth wear.

Jaz’s Introduction

So this is an occlusion-based one. Dental students and young dentists, it’s a lot of things that we discussed that might stretch your mind a little bit. So if you’re new to the world of occlusion, you might have to listen to it a couple of times, you have to hit the books, you have to speak some mentors. It’s okay to listen to something that might be a little bit beyond your depth at this stage. Certainly, when I was doing inclusion, I had a lot of that. And I slowly, slowly, slowly, you know, gained more knowledge, spoke to more mentors gain new perspectives. So just because we cover some themes that you might not understand in this episode, doesn’t mean you shouldn’t give it your best shot. Now on that note, if you are looking for some basic, but powerful, impactful, actionable, and practical occlusion tips, then I’ve set up a free monthly resource right to your inbox. Starting from August, it’s worthwhile just joining now, if you head to www.occlusion.wtf, that’s right. It’s www.occlusion.wtf. Listen, I’m on a mission to demystify occlusion. So with this very practical gem that I’ll send you every month, I’m hoping to go a long way to help our peers. So do check it out, sign up, and I look forward to sending you some occlusion goodness.

In this episode with Dr. Carlos Sanchez, from North Carolina USA, we discuss treating the worn dentition with something called the additive equilibration technique. So people think a equilibration is usually when you get to a bur and start drilling teeth away. Well, this is additive equilibration, we are creating the “ideal occlusion” or “ideal occluding” scheme by adding for example composite or ceramic or whatever it might be to get to our ideal restorative results. So it’s not so much for equilibration. As you may know it before it’s additive. It’s restorative. There are some themes discussed, similar to the dahl technique, which is quite refreshing because in the USA, it’s not used as much so it’s nice to hear it in American dentist, Dr. Carlos Sanchez talking about the dahl technique and the way he did so I know you’ll enjoy this perspective. If you listen to the last few episodes with Dr. Javier Quirós. You know how much I love the CaSi instrument, well, actually Dr. Sanchez invented this instrument. So it’s something that’s distributed by Cosmedent or Enlighten Smiles in the UK, and I’ve raved on about it already. I’m not gonna go again. But I want you to check out all the other instruments that Carlos has made. They’re really amazing. I’m gonna show them off in the clinic. The other thing I found on Dr. Carlos Sanchez’ website is the Vacu-Grip. This is like $10 for five of these little things. And let me tell you why I fell in love with it, because I’ve got one now. So you know when you’re washing your ceramic, so you’ve etched your ceramic, maybe with a hydrofluoric acid for 20 seconds, like your Emaxs, for example. And then what I usually do what I hold the crown in tweezers or my glove, and I’d wash it, and make sure that I wash it over the sink, and that the sink has got some wet tissue paper inside. And the problem with that is it’s over the sink and it’s away from where I was initially, and it to get a little bit messy. So what the Vacu-Grip is, is a little insert, little plastic insert that’s got foam inside, that fits nicely into your suction. So I try this by putting the crown into the Vacu-Grip which goes in your suction, it’s like a little tiny black bit of plastic piece. And now I’m holding the Vacu-Grip that entire unit upside down and my crown is not falling. So it’s like extra gravity, it’s sucking the crown so that it’s not going to fall out. So I can even turn it all upside down and the Crown will not fall. So you can imagine that when you’re washing your ceramic. Now you can do it into the Vacu-Grip and the Crown’s not going to go anywhere. And it’s a nice and safe way to do it. So check out the Vacu-Grip and all the other products that Carlos Sanchez has on his website, that’s aesthecon.com. Again, I’ll put the show notes on the website protrusive.co.uk, and on the YouTube watching there. So you can see all the awesome instruments including the CaSi and a Vacu-Grip and all the other lovely brushes that he has on his website. There’s some really brilliant instruments that Carlos has invented. So he’s a true innovator when it comes to instruments in dentistry. And I hope to share some of those with you.

Today’s Protrusive Dental Pearl is how to use PTFE. So for example, we use PTFE in so many different scenarios, and one of the most annoying scenarios is when you are preventing the etch and the bond from contacting the teeth that you don’t want it to touch. So it’s a great way if you’re doing onlays, bonding onlays or resin bonded bridges or veneers or whatever, you know, I like to floss some PTFE into contact so now that he won’t hit that tooth, but the issue that we have in this scenario is that unless you are with your finger and thumb holding on to the PTFE it gets hoovered into the suction. It makes it horrible noise which is not very pleasant for your patient and gets very messy and it’s not so nice. It might even pull off your PTFE or just make that horrible unbearable sound which I absolutely hate. So there are a few ways I’ve seen some dentists manage it. They often get some liquiddam or, some flowable composite, and they sort of tack cure the composite onto the adjacent teeth to keep the PTFE there so it doesn’t get sucked away. But what I found really easy trick that many of you probably already do is once you’ve placed your PTFE, and then you manipulate it onto the more distal teeth, either will then floss that PTFE through a more distal contact. If you’re watching the video here, great, you get the idea. If you’re listening, just imagine you’ve put some PTFE through some contacts, and now you’re extending it. So let’s say you put it between the premolars, lower left first and lower left second premolar, you put it there, and now you can extend it on to the first molar, maybe even to the second molar, so that it’s long enough to cover all those teeth. And then you’re gonna floss it between the first molar and the second molar. Now that you floss that PTFE in that area, it’s no longer gonna get sucked into your suction. And it’s not gonna make that horrible noise. And it gives your PTFE some security and some resistance to being sucked away. So it’s not going to make that horrible sound. And you get to keep that PTFE in the stable place. So whether you keep the PTFE there the whole time, or you remove it after your etching and bonding, it’s up to you, obviously, how you want to do it, but it’s a great way to keep that PTFE stable. So hope you liked that little pearl. And let’s join Dr. Carlos Sanchez to talk about all things, occlusion and additive equilibration technique

Main Interview

Dr. Carlos Sanchez from North Carolina, USA. Welcome to the Protrusive Dental Podcast. How are you?

[Carlos]

I’m doing great, Jaz, what a pleasure, man. It’s a pleasure to be here with the Protrusive Dental Podcast. So it’s a joy.

[Jaz]

Well, it’s great to have you and it was amazing again to find out that you’re also someone who listens to the podcast. And you’re and as we had a zoom session a few weeks ago now just to catch up and learn about each other’s interests and stuff. I mean, your occlusion background really interests me, your sort of reflective practice that you’ve been doing in North Carolina, I think you said you’ve been in the same practice for many years. Is that right?

[Carlos]

27 years

[Jaz]

Well tell us about yourself. Tell us about your practice. And tell us about your journey within dentistry and occlusion?

[Carlos]

Absolutely, I’m going to disclose my age, been practicing for 30 years. I’m a general dentists and but I’m a geek. I love all facets. I’m not into the academics, but I definitely like to get in there. And you know, as I do my stuff, I’ll make sure that it is a science base. But I was in the military for about three years. That’s where I got my experience in everything. My wife is a dentist. But long story short, we were able to settle him Kannapolis, North Carolina, love the environment, and from there, I journey into different intrapreneurship with practices and so forth. And interesting just leading to the occlusion. You know, you get out of school. I was very fortunate that I went to University of Iowa, shout out to Iowa. But I feel comfortable with giving me a pretty good foundation. Not perfect. Not perfect, but a good foundation. So I thought when I got out there, it’s like, Okay, I’m gonna get out there. I’m gonna rock and roll do this and that, three, four years into it. Guess what? I got burned, man. I got burned. I learned my lesson. There was a particular case, did some Crown Lengthening on top and bottom. Nothing that posterior. The gentleman left, long story short, it was a journey. A good year with the insurance. I didn’t get sued or anything like that. But I learned and I learned and I said to myself, You know what, I don’t want to catch myself in this position again. And so that propelled me, that’s how I started in this journey as far as occlusion.

[Jaz]

And what happened in that case that made you think that okay, I need to go back and and do further learning in occlusion. What was it? Was it a failure? It was a premature failure. What was it?

[Carlos]

Two things actually, lack of my communication with the patient. That was another words, I just assumed. And I didn’t explain myself well enough. And I’m just being candid with you. That was so

[Jaz]

It’s very humble of you.

[Carlos]

No, I mean, that was one. Second was that I think that was the big picture. The second one was standing in touch with him because he moved, so basically what it was, worn dentition, top and bottom, missing from, I know the nomenclature is different from the US and in Europe and everything but from the canine bags, he was missing those very short, efficient, like so and so naturally back then you do crown lengthening, build him up and so forth. I didn’t pay attention to my, this angle right here. That needs a coupling and the disclusive angle. Looking back, I made it too steep like this. So I didn’t pass

[Jaz]

Too steep of a envelope constriction

[Carlos]

Yeah, the envelope of function, there was violated the envelope of function or constricted rather than open it, I constricted. Absolutely. And so he moved to the beach. And that’s where I got the letters saying that, you know, this whole case needs to be redone and so forth. But long story short, there were some good colleagues. That’s why you know, as colleagues, we have to be attentive, you know, Help each other out. And there were two gentlemen over there that evaluated the case says Carlos, you haven’t done anything wrong, everything. The only thing was, you know, the posterior we needed to build them up and so forth. And my thing was that since he left, there was no way I could do it. I even propose to the gentleman, well, come over, whatever you need to do. I’ll do it. So long story short, that was the big aha. It’s like, okay, I got to make sure that I side move in progressing my evolution in my field, that I don’t do this. You know, you don’t want to make the mistake again. Make it more predictable. And so I started my journey with Pankey. I remember Pankey for the whole week. I again finished the whole Pankey because it was such a long process. Did the Peter Dawson, listen to Spears, let’s see who else and then I was very blessed to meet that to be on my chorus. He’s a gnarthologist, this is how you know what I call them as they’re the ones that foundation for prosthodontics and so forth. You know, those are the guys that say you had B.B McCollum, you had Stuart and Skyler. They started the whole, this whole journey of occlusion.

[Jaz]

You mentioned some real big hitters that in the field of occlusion and dentistry in general, a question that I get a lot is how do you pick, now I really admire like many of my guests who I’ve had on, what I admire is that they haven’t just listened to one’s growth or and then ran with it, which is fine as well. There’s nothing wrong with that. But a lot of the guests I’ve had on very privileged, okay, the done Kois, but they also did Pankey. And then they listened to Dawson, and they respect Spear and they listen to everyone, you know, and they develop their protocol that works in their practice. How does a young dentist choose which path they will go for first, and you think it matters so much exactly, you know, between Spear and Kois, who they ended up going for first?

[Carlos]

No, you know what I think and this was the hard part, I think in dental schools is understanding the basics. You know, the anatomy and the physiology. That’s the most important part. Because if you look at, you know, there’s different, you have the CR camp, you have the all vi, neuro-musculature, you have those. And we can all agree that you know, you want simultaneous contacts, guidance that’s both, but where they vary is where you start, which is joint position. And among those is those positions, how to get there. And to me, doesn’t matter how you get there, just get there. You know, once you get there, get there, you know, if you want to use a Kois deprogram or use it, get your leaf gauge, get use a cotton roll, just get there, make a diagnosis and move forward, right? And then how do you put stuff together? Well, you know you got to respect that, a Kois is mentor, was that to be on my course. We had a long talk and everything. He was from the Air Force. One is an incredible clinician, but, you know, he has a certain way of where he likes to start on the Posterior. There’s nothing wrong with starting the posteriors. I like to start in the anterior because I think the actual, I do more, get more from the, as far as the aesthetics, phonetics, I test the joint, if I started the front. But started the joint. once you get your diagnosis, then it’s just a matter of what you have in your toolbox to implement the final result. And always start from the end and look back. You know, look at my nice picture and look back, don’t get intimidated.

[Jaz]

You’re very much Carlos, you’re very much echoing the same thing that you know, we did a two part episode with Dr. Bill Supple. He’s the president of the AES. Have you been to the AES before?

[Carlos]

But one of these I have not

[Jaz]

I’d love to go, maybe 2025. I kind of sounds crazy thinking so far ahead. But I’m a family man. And I’m just thinking kids and stuff. So I’ve been I’ve actually emailed 2025 Bill Supple with that. I said, Okay, I kind of told him at 2025, I might see you in Chicago, for AES. But anyway, well, what he said in the episode was very similar to what you said, like look, the endpoint between all of them is very similar. And they all care for the patients and they will all if you follow one of them to a tee, you’ll get a good result. It’s just how you get there. And the little micro steps will vary that little squiggle from the point A to point B will vary. But the point A and point B are invariably the same, ie getting the correct diagnosis and being able to communicate that to the patient and then getting the something that you’re proud of and the patient is going to be able to get longevity from is the same. So I’m glad we know we covered this again, because it’s important to remind ourselves we get very worked up about Oh, but you’re Kois and your’e Pankey, it doesn’t matter.

[Carlos]

It doesn’t matter. It really doesn’t matter. It really doesn’t matter. You know, I was one of those back in the DNS. And I try to, you know, talk to, it’s like politics and religion. You cannot convert anyone, you just can’t. But no, with occlusion, it’s the same thing. You know, the occlusion and here’s one thing and I’m gonna say a couple things about gnarthology that I’m A little bias, little bias. I want to keep things simple. Well, you know, joint position. That’s what we sell. We do our diagnosis, right? But as far as finishing the cases, we’re not worrying about the lateral and the central, we just worried about the coupling and the anterior, you know, the envelope of function. So I’m like, for example, of course, a lot of the viewers know this, your traditional Pankey, Dawson and so forth. You want 28 contacts simultaneously. Well my friend, it’s hard to get freaking 20 contacts especially in the anteriors, and, I mean, you’re going to do just no way. Okay? Now, I’m not bad, and I’m not gonna bow my head, there’s no way you can tripodize a full mouth in gnarthology. There’s no way but the beautiful thing about this, if you understand the big picture, understand the stabilizing the tooth, it doesn’t matter, just stabilize in that tooth. Then, with that, you first of all, if there’s instability against with the patient and everything, if you start stabilizing one or two teeth, it’s amazing how the body starts saying, oh my gosh, I think this guy knows what he’s doing, the body does, right? And then you start seeing some progress. So what I’ve learned in my 30 years is not the big picture. But you then you can pick and choose, some patients don’t have to go to the nth degree, you only need to do one of a couple things, you know, just a man working in offense here and there. And bam, they do well, another person and the other one you may do is before you get started You and I know this is before you start on upper posteriors, make sure where the first point of contact is because if you change that, depending on how that patient react, some people have wide zone, some people have smaller or you can put a rock on me and I’m fine. My wife you put something oh my god, what have you done? So you have to be able to have that in your toolbox so you minimize your problems, right? Right. That’s what the thing is we want to minimize it and we want to look good, we want to look good in front of the patient and so forth. And so with gnarthology was, the way and the right time when, I’m a liberal gnarthologist and I’ll explain why I’m liberal gnarthologist because yes, I understand the tripodization, I understand this for what up disclusion. Yes. But hell, I can’t do that all the time. But what I realized if you can do it one or two, bam, it’s amazing how that patient does. Now

[Jaz]

So really what, just to really make it clear to those listening and watching our dear listeners, the Protruserati, when you say stabilize a couple just, what do you mean by stabilize a few teeth, like just make it really tangible, like, describe what you mean by stabilize? In that context.

[Carlos]

I had a patient that came in and I have a document and so forth, woke up with a pain on the right side, lower right side, came to me and just was distraught. Let’s just say I’m hurting the muscles hurting me and the whole nine yards. So my thing was, okay, let’s take a look at this. How am I going to start with this I’m like I said, I’m a leaf gauger. So I owe a medical history and so forth. Because that you know, that’s another topic we’ve met with the medications increasing muscle activity. So naturally, she’s there was a reason why she was having an issue, that tooth was some in the way of her function or whether it was clenching, grinding. So it was instable. So I come in, go to buy my leaf gauge, to check out how to joint, the muscles and the teeth. I get the teeth out of the way, check the inferior pterygoid to deprogram and see where it is in position, right? And then from there with the warm compress, figured out how she does and I also use pressure point readings. I think we talked about that earlier. It’s a modified dry needling, I’ll just go straight to the source, and just put it in, put that breaks up the lactic acid.

[Jaz]

Well, so using a like,

[Carlos]

I’ll just use a 27 gauge needle. I just take a wipe it down with alcohol. And I’ll tell Mrs. Jones, you’re going to feel a little pinch, I’ll find where the tight contact is. She has a leaf gauge, she’s pumping out muscle. I’m checking it, I go in one or two, warm compress, wait five, six minutes, go take a cup of coffee, do whatever you need to do, come back and you’d be surprised. You’d be surprised how the patient, so naturally on this particular case, that on the right side was number 31 was had a distal buccal fracture. And wants it stable now you had one, gentleman having tried this back in the day, well you can put it, you can add to that too. So I need to do that. But my thing was this I went to the front stabilize with the canines, I added that was my first point of contact. There was about a millimeter or two, went ahead, use the leaf gauge, created my vertical, use my restorative adhesive, place a composite and immediately she was able to respond. Why? Because no longer was she coming in straight lateral enough The non working interference are already removed, because you have the anterior.

[Jaz]

Essentially, you created a more harmonious occlusion as I say in the textbooks by removing the posterior “interference”. So that, that tooth was no longer taking all the brunt of the parafunctional forces. And then you recreated some form of anterior guidance, right?

[Carlos]

That’s it. That’s it. That’s it and and I used to Canine. Now bring it back again to the gnartholical is what the beautiful thing about it, all I got to do is worry about the canines and back for you know, equal contacts. And for the anteriors, what is the purpose, the function of the anteriors are there for disclusion, they’re not completely touch, they’re ready and set for disclusion. So as soon as you move boom, you get the disclusion, left and right, you get the disclusion. That creates a labor three system is the least mechanical offensive. Right there is anytime you have a posterior interferences, a class one, that’s a seesaw, you have the joint and the muscle, they’re going to be sold. Especially remember, you have you ever seen a patient comes in, and they have where the canines and you wonder why they were in the canines, you know, this happens at night sleeping postures. So if you see, if your left eye sleeper, you’re gonna put your head like this, it just goes this way. And you’re going away this what’s going to happen, this joint is going to be the painful one, that mall or back is gonna be a fulcrum, like, you know, you’re number 1415. And you’re going to see canine where the opposite side, not the person toss, in turn, you’re going to see on both. And what’s beautiful, I have documented cases that patients in the back, you barely see a little bit of wear in the front, because I’ll ask him, Are you are you the teeth, a very revealing, let me put it this way, the teeth are very revealing. They’ll tell you how stressed they are and everything. Just think about it. Because you know what 24/7 goes deep, and so forth. So leading, leading to the knock knock

[Jaz]

before you before you progress on. And that fluctuates want to make a point that I actually posted an Instagram story maybe a few months ago. And it was just like my nurse who’s been working with me for almost two years now in this practice, I joined this post pandemic, or just middle the pandemic, I guess. And she has been amazed exactly at that finding that you suggested whereby you can predict the sleeping posture of a patient based on the wear patterns on the teeth. So my success rate and getting this right is about Yeah, 95%. So you would think that if I guess left, the right would be 50%. Right. But it’s that 95% Even then I think some patients just get the left and right confused, really. And I know and I actually know which how they sleep. And they basically might start one way, but in the middle night, they go to the other way. So essentially, if they got more were on the right side, they’re probably sleeping on their left, and they’re grinding away from the mattress, too. And it’s amazing when you start picking these things up is so the patients start getting freaked out.

[Carlos]

And you just tell your significant other, if that patient comes in and you have an issue, because a lot of time, you know a lot of time 80% of the issues with the muscle, it’s all muscle induced and so forth. We don’t have to do a lot of stuff, you know what, and that’s another step you have to do. But you educate the patient, you know, you take a walk to oxygenate you, you give them a little D program on the front, it doesn’t matter what if the cotton roll, you can put a cotton or you can use anything warm compress and sleep on the other side and have your your mate sleep on the other because you don’t sleep facing each other. Right. Right. So anyway, so yeah, and so you know, going back to the, as far as the Yeah, the occlusal scheme is I don’t have to worry from the canines back. So that’s beautiful. I don’t have to worry about you know, getting this perfect. Don’t get me wrong. I mean, don’t get me wrong. Do you want to have in an hour? I can show you all share videos later on? Yeah, sure. Whenever you want, you can you can you take you take the articulating paper. And once you do the canine guidance, you slide it just you automatically create that happening. And that minute this collusion or no contact that is necessary because just think about it. If you put all the teeth together, it is hard. If you have a little interference it means you’re in kind of the upper one against the district a little is going to push your form and guess what happened. Teeth are going to spend your lower teeth are going to be sensitive. So it’s important it’s important to have the letter neutrality that little space in there because we’re not perfect that inevitably we have that means you’re drifting when we’re born in teeth setup. We have a means you’re drifting that with with the teeth are not perfectly nobody’s walking with CRS and MIP equally no one it is so inevitably you’re going to keep going forward and you’d get this thing like this was beautiful is when you get mobile teeth and you add to the canines and so forth, is how things start talking knob hygiene improves, it’s insane now this is not an I will lead slowly to the to, to the canines. My thing through my process of Peter Dawson and all that, you know, they said okay, oh, I remember Tanaka, Terry Tanaka. Great, incredible if anybody wants to go see him, the guy’s insane. But I remember he’s saying that don’t ever make nonworking interference or adjustments when you mount them unless you have canine guidance. And it makes sense, it makes so much sense because you’ve been too aggressive. You know, anytime you start cutting away, that have an interior protection, you cutting away teeth to structure. So that’s stuck in my head. That stuck in my head, too, when I would build my chorus with the leaf Gage, and he’s a big leaf Gator. And he’s the one who made it popularized and now it’s now now unfortunate or Peter, when Peter Dawson passed away, they’re starting to use a little bit more into camps, Spears Jesus, as you know, one thing with this

[Jaz]

great tool. I’m a huge fan of leaf gauges for about six years myself now. And it’s great. You know,

[Carlos]

when people say to me, you know, people, oh, you’re gonna posture most of your life did they join or they’re digitalized? Or whatever, you can pass the relaxed length for the inferior lateral pterygoid. That’s a partial go. You can’t go any further than that. And

[Jaz]

also, the vector that the master and temporize that anterior temporal is the vector that is made, it won’t allow your condyle to go all the way back. Now, in a very deep class, you’d have to, you’re probably a little bit more mechanically disadvantaged there. So it’s gonna be a bit careful, right? But yeah, on the whole, in most cases, it’s very safe to use. And for a lot of dentists, that what they told me is that their occlusion, their journey in occlusion became a lot easier. And they were able to progress in their journey. Once they were able to get a leaf gauge, because a lot of dentists when they’re starting to think for mouth, they really stumble on, you know, the looser gauge and then checking and verifying the contacts. Sometimes. CR is like what the unbuckled teachers one of my, he teaches Dawson in the UK, so it’s a buddy of mine, a really fantastic dentist, great communicator, and he says, centric relation is like playing golf, okay, you’re never gonna get a hole in one every time. Okay, with the leaf gauge, you get like 97. There, right? And then you get your temporaries. And then you get a little bit closer. And finally, you get in the hole, basically. Okay, so the leaf gauges is that first swing that gets you almost there. And sometimes you get fully there, if the patient’s relaxed enough. But if there’s few ngrams, and their muscles are upset, it still gets you closer to where you need to be, would you would you agree with that?

[Carlos]

Oh, my God. 100%. And here’s the thing going back to the diagnosis and the muscles now, you know, and the anagram cheat you mentioned is, you know, naturally we have this normal stimulation that we our muscles develop this, this pattern. And what they leave with delete is to say you separate the posterior teeth and in the 80s with Willington and Soho they showed that you don’t use, you don’t shut down but you reduce the electrical component of the master immediate territory, you know, climb down and so forth. But what you also do on Tuesday loading the joint right you load him by putting everything in the front loading the joint you test them that joint is during inflammation is that capsule on the lateral side and everything. And I want to say one little thing about the joint because I’m a geek, I want to share this with everybody’s let’s remember that the capsule is made of dense fibrous connective tissue. And what that means is it has mesenchymal cells and it has the ability to reshape read reform itself, all we have to do is create the right environment. So what do we do we do the diagnosis and then we create the environment. Okay, so that’s the patient has a dislocated disc and so forth. You put the leaf gauge, within a minute or two they’re crying, you take cotton Ross put it in the back, because remember this the center point of here is your first molar. The first was the first two that comes in and the permanent is the first molar that is the that is that weight. That is your center point. That creates you guidance and mixed in tissue you guidance is your first motor. Anything back of the first model you decompress in the joint and I don’t care what people say you can decompress with my experience with 30 years I put something back there that feel better is good right? And if I put anything in the front anterior to that you load in the joint okay? And and in a lot of times is the module needed to go or the infield the lateral Tango the if you’re terrible, that is time that is type what you do is a we lose it releases what you have released. We released this what you have to do is be patient with the leaf gauge especially somebody has comes in as symptomatic and so forth that you pumped up muscle you pump it 555 to six seconds like rocket bottle said there’s something magical about six seconds pumping and really supporting and release that makes up muscle finalize the contraction, it releases and so if we understand that disk This is like, man, we don’t need to go surgically, and they’re just provided by the environment. Okay, so somebody has this problem. However, take the full apply. Here’s the other thing, you take a full mouth guard, I don’t care whether the segment or just the full price, create the most pivot in the back, don’t don’t, don’t go. In other words, don’t bring the job forward, you bring the job for we got two parts out of position, you got the job forward, and you got this guy position, you have two parts. I don’t want to mess with that and stay home, just decompressive weight, monitor that patient, monitor that patients so that that pivot is in the back and ethics in the front. And I’m telling you, the younger that patient is, you get remodeler not that this is beautiful, and then you can rock and roll then you know a lot of times they need ortho as the other thing is we don’t utilize ortho that much. Orthodontics is underutilized. And it’s and it’s unfortunate. But that’s the thing about the the dentist I want to make sure is it everybody can get that pay attention to this. All you have to do is make your diagnosis. And then it doesn’t matter what appliance you use psychology. Well, I used this appliance all the time. And in my mind, I said hmm, really,

[Jaz]

a lot of the studies Carlos that I’ve done on appliance type and generally TMD and conservative care, giving, you know, educating the patient home therapies analgesics and occlusal, appliance physiotherapy, they all show consistently 80% Plus success rates as not so dependent on the appliance type. So I completely agree with you. A lot of appliances will you know just disrupt the system disrupt the neural links and help the muscles heal. And it’s great that you mentioned the muscles because yes, we talked about the disc but the superior lateral pterygoid attaches into that disc so a lot of the issues are muscular based so once we can calm those lateral pterygoid superior inferior down then the disc has an ability to potentially return to where it wants to be. Yeah,

[Carlos]

remember the this sense here and the front desk yet gets a superior head or lateral target is the top right. And the posterior of the bar lamina is on the elastic connective tissue and it’s made to go you know it is a component that goes down and back and so forth. When you treating like TMD you you treat him you your targeted and you fear a lot of territory. It’s the lateral territories that you’re you’re trying to get those are the ones those are the those are the only muscles that are there the troublemakers. Yeah, they’re the troublemakers. And that’s what you have to gear your your therapy. And so if you understand this, this mechanics in the mechanics is very simple. I just everybody would hear Shanklin, you load the John, you put something back here you decompress. You make your diagnosis however you make it if the storm problem target you therapy to be in the back, if it’s Marshall tardy your therapy to be for that. And I said No, he doesn’t, you know, people say oh, you Susan, what use one use one orthotic. And based on that you make the adjustment. And remember the joint always Trump’s the muscles, it always says what happens is you get a cold a combination here and there. But what happens isn’t a true joint that I’ve seen in my cases and everything, when in doubt start in the back, when in doubt all your plans start in the back. And then then what’s going to happen is if the appliance is too thick, the anterior portion of the temporalis it’s going to it’s going to you’re going to find out this and then to the mass of meat eaters are going to be tight, but you can load the joint and it’s gonna be fine then you said Mrs. Jones, I got you covered. Now we’re going to move everything to different use the same one you cut the back, you put the front and said go home, come back because all that was pretty good. There you go. So essentially

[Jaz]

just to make it very tangible for for listeners watchers, in this primary joint patient, you decompress the joint use an appliance that is thicker or, or more involved posteriorly than anteriorly until you get the joints to make some sort of healing and then you convert it to provide some sort of anterior guidance to relax the muscles. So as you said joints first than than muscles,

[Carlos]

and I’m sorry to interrupt adjust, but on the posterior, what you have to do is use one the most posterior tooth, the palatal most users as you pivot. So in other words, what’s going to happen is you’re gonna use the maxilla. So the bottom, you’re going to use an upper appliance, most likely I use lower appliance for I use pay. But if you say for example, if I was somebody came in with TMJ, I use a full appliance, I want to make sure that the most buckled functional customer, the bottom one just hits my top, the posterior, just one little point right there and just skate on that. All you want to do, you don’t want any you don’t want anything in the front because anytime you hit anything different you load into joint and you’re gonna put pressure on the job. Wow. That’s why

[Jaz]

Dr. Andy toy set I think was 38 or 40. We talked about the PG o posterior guided occlusion. So it’s very similar the concept of the PDO appliance to what you’re saying just to those my listeners who remember that episode, very similar, and I use the pugio appliance occasionally for primary joint patient, but it’s great that you say that in the interest of moving forward I’m Carlos, anything you want to add to this before we now talk about additive calibration?

[Carlos]

And yeah, let’s so no, not that we can get another word now, in my evolution with mythology and so forth was I started noticing, you know, how am I going to treat this patient patients that have worried and impatient people that come in. And so when Tanaka said don’t do not working in offense and so forth, and then thought to build my chorus, he’s using the liftgate. I said to myself, well, first what I did was I started putting composite where it was worn down. That’s that was my first time without using a loop gauge. And it was a failure. It was a flop. Why because I didn’t have a reference point. I didn’t know my vertical, I will just add him. Patient will come back to knock it off. They didn’t it was a mess. But I didn’t give up. I didn’t give up and then I had an epiphany. So why don’t you just leave cash the first point of context Ah, that’s not truly there that you know that it’s an actual point is and then I evaluated the interior overjet I started evaluating and this I just started slowly make sense, you know, this way too much like this is going to be an ortho case. That was another thing and I and I’m going fast. I had this lady for five years in ortho poor thing. She comes to me and she goes, can you see and I’ve been in for years I want to get my teeth corrected and so forth. Can you help me so I put the lead gauge you know, she’s already like this she went home like that. And I said dear, you’re searching

[Jaz]

surgical case. Exactly.

[Carlos]

So I called the orthodontist I called you and I said you know what you’ve done I know that but you know, if you really want to, you want to present it in such a way if you want to guess this will be orthodontics. Just remove everything and let’s fit let’s figure this thing out. Okay, here’s a little tip Pearl, no one can afford love for you know, the correct this. What you do is use plastic Jesus segmental appliance and a knife, you create your ramp so that when you sleep, you get the seclusion. I learned that from my course. So not everyone has to be crippled and 24/7 you use your posterior teeth. So if somebody is like this, you stabilize the back and I’m jumping,

[Jaz]

just to make us because because you’re doing visuals, I just want my audio listeners if someone has a very large overjet in their centric relation, so if they got a very large horizontal slide, how would you Yeah, how would you with issues and who may not be able to it’s not the right time in their life to consider surgery? What are you suggesting for that? Because make

[Carlos]

it make them six through 11? Making a segment Oh, six through 11 A little plastic splint? And really, yes, and you create your ramp and and you just adjust it. And that’s it.

[Jaz]

But that’s for that but that’s for nocturnal use only right. That’s for sleep use. That’s for nocturnal.

[Carlos]

Yeah, right. Yeah. Because yeah, you’re nocturnal, not during the day. Because you know what, how many times a day teeth if we use our teeth are functioning intended, we weren’t needed during the day we don’t their teeth don’t come together only when you swallow infonetics you don’t so so you really don’t.

[Jaz]

Those patients who have who are poor functioning because they’re clench and grind things that you shouldn’t be doing. So I’m not we’re we’re very much cut from the same cloth. I couldn’t completely agree.

[Carlos]

What I do. It’s some of those cases I’ll do tell him use it for about an hour or so in the afternoon. dependent, you get the segment applies. But you have to make sure you adjust it to the vertical, the posterior don’t leave them open. Because some people love this thing. If you wait 24/7 Guess what the posterior teeth are gonna super erupt. So make sure you have you worked out the occlusal scheme on that. So canines, I had no success with just adding. Then I had an epiphany using the leaf gauge. So there that’s where everything just changed. Go to my leaf gauge, find my first point of contact, evaluate my horizontal.

[Jaz]

Call us I mean, I just want to stop me because I’m loving the drill. So now we’re talking about a journey of additive calibration. And a common question again I get is when you’re using the leaf gauge and did call or something something you’re so advanced in your journey now that you’ve been doing for so many years, the beginner dentist the first stumbling point they get Believe it or not color says how do how do I know how many leaves to use, right? I’m like, it doesn’t matter just stick enough in to disclude the posterior teeth. There’s no magic answer depends on obviously the skeletal stuff but just put enough in to disclude the posterior teeth is any guidance they want to give on.

[Carlos]

I’ll give you a couple tips. Yes, that’s very good because it’s so dependent on what you knew by the the point one millimeter in thickness. Each one is supposed to be point one so you know 10 is supposed to be a millimeter with that said is arbitrarily arbitrarily you select Yes, the Amana I usually go from 20 to 25 That’s my my starting point. Usually 20 Depends on the bylaws. Now you put them if you haven’t put them in, you have a slide forward, slide back just just to just to keep it in place. And then you’re going to have a squeeze for five seconds, relax for six seconds. Why? Because you’re in fear a lot of territory is tense. You’re going to start you’re going to be working on you’re working on that on the inferior lateral pterygoid.

[Jaz]

It’s the Masters enterprise and military buoyed by contracting, which then should give the cue to the lateral pterygoid to say, Hey, you guys are needed here. You guys need to relax

[Carlos]

to relax. Yes, yeah. When I think of the leave case, because I’m always I’m thinking of the inferior electrical, but yes. Yeah, the electrical activity emptier temporalis muscles need to take are slowing down. And then also the inferior lateral pterygoid is also relaxed, because remember, the inferior head works opposite of the superior head, as the inferior head contracts the superior head, we not just to allow this to come forward and back. But anyways, so you do that. Now what’s going to happen? Here’s the pearl. After five minutes, let’s let’s let’s assume you use it for five, let’s say you five minutes to patients some leakage going look, I tell him, if you feel contact in the back, add some more leaf gauge, because my experience has told me that what happens is yeah, the same fear a lot of turbos will act and the condyle seat, you get the posterior contact, more more, more noticeable

[Jaz]

as the condyle is sitting further digitalising not disclosing the wrong word. It’s just the lateral pterygoid seating seat

[Carlos]

series going home is getting home, the doors open he’s getting. But so that’s important, because what happens is, if you’re too quick with the leave gift now, if somebody’s not having any pain, and so forth, yeah, within five minutes, but if you if you have somebody suspecting that muscle problems, and you really want to work on this mountain, the case and so forth, then my thing is pay attention to the thickness after five minutes, if the patient is not hitting in the back end, go back and check, check, check with a tickler paper that your photos are in here. And so I’m not hearing you go back there they are hitting. So go back and check. I like to look in there, it’s the second game before I start second again, you know, I think it’s this patient is gonna hit on the left side first, you know, or depending on the rotation. So I’m making a game for me, you guys, which is going to be the first but here’s the thing is after five minutes, check and see make sure there’s no plans. Now, once you had the first business

[Jaz]

commercial, there’s no contact, make sure there is sufficient posterior clearance, exactly,

[Carlos]

just posterior to so muscles are quiet, everything is good. You look at the canines, and then that’s why you have to make for me four millimeters is the maximum for the novice for the novice people that I’m going to start adding composite. But let me also regress a little bit with the leaf gauge. And for those that are don’t feel comfortable, and you want to get in there, there’s nothing wrong with the patient, putting the leaf gauge get behind the patient like Peter Dawson has said and then just get a feel for it and get views I’ve had the assistant older and you get a feel and that’s how I develop my sense of manipulating the joint because I remember going to Peter Dawson over there you know Romans if they join and so forth, you know, you need a talented dentists and you need a patient is very cooperative. When the leaf case get on board, I use both up and then now you know it’s just alivio sometimes you can get them right I’m not gonna go there. But you can get somebody in this remember central what is centric relation, it’s a muscle induced position. You don’t put the patient in centric relation they go there the inferior turbo has to relax and wherever they conduct those tests and tribulation. Now, the question

[Jaz]

I think Pascal Manya uses the term passive de programmation. So it has to be passive like you cannot lead them there you cannot afford definitely not force them there is a

[Carlos]

relation centric relation should not be fortunate, it’s a muscle induced, you get the teeth out of the way with the leaf gauge, the inferior a lot of target relaxes your home. And wherever that that condyle is, that’s where it is, you know, people get, oh, talking about the joint and everything well, you know, anterior posterior, I don’t care where it is. I don’t mean, as long as I know that I’m there and I can load it and everything. That’s all I care about my clinical part, and so forth. So so

[Jaz]

right, one of my mentors, Michael milkers, he says that, you know, we get very worked out about exactly the, the, you know, the seven o’clock 12 o’clock, all that kind of supposition. Well, you know, the only way you can verify is by getting a scalpel and cutting and then peeling it back and say, Ah, I’m there, it knows how to do that. So therefore, you go with your signs from the muscles, and again, it’s your first record you’re taking, you have an ability to verify and refine in the future.

[Carlos]

Yes, absolutely. Absolutely. So, you know, with the leaf gauge that would be don’t, don’t, don’t be afraid to use it. You’re not going to cause and here’s the thing, and I’m going to give another tip f the patience as using the leaf gauge. You tell A patient Mrs. Jones, I’m going to split this deprogram on the front. This is what’s going to happen you’re going to feel some tightness what they do, they’re going to feel some tightness it’s going to be okay after five or six minutes, it’s going to go away if it doesn’t, we’re sure if it’s a TMJ or capsulitis within three or four minutes, they will like to hate it and then and then what you do kidney stones you know what? Okay, I got you covered. Take cotton rolls immediately put them in the back don’t have any squeeze just relax and guess what? pain goes away. Now you just made the diagnosis you got you got some some type of capsulitis synovitis muscle and treat that first before you go doing your you measure twice cut once and you work with that. So okay, so you use

[Jaz]

let’s just you describe the leaf gauge beautifully so I think a lot people got value from that so very common question I get Carlos now let’s talk about it you have a generalized where case maybe and you are using your diagnosis, you’ve got your leaf gauge in you feel as though Okay, I’m gonna start adding to the canines here as you’re gonna say to to recreate some sort of anterior guidance and coupling anteriorly Do you have the leaf gauge in place as you are doing your your bonding or do you get a wax up first, I feel as though you’re you do a lot of freehand stuff, tell us your

[Carlos]

workflow. So let me let me let me walk you through the procedure. So the person will will go ahead and of course dependent after six the patient has to leave gauge, find my first point of contact that takes time that takes time to find the first point of contact and that’s critical because if you get sometimes when I get a little bit too quick and everything and if I don’t pay attention to that then I’m having to adjust a lot so pay attention to the first point of contact and once you get that nail in and everything you look at the verdict you look at the horizontal and there is going to be as such then you do your restorative protocol I use I’m a fourth generation opti bond and micro he canines microchip abrasion air abrasion yes yes sir. Air abrasion edge.

[Jaz]

This is again this is with the leaf gauge in place or is this is this is out but I don’t have any close to the teeth together again because

[Carlos]

everything right, no, you activate anything. No, you have to stick your hand in there and you work with your system, but you don’t have to close down you don’t do that. Once you have you’ve done you’re setting up your your restorative your teeth you’ve gotten in prepare edge Brian bottom edge Bong. Here’s the key is what I what I’ll do then is I’ll take a piece of plastic, this is the most expensive part. I’ll take a piece of plastic layer over when I put the composite I’ll put the composite, put the plastic over it like that. And then I put my leaf gauge in top of that have the patient now here’s another pearl have the patient bite on the back teeth. Because inevitably if you say bite down to the phone, they’ll go back. Practice

[Jaz]

like coaching coach you have to coach your patient

[Carlos]

coach and guide him through coaching. Now I also use cotton rolls I have three cotton rolls buckle and he’s shy and on the lingual bandit and I’ll put the corner just to try to contain the moisture then I’ll put this put the leaf gauge have the patient bite on your back teeth imagine binary bucket they’re gonna bite down leave K chan plastic in place my sister is going to come in and like you whom like your

[Jaz]

mouth but just to just to verify because I’m kind of seeing where there’s going cuz I’m trying to visualize this way of doing it because it is new exposure to this exact way of doing it usually I’m led by a wax up and stuff so I appreciate the the freehand the the a the complexities of it but be I’m loving where it’s going so but you’re not adding camo you’re not planning to add comps it where you’ll have the leak. This is we’re talking specifically the

[Carlos]

canines here just to canines just again,

[Jaz]

okay, and the piece of plastic in the guise to describe it at home. It’s like It’s like thick cling film. It’s just like clear mylar. It’s like a piece of wrapper. It’s like a candy wrapper or something. Very clear plastic. Yeah, that’s the most expensive part. It takes a lot. Okay, so do you have composite on both the upper and lower canines? Like uncured

[Carlos]

question? Yes, it varies. Usually, let’s assume an easy case. The overjet is not that great. So I’ll just use the most of the time. 80% of the time, I’m just adding to the lower ones. Very seldom our to the lingos of the posterior unless you have a really steep you know a big overjet Alright, so most of blindsides send the represent all the actions in Psalm 22 and 27. Just the canines. Those are the canines. Well that’s it. So what happens is,

[Jaz]

and the reason for using the wrapper is so that the upper and lower compasses don’t stick together. It’s just some spacer

[Carlos]

and also for saliva. control, even though try to get by my environments, I don’t want to lie they get in a lower. So what this does is it protects, it doesn’t allow this a lot to get in there. It minimizes, let me put it this, it minimizes the contamination of deposit. I know, I know there’s people that does that without this plastic thing. I like the plastic and and however you want to do it, let me put it this way. But the key is this Yeah, here’s the the pearl is based on the thickness of the first point of contact the vertical. That’s how much composite you’re going to use in the front. So you don’t have to put this glob in there. So say for example, you have about a millimeter, just stick about a millimeter millimeter of composite. Now also pay attention or how that canine is. Because just the same thing is you don’t want to put say, if you put it on the distal side of the of the canine, it’s going to push your jaw forward, if you put it on the music on the bottom one. So pay attention to the position of the canine Where do you need to put the composite, that’s another advantage. But when in doubt, just put it over use a kasi instrument that has the instrument becomes so easy just put it in, left right left, right, put the plastic bag down like your now when you remove it, you’re going to see a blob of material. And you’re going to see a little edge on the side. Before you do anything dried up, put some flowable composite, put a little bit of flowable composite, then if you’ve done your homework and is and you’ve done your vertical correctly, have the patient bend down and what the patient is going to fail. I tell the patient Mrs. Jones, as we do this procedure, when you first close, you’re going to feel two boulders, I’ll tell them you feel two boulders in there, you got two rods. And then now we’re going to go into the back and see how it is. So if you’ve done your homework, you take that in checking the back and you still have the first point of contact, which is usually the means you’re in kind of the top one against a disability plan of the lower one that pushes you forward. Okay. So I’ll go back there, and I’ll adjust it and guess what? Everything drops back.

[Jaz]

Okay, so you’re adjusting your Are you adjusting the posterior interference,

[Carlos]

the first point of contact of interference. Now some people are gonna say, Oh my God, that’s heresy. He has mounted the article, you know, have mounted the case. And what’s going to happen that my experience of 1510 What I’ve been doing this, I’ve yet to cut in anything. So you know, for those that don’t feel comfortable, that’s fine. But what I’ll do is I’ll just that and then what happens is the jaw drops back. It just dropped back a little bit. And you said Mr. Hyde, it’s not perfect. They still feel kind of a little heavy. And then what you do is you come in and you just shape it, you just reshape it, reshape it, make sure because you don’t want to because of the plastic, it gives you some irregularities. So just shape it, polish it up.

[Jaz]

So using the soft like this and that kind of stuff, right?

[Carlos]

Do you want to do it? Yeah, however you want to do it. Now. This is interesting. I will probably say 40% of the cases. This is crazy once I adjust this, everything because remember, the muscles are like your shock absorbers. Everything’s we settled in a lot of time. Guess what? Catches catches, catches catch, everything is balanced out any material because I have the spacing. I already have but right. Boom, you ready to go. I mean, it’s it’s amazing. It is amazing. I other cases, other cases, you’ll get a unilateral everything is contact, and you get an opening here, right? Unless you have bridges and so forth. That’s different but but I tell the patients who said I’m going to have to come back in two weeks. I usually follow them up in two, four and eight. By then by the eighth week if one tooth has not settled and you choose what you want to do, you can put composite you can just leave it alone. You can leave it alone you no one wanted me now. Now what happens is you asked when did

[Jaz]

you call us just to complete the visualization here. You’re sending the patient home now absurd compared to their preoperative state? You’re sending them home with four canines, a polished

[Carlos]

four or two? Not not? Two? Yes,

[Jaz]

yeah. Agreed agreed for or two, you haven’t yet done anything to the incisors. And other than maybe just gently adjusting their posture, first point of contact, you haven’t really done much to posteriors. So this is kind of like we spoke about on Zoom about this before. This is kind of like the start of a doll concept doll technique. And then when you see them again, at two, four and eight weeks, he said, What are you checking for? And what’s the next step from there?

[Carlos]

So what I’ll do is the following is I’ll check a document and say, Okay, let’s, let’s, let’s, here’s the worst scenario, one scenario, just canine guidance, and I’m not getting anything. There’s space in between them. Okay, that can happen if you don’t pay attention to the first year. So what I told the patient a lot of times is I’m going to put you in a diet. I’m going to, I’m going to put you on a diet because we’re gonna be hitting on the canines, right? You’re gonna go home, you’re gonna defend a diet. I’ve only had one patient that came back and says Carlos, you got it. You got to take this thing down. And I did one page. And I remember though, but most of the time we told Mr. Jones, you’re gonna go and, and what’s interesting too is within 48 hours, maybe maybe three days, most everything is just feels fantastic. So sometimes when they walk out by the office, because when they come back there, so yep, Carlos, as soon as I left, I felt good. But so I’ve told the patient, you’re gonna feel the bullish, you’re gonna leave, you’re gonna come back on when I come back. I’m documenting really well, where they, where they feel the where the space is and where they contracted. So let’s assume there’s no contact at all. And two weeks they come back, they may say, Oh, I feel a little bit snug here. Let us know usually

[Jaz]

very posterior, usually second molars, first molars, right? probably be the last ones.

[Carlos]

Yeah. So I feel I feel that now what I’ll do is this this is subjective, it is very pronounced because depending on the height is in a submission or missing part of the apple elicit this stole it, I may take it off. I may, I may remove it. If not just leave it alone. Okay, check the other ones, then 100 Come back, like I said, and a month from there. So it’d be two, four and eight, then you may, on the other side, pick up conflict. Why, because of the dog principle, thanks, we’ll go to the path of least resistance. The only thing that will keep you from keep coming together is what you cheek, your tongue. And I’m working in offense, sometimes not working in offense, that can that can hold that two things in place. Or there’s a study that was done a long time ago is because of somebody told me because of growth hormones, when you stop at a certain age, growth, hormones can change. But that’s besides the point. But so you might you’re monitoring the disserve equilibration that is occurring, and at the end of four, four months, four weeks, then what you’re going to do is figure out if everything is stable, do I need to add, sometimes you just leave the patient alon

View Details

Welcome to PART 2 of composite excellence with Dr. Javier Quirós where we cover the procedural details such as the interproximal management of composites and the prevention of stains.

https://youtu.be/6ESub-OVqgQ

Protrusive Dental Pearl: There is a benefit of having nice tight contacts on our temporary crowns – but how can we polish our temporary crowns without ending up with open contacts? The trick is to get a Sharpie pen or indelible pencil and color in a small circle (maybe about two to three millimeters) mesial and distal of where the contact area is. Now finish and polish your temporary crown using burs/discs BUT do not touch that penciled mark. Ta da! You have just maintained the contact area. I know, why didn’t anyone tell you before?!

Highlights of this episode:

7:23 Mylar Pull Technique

9:57 The 5 Ps of Composite Success

23:49 Digital Facebow Transfer

Check out the upcoming courses with Dr. Javier Quirós!

Be sure to watch the first part of this episode Composite Excellence Part 1 and you’ll surely love this series!

View Details

A Restorative Dentist once told me, “Composites are like being married to a supermodel….sometimes you forget how good looking they can be!” – I had the pleasure of hosting Dr. Javier Quirós who shares his vast experience with composite veneers and restorative rehabilitation with composite resin.

https://youtu.be/D_ahHFXosqA Check out this full episode on YouTubeReady to learn the management of Bruxism and TMD online? Click here to enrol to SplintCourse

The Protrusive Dental Pearl: Check out this Casi 3C instrument distributed in the UK by Enlighten who are the sole distributors of Cosmedent Products. This is a non-stick instrument that provides a perfect curved shape that beautifully forms the palatal contours of your incisors. Watch this video below:

https://youtu.be/QDoD182j-DU

“It doesn’t matter what material you choose, porcelain or composite. What matters are your beliefs, your morals, and your principles of treatment planning” Dr. Javier Quirós

Highlights of this episode:

7:32 The start of Composite Veneers
11:23 Which Type of Composite is Best?
14:07 Composite Veneers of Lower Incisors
17:39 Ceramic Rehab vs Composite Rehab
23:35 Composite Prep in terms of Occlusion
33:31 Minimum Thickness for Composites
38:26 Injection Moulding
43:44 Treating Toothwear with Composite

Stay tuned for Part Two!

Check out the upcoming courses with Dr. Javier Quirós!

If you enjoyed this episode, you’ll surely love this Composite vs Ceramic with Dr. Chris Orr

View Details

What happens when conservative care fails? What if you have prescribed patient education and the ‘best’ occlusal appliance and none of it is working? That’s where surgery MAY be indicated for certain diagnoses. Listen or Watch my podcast with Professor Andrew Sidebottom Maxillofacial surgeon (who is limited to the management of TMJDs) to help us make timely and appropriate referrals to provide the best possible outcome for our patients.

https://youtu.be/7m30jvUPlMA

Need to Read it? Check out the Full Episode Transcript below!

Ready to learn the management of Bruxism and TMD online? Click here to enrol to SplintCourse

Protrusive Dental Pearl: Head over to the Protrusive Dental Community Facebook group where I posted an 8-minute walk-through video on how to screen which patients are at risk for getting a bite change or AOB after an occlusal appliance and how you can minimize that risk.

The highlights of this episode:

12:47 Why you need to provide Conservative Care first
15:57 TMD is a Spectrum
19:21 Early Surgical Intervention?
21:42 Acute disc displacement without reduction
26:40 Imaging used when managing TMD patients
35:10 Pain Management
41:03 Arthroscopic procedure for TMD
50:29 How much does TMJ Surgery cost in the UK?
53:22 Successful management of temporomandibular disorders

Check out these studies as mentioned on the podcast.

Orofacial Pain Prospective Evaluation and Risk Assessment StudyDownloadA Real-Time screening tool to aid management of Post-Traumatic Stress Disorder in facial traumaDownloadTemporomandibular-joints-in-asymptomatic-and-symptomatic-nonpatient-volunteers-prospective-15-year-follow-up-clinical-and-MR-imaging-studyDownloadAlso check out Prof. Andrew Sidebottom’s website for more information and download leaflets.

Check out the Tubules Congress in Heathrow October 2022

If you enjoyed this episode, check out Stay away from TMD! [SPLINTEMBER]

Click below for full episode transcript: Opening Snippet: So I think understanding TMD is about understanding that it's a spectrum of care from joint related right down to muscular related, and patients are somewhere in the middle of that. Probably about 90% of the patients I see down at that muscular end as you say.

Jaz’s Introduction:

What happens to our TMD patients when conservative care fails? Like you’ve done your patient education, you’ve given him the best occlusal appliance, you’ve worked alongside your TMJ physiotherapist, you’ve been through exercises, and you’ve even counseled them about the importance of recognizing awake bruxism, a huge player, and all this stuff isn’t working. What happens next? Well, depending on your diagnosis, the next step for some patients will be see a maxillofacial surgeon, but not any old maxillofacial surgeon, you ideally want to send someone who’s got an interest in TMJ and TMD. So I’ve got today a private physician, private maxillofacial surgeon in the UK, who exclusively treats TMD. So what this guy doesn’t know about surgery and TMJ. And what happens in the latter parts once conservative care fails, how the referrals manage, when should we refer these patients, which patients are suitable for referral to Maxfax, once conservative care fails. Let me give you a clue, if your primary diagnosis is muscular, then really, you know, really need to go and exhaust conservative care and the physio and by the way, most TMDS are of a muscular nature that myalgia and myofascial pain and there’s no real scope for surgery when it comes to muscles that are upset. That’s when we really to give the best conservative care we can and involve a pain specialist sometimes potentially Botox and lots more which we will discuss.

Now if you want to learn more about occlusal appliances, bruxism as a GDP as a restorative dentists who wants to just not be afraid of doing a TMJ exam when the patient comes into an emergency slot and they’re complaining of pain from their jaw, or they got like a facial pain and you take a step back and think Whoa, I have no idea what I’m doing here. Then I’ve set up a course just for you. You guys know that my flagship course is splint course so it’s www.splintcourse.com I’ve just relaunched it, got hundreds of very happy delegates all over the world. And we’re continually, it’s like a school family, little community on Facebook. We have these monthly meetups on Zoom, but the entire course is online on demand. Dentists from Singapore, Estonia, Ghana recently as well, India all over the world, UK, loads from the UK and US have joined the course and now are implementing knowledge that they can help their patients with bruxism management and TMD and relaxing the muscles and just doing a good examination of the joints and muscles. I initially set this course up because I was so confused many years ago about which splint do you give when? How do you give a really good Michigan splint? How to actually adjust a soft splint? So it’s got some sort of occlusion, right? And a lot of times soft splints we’ve been guilty of just you know, grab and go and just give it to the patient and let them leave and claim your 12 days or, or whatever it might be. But actually, there’s a little trick that you can do to get some occlusion on your splint. Now I cover all of this in a lot of depth with clinical lectures and visual animations, PDF downloads, you name it, I really, really made something I’m super proud of. And that’s going to help you save time, be less stressed, and actually be able to charge appropriately for your appliances with confidence. But don’t take my word for it. Have a listen to Aoife Egen, one of my lovely Splinycourse delegates. I admire Aoife so much because she demonstrates that it’s all about implementation. Knowledge is nothing about implementation. So I congratulate Aoife for applying the knowledge from splint course. Have a listen to her experiences

[Aoife]

My experience with undergraduate and postgraduate was very similar and in both cases, and I felt it was lacking. So when I started Jaz’s splint course and I was going through all the modules, I just found it such a welcome shift in thinking. And I was really, really delighted to have come across it because I felt that it was the first time I was finally going to be able to really apply and yet kind of actually use all of the information was very logical compared to the theory based approach that I had experienced before that. So I started this course in December I think and so I kind of went got through all of the information by about I think the end of January. And then as it happened, I was going coming back from maternity leave at that stage. So in the last six weeks or so, I’ve applied so much of the principles from Jaz’s course already, and it’s just been great, you know, just immediately, my diagnosis has been better. Even something as simple as, you know, before, I had always just written like, you know, as part of my notes, extra oral examination, TMJ, and then a note about it. But now I actually understand what it means to if there’s a click or, you know, I just have found my notes are more detailed. And I’m not just kind of noting it, and then doing nothing about it. But I’m actually kind of acting on my diagnosis a little bit more. Sorry. All right. I just hope Jaz hears this now

[Jaz]

Ladies, I heard you loud and clear. I love to hear that. That’s fantastic. Thank you so much Aoife. Now, the biggest excuse I hear from colleagues, they message me in terms of time, Jaz, I’d love to do your course. But I don’t have the time, I can’t find time in my busy life, to sit in front of a laptop. And watch these videos as fascinating and engaging as you make it Jaz. I don’t have the time. But you made the time to listen to this podcast. And I realized this afterwards, when some of my delegates were not making as much progress I want you to do well, I want you to make progress. So then I decided to put the make the course as a podcast as well, because then a lot of people can while they’re commuting, make time for education. And therefore now a new feature of the course is that you can download the mp3 of the modules. And listen while you drive, or on the train or chopping onions or whatever. And you gain most of the knowledge like that you reference it with some of the videos you have the course ebook, and all the PDF forms and gives you a new way of learning through the medium of podcast. So that’s right up your street, head on over to splintcourse.com and enroll today.

Before we joined Professor Andrew Sidebottom, the maxillofacial surgeon, we talking to you today, I’ve got your Protrusive Dental Pearl And this is a video I posted on the Protrusive Dental Community. So if you’re not part of the Protrusive Dental Community on Facebook, search it up, join. It’s a lovely little community, very helpful. I’m proud of it I one of my colleagues, Maria posted a case whereby she gave full coverage appliance, upper and lower, full coverage like a retainer and a full coverage appliance to a patient and she developed anterior open bite. And so this happens right? So it’s not just a small appliances and over eruption and that kind of stuff. And I’ve talked about it before, but a patient now has an AOB. So inspired by that problem, I saw an opportunity to make an educational videos, eight minute video made to ship to walk you through with a patient life patient there exactly how to screen which patients are at risk for getting a bite change or AOB after an occlusal appliance and how you can minimize that risk. So it’s a free eight minute video you can watch, I pinned it to the top as a featured content on the Protrusive Dental Community. So you could check that out as your Protrusive Dental Pearl. Otherwise, I hope you enjoyed this podcast. I’ll catch you in the outro.

Main Interview:

[Jaz] Professor Andrew Sidebottom. Welcome to the Protrusive Dental Podcast. How are you?

[Andrew]

I’m good. Thanks, Jaz. How are you?

[Jaz]

I’m great. I just came back from Porto on holiday we took 16 dentists to learn vertical preparations with George Andre Cardoso in Portugal, which was amazing. And we’re feeling a little bit tired. I’ve got a few ulcers. I’ve lost my voice a little bit, typical. But hey, I’m good. I heard about your weekend before hit recording, very family orientated which was nice. Like how do maxfacts people? How do you get time to have a life? Serious question like you guys must be so so busy. Well, how do you manage it?

[Andrew]

So I mean, I think I stepped down from my NHS work 18 months ago and just do private work now which has given me an extra day a week. But yeah, it was chaos before and doing a one in four on call was was hard work. But yeah, I’m enjoying life a bit more now.

[Jaz]

I’m so glad to hear that and please give us a flavor and I want to know as well. With going private MFS like you do you have your own niche within MFS and what are the types of surgeries that you have niched into?

[Andrew]

Okay, so, as an NHS consultant for 20 years, I developed a practice in TMD and facial deformity. I became one of the go-to people for TMJ problems from other IMFs around the UK and Europe. And the the facial deformity side of it fits in nicely. In addition, all of us kind of Do wisdom teeth and dentoalveolar work as well and I still love doing the basic dentoalveolar surgery. I just like getting my hands wet. So that’s great doing that. And so my private work, probably about 60% Is TMD-based. And then 40% is general Maxfacts and facial cosmetic surgery.

[Jaz]

I’m so excited to have the chat now. They told me the background terms of how much work could you do with TMDS right on my street I am sure I’m gonna learn so much from you and we are all asked you got a platform of GDP is it all over the world who tend to listen to Protrusive Dental Podcast because they’re a little bit geeky. They want to a bit more, they like the nitty gritty details. And they have an interest in some way in occlusion or TMD. Or that’s why they started listen to this, that’s why they clicked on this episode. So let’s scratch that itch for so many listening. So first, just tell us where you work. Tell us where you work. And how did you get into that niche of TMD. Because most dentists I speak to want to stay as far away from it as possible.

[Andrew]

And I think that’s true of most maxfax surgeons as well. We, what did I? How did I get into it? I kind of got into it almost not quite by default. But I at dental school, I went to a very interesting lecture by a chap called Richard Juniper, who at the time was a consultant in Oxford, and specializes in TMJ. And I was really intrigued by his kind of anatomical understanding of how the joint works and their relationship with the lateral pterygoid to the disc and the head of the condyle. And then went off to do my SHO jobs ended up in Birmingham with a chap called Bernie Speculand, who was one of the first guys in the UK doing TMJ replacement and TMJ surgeries. Liverpool as a senior SHO, none of the consultants was interested in TMD. So I got dumped with all of that work by the seniors, and thought I ought to start learning about it, went back to med school, married an orthopedic surgeon. And by default, therefore, you’ve got to know a little bit about joints. And went through did my higher surgical training in Liverpool with a guy called John Cooper who again was interested in TMD and came to Nottingham and just that was part of one of my areas of interest, along with facial deformity, cranial facial surgery, and just develop the TMJ stuff along those lines and set up a specialist clinic literally in my first week in 2001. As a max fact surgeon in Nottingham, and having the time to spend with the patients at the first visit, when they get referred to secondary care is the key to management of these patients is spending time with them.

[Jaz]

That is brilliant. I love your story and how one stem from another and the fact that you married orthopedic surgeon, I think gives you an edge for sure. It totally gives you an edge. I love that. The kind of themes we’re exploring today, if we were to achieve two things on this episode is one to gain insight what happens when us, dentists have really exhausted conservative care, and they come to you? And what are the types of diagnoses that lend themselves to a better prognosis? What kind of surgeries do you do? I mean, in this short time, we can only cover so much I know you’re coming to visit us on the live of Splint Course, which I’m really excited for you to meet the delegates who have taken a real interest in the conservative management TMD. So really excited to see you in May and June for that. But the first question is, what do you think? What is the level of care that you want general dentist to have carried out before that patient is referred to you? Because and please do tell me what percentage of referrals that come up come to you sort of bounce back and say actually, there’s no indication for surgery? And then do you sometimes just take over and do the job that perhaps you feel that our colleagues should have done?

[Andrew]

Yeah, so one of my roles at the moment is as the East Midlands advisor for NHS England, Oral Surgery, so I’m the emcee and lead for oral surgery. And one of the things that we’ve done is send out a missive to all the dentists in the region about what they should be doing for patients in primary care for the initial management of TMD. The guys in Darby audited the referrals before and after that, and found very little change in practice. And that roundabout 80% of patients had a basic rest, anti inflammatories bite splint protocol, before they came into hospital. The Royal College of Surgeons guide suggests that patients should have a six months of conservative treatment prior to referral in. I don’t agree with that. I think that misses some of the patients that will benefit from early surgery, particularly younger patients with an acute severe restriction of opening. So I think a basic rest, anti inflammatories, reassurance that the majority of patients even that we see in secondary care, don’t go on to need surgery. And reassurance that clicking is something which about a third of the population have any way and most people with clicking don’t get problems. So don’t worry about the noises that are coming from your joint. We don’t worry about noises in our knees and hips and shoulders. So we shouldn’t worry as much about TMJ noises as some people stress and basically to just give that reassurance that you know, the biggest thing I would advise everyone not to say is never tell a patient they’ve got arthritis because as soon as you say that they assume they’re going to need a joint replacement,

[Jaz]

Especially if they started googling it.

[Andrew]

Absolutely, yeah.

[Jaz]

Which they do. TMD patients I’ve had, which eventually watch my dental podcast, which is, can you believe it, they didn’t know, my podcasts are meant for dentists. And they search these terms, which only a dentist would ever search, right? And then they end up with me and they come, and then I’ve seen a few of them. That’s kind of like how I’ve also made a sub interest in TMD. But my mission was always to be really good with conservative care, because I can treat so many of my patients with really good conservative care. And one thing maybe we’ll touch on is giving an occlusal appliance with intent based on diagnosis. And with that comes, you know, one important consideration that yes, you know, you shouldn’t say arthritis and stuff to your patient, because they’re worried, but loads of these patients, their diagnosis is in the muscular region. And correct me if I’m wrong, but you know, they don’t, there’s gonna be no indication for surgery for somebody that’s muscular, that definitely needs rest. So just please expand on what percentage of referrals that you get are perhaps muscular, and they’re not, you know, osteoarthritic or intracapsular, that you feel as though hang on a minute, we need to just go back and break things down, go back to basics and apply conservative care.

[Andrew]

Yeah. So I think understanding TMD is about understanding that it’s a spectrum of care from joint related right down to muscularated. And patients are somewhere in the middle of that, probably about 90% of the patients I see down at that muscular end, as you say. So of the patients that get referred to us in secondary care around about it. The easiest thing to think of with TMD management in secondary care, which I tell all my trainees is it’s an 80% disease. So 80% of the patients we see in secondary care, get better with conservative measures. 80% of patients who go on to have arthroscopy get better with that, of those 80%, 10% don’t need further intervention, despite not getting better with arthroscopy, because it becomes very clear that they haven’t got the joint related pathology. Of the remaining 10% that go into open surgery, 80% of those get better. And of those that don’t, when they’ve got significant pathology in the joint that go on to joint replacement, you look at that. And of those 100 patients who have come in initially to secondary care, probably one will go on to open surgery. And about point one will go on to need a joint replacement, so very few. So as a surgeon, Maxfax surgeons aren’t interested in it, because you don’t operate on the majority of your patients.

[Jaz]

That’s an interesting take, cctually. If it was more surgical lead, maybe Maxfax would have more of an interest in it. But you know, we agree that there’s so much general dentists can do with good conservative care, perhaps teaming up with a local physiotherapist and following a hierarchy of things, where we’re both well acquainted with Kreena Panchal, who again, will also be there in the dates of May and June on the live version. So it will be great to actually put our heads together and see how can we help our GDPs give better conservative care, and that’s essentially what it’s about. And with that Prof, I want you to say, there’s a rule that one of my mentors taught me about PDQ. And just as you said, with the clicking, and lots of patients get concerned and worried. And you should just reassure them a clicking is normal, PDQ. So it’s only really an issue in any real diagnoses within TMD, which is an umbrella term, if it gives a patient’s pain. If PD means let’s say dysfunction, okay, so they’re not able to chew properly or quality of life. If it doesn’t satisfy any of those three, then really, there’s there’s no reason to actually intervene at all, not even with conservative care. Really, if it’s not giving any of those. When any of those three happen, then of course, conservative care. And if that fails, which 20% time it may do, but to be fair, I think if we only had a group of patients who had muscular symptoms only, and you gave them really good conservative care, and we can get into heated debate, maybe but not just give them a soft splint. Okay, well, we’ll talk about that towards the end, then I think we will go beyond 80%. And some of the literature says that, but the general lecture 70-90% patients will get better, even just without an appliance, just giving them some advice and rest, a physio, no appliance will do well, and we know that. What are the kind of cases that you think dentists should and it’s really interesting mentioned should be referring to you without conservative care first, because you feel as though okay, this patient is just going to be worse off in six months with conservative care, and they actually need early surgical intervention. Can you describe those type of cases? So the diagnoses.

[Andrew]

So it’s a term that I’d be amazed if any of your listeners come across, which is called Anchored disc phenomenon. And basically what that is, is with repeated compression of the joint and one of the things that we’re increasingly aware of is that TMD is related to repeated compression, micro trauma of the joint from clenching or grinding, usually clenching rather than grinding. And to put it in a simple term, they squeeze out the fluid of the joint. So if you wash out the engine oil, the engine ceases. And what happens with the joint is that you lose the glide component. So your initial rotation of about two, two and a half centimeters in the lower joint space continues, the upper joint space loses its viscosity, it loses its lubrication and sticks. And so the disc is stuck against the fossa, you don’t get the glide. So they stick it round about 25 millimeters. And anyone with that onset suddenly, so they getting on fine, suddenly they come in, I can only on my mouth two fingers or less, needs urgent referral, because those are the ones that do extremely well with an early washout and early arthrocentesis. And do extremely badly if you delay and delay and delay. So those patients who are delayed beyond one year, their outcomes are about 50% success. Whereas those that are treated, within three months, you’re looking at about 95% success.

[Jaz]

Wow. And we and these patients are different from that patient in their 40s or 50s, who’s always had clicking, clicking, clicking, and then sometimes they get the the lock, which they can fix. And then eventually they get down to two fingers. And we suspect a disc displacement without reduction. So the disc is not able to come back on the condyle, the condyle cannot translate as well. And that’s a different beast to the kind where they get like you described more sudden. And that makes sense. Now, when it comes to patients who have intracapsular disorders, and they have that disc displacement, locked or the closed lock, and the jaw deviates towards, or deflects to one side even and they cannot open, they’re in pain, acute pain. Why do you see the success in conservative care in there, because this is where I give reduced prognosis to my patients, I can still help a lot of patients. And actually funnily enough soft splint, the bite raising can help those patients to recapture and then various things. But the longer that’s happened, the worst prognosis? Is any evidence that early surgical intervention in those kinds of cases can help or what would you advise general dentists to do in those acute disc displacements without reduction?

[Pav]

Yeah, so I think a lot of this is dependent on understanding the basic kind of pathophysiology of what’s going on. So what you’ve got with this displacement is that you’ve got compression of the joint. And if you compress the joint often enough, it starts getting thin, and the retrodiscal tissue stretch, and then the disc slips forward. So when you open, you go past the back end of the disc, and then you get the click as it relocates in position, the click can also occur, because the retrodiscal tissues thicken, in adaptation to the increased load. And that can also click over those. So those are the ones that you can get click click, sometimes. The reason you get a lock isn’t that the kind of old fashioned thought processes of the disc is just stuck there in front of the joint, what actually is probably happening is that you’re getting to a certain point on the retrodiscal tissues, the tissues are so inflamed and uncomfortable that the muscles Stop it, and they go into spasm and they stop you moving forward. So that’s either spasm of the lateral pterygoid, on the front end of the disc, or spasm of the opening muscles, the masseter temporalis, which literally, because it’s painful, it stops you’re moving, it’s like a limp. You don’t on purpose limp when you’ve sprained your ankle. And it’s the same with your TMJ, your body knows that it’s going to be painful, and it suddenly says, I’m not going to move there. And then your jaw deviates over towards the side where the pathology is. And you get that restricted opening. So trying to release the muscle spasm, trying to offload the joint with your splint is going to help that patient in the initial phases, and probably will get significant number of those patients improved with good splint therapy, good rest and avoidance of that whilst you’re waiting for a referral onwards. But yeah, don’t hesitate to get the splint in there and kind of offload the joint really.

[Jaz]

Do you think that kind of patients should be also going down the conservative care for six months before referring to someone like you perhaps or is that warrant a referral to you to start also being involved in that patient’s care?

[Pav]

So I think the problem you’ve got in Maxfax is that there’s only about a dozen of me around the country. And there are about 300 Odd maxillofacial surgeons who aren’t comfortable providing early arthroscopy, arthrocentesis and therefore, what will happen is that they’ll get referred in. The patient will be seen by often a junior member of staff who will say, Oh, yeah, these need conservative treatment, or they’ve been having conservative treatment, or let’s give it a bit longer, and they get delayed in the system. So it’s about knowing who to work with as much as how to get that process going. And, you know, I’m not being demeaning to my colleagues, some of them are brilliant cancer surgeons and what have you, and I wouldn’t want to touch that side of things. But similarly, it’s an awareness that you’ve got your own limitations of what you’re comfortable with, then it’s probably worth referring into somebody who does have, most regions will have one or two surgeons who have an interest in TMD management. And it’s really about finding out who that is in your area, and working with them to kind of get those patients referred into their clinic. At the moment in the NHS, it’s a disaster regardless, because I don’t know what it’s like for you guys down there. But at the moment, for a routine referral in East Midlands, it’s like 40 weeks Wait, and TMD will be a routine referral. So you know, you’ll have a 40 week wait, and by that stage, they’ve missed the boat.

[Jaz]

Agreed. And this yeah, like I said, similar here, and just on the idea of getting finding someone who’s local to who can assist you, as a general dentist, with those complex intracapsular locked as acute, but I think we still need to apply conservative care that might be just a little bit different. And we’ll talk about that when we come to the live courses, obviously. And that may help patients a lot while they wait, especially if you get that lateral pterygoid to calm down, because I like to lateral pterygoid to calm down and a lot of those cases will get better. And just like you said, the beginning, it’s everything that’s a spectrum, there’s no purely intracapsular, probably less purely intracapsular, there’s always a degree of muscular involvement as well. And one of my favorite analogies for the relationship between the condyle and disc is that the disc is like a bar of soap. And with the compression that bar of soap can slip. And obviously that’s a very simplified way of thinking about it. There’s lots more anatomical changes that can happen. But essentially, yes, when someone gets restricted opening and your suspect a disc displacement without reduction, my Inkling is to help out. But I’m also thinking about imaging. So let’s talk a little bit about imaging of those patients who either conservative care has failed, good conservative care has failed. Or they have disc displacement without reduction before even surgery, what kind of imaging Are you providing for these patients?

[Andrew]

So I’m probably a little controversial in my views on imaging. I very rarely will get an MRI. The reason being that the MRI scanners we have in this country, first of all, the majority of 1.5 Tesla. And so the views aren’t that great. The radiologists are few and far between who are good at interpreting them. And when you look at the best series in the world, from the likes of the ninth People’s Hospital, Jiuyuan unit in China, even there, the accuracy of diagnosing a disc tear is about 50%. And so if you base your surgical intervention on your MRI 50% of the time, you’re going to be wrong. An audit that we’ve done and not seen as similarly done a similar audit in Oxford, and colleagues in America have audited their practice. When you do an arthroscopy and you find a disc tear, a lot of colleagues would say, Oh, you need to take the disc out. My feeling is based on an audit of 115 patients that we’ve presented, but haven’t published yet. 50% of them get better with a disc tear. And that’s its own disc tear, which can’t heal itself because it’s avascular. So if you then said, Okay, well, I’m gonna base a surgical discectomy on an MRI scan 50% of the time, it’s got the diagnosis wrong, and 50% of the time, you’d have got better with just an arthroscopy. So, you know, 75% of your patients, you’ve taken the disc out unnecessarily. And that sort of data correlates with a couple of studies in the literature from Sweden, a chap called Anders Holmlund did a lot of work on diskectomy and found that following arthroscopy, if you did a diskectomy, about 50% of patients got better. Whereas if you didn’t do a diskectomy, if you didn’t do arthroscopy, 80% 85% of patients get better with a discectomy, so that means 35% of patients probably would have got better with arthroscopy alone, so it kind of correlates with all that. So that’s why I’m not a huge believer in MRI. MRI, in theory, if you take a good history, and do a good clinical examination, the MRI will only confirm what you clinically know.

[Jaz]

I’m glad we’re in the same viewpoint actually because I find as a GDP who’s got an interest in this difficult for my patients to accept having an MRI and going to London to have it. There’s a few people I know who do it but they’re few and far between. And a lot of time with my history and knowledge of anatomy, you can get, you can suss out the diagnosis. So I agree with you on that. I’m sure there’ll be times where something’s just not quite right. And you will need to take some form of imaging. I recently had one of my delegates on Splint course in our Facebook group, he posted a case where acute pain on the right, limited opening with a deflection so we’re discussing, okay, we suspect disc displacement without reduction on the right side, but it’s quite sudden onset. Can we explore? So he referred on and they did take an image now I’ll have to check out I’ll put this in the show notes. Exactly what type of imaging it was because I don’t want to get it wrong. We know that MRIs are good for looking at the disc and soft tissues, we know that CBCT’s are better for for hard tissues, but they did diagnose a right side condylar fracture, which was fascinating. And they were they were surprised in the report that they wrote. So yeah, those kinds of things yet, when the when something’s really unusual, then I’m sure you guys are would do that. But for many cases, it may not change your management, is it is that fair to say that with your differential diagnosis about imaging, it may not change your management with the presence of an MRI?

[Andrew]

I think the other thing that you need to understand about an MRI, have you ever, if you’ve ever had an MRI, you will understand

[Jaz]

For my shoulder? I have Yes.

[Andrew]

So it takes about 30 minutes. How do you lie still for 30 minutes, with your jaw, it’s and then you’re trying to open a jaw into a bite block, which is an unnatural movement, you’re not going to move past a point that might be painful. So if you had a painful click, you’re going to stop before you get the pain because you’re not going to hold your mouth for three minutes with that pain in that painful position. So you will often get an over diagnosis of limited disc reduction from the MRI, not because the radiologist has got it wrong, but because of the unnatural surroundings that you have with an MRI, you know, and everyone that says oh, well, you get a dynamic MRI. A dynamic MRI doesn’t show a joint moving like that. It shows a joint in that position for three minutes, then that position, it’s then that position for three minutes. And then they combine it to make it look as though he’s moving. And even with that, it’s not natural. So you’ve got to take your clinical diagnosis, your clinical diagnostic skills, to the level that you’re thinking, Okay, what’s going on inside that joint and you’ve got it in your brain, what movements are happening, and then you can use your MRI to confirm that. So one classic, I remember I got asked to go over and treat a Saudi in Saudi Arabia. And this girl was the daughter of the hospital owner, multibillionaire and the MRI showed an anchored disc. The MRI showed a disc displacement without reduction. And they said, Oh, I think she needs a discectomy and they had various people say that I said, Okay, well, no, we’re going to do an arthroscopy. So I did an arthroscopy on table mouth opening went from 20 to 44 millimeters post op, three months mouth opening 45 millimeters pain free, disc relocated on the MRI. That’s an anchored disc phenomenon. But what the scanner show is that the disc was stuck in front of the joint. So you’ve got to listen to what the patient’s saying. Listen to your experience and work through that and think, Okay, what could be causing this and the anchored disc phenomenon is it tends to be under 30s. I’ve always been aware of these younger patients with acute severe restriction. Yeah, the majority of kind of teenagers, it’s myofascial pain, been caught out a few times with new diagnosis of rheumatoid arthritis or inflammatory arthritis. A few others that you get this acute severe anchored disc phenomenon, but a lot of patients under 30 is muscular. But those acute severe restrictions is going to be an anchored disc before it’s going to be a disc displacement without reduction.

[Jaz]

Well, that’s a really great insight. And just to add to an MRI study that was done, they and I’ll put the exact reference in the show notes, you’re probably familiar with this study where they had symptomatic patients, and they took an MRI, but they had asymptomatic patient patients, and it took an MRI of the joints. And they found that a quarter of maybe even a third a quarter to a third of these asymptomatic group have a disc displacement with reduction and had a pathology. And then about a third of the patients with symptoms had no pathology on the MRI. And what it also goes to show is that we very much need to respect the biopsychosocial model of disease and just because those patients had a MRI diagnosis of disc displacement with reduction, they had some sort of pathology per se. It didn’t correlate to pain and What physical abnormalities or pathophysiology or problems, they don’t always manifest as pain because pain is very complex beast. Do you work with other specialists when it comes to pain management? Because I imagine that’s a big part of what you do. Please tell us more about your reflections on the relationship between an actual disc injury or positive finding or lack of and pain.

[Andrew]

Yeah. So I think the first link you were saying about working with a physiotherapist, the more treatments I’ve carried out, the more I’ve worked with physiotherapists. So I’ve got now about six or seven physios that I work with around the country. All of them are pretty much specialists, TMJ physios, you can access them through the acptmd.com website. And Kreena who is on the course is one of those and I work very closely with Kreena, I’ve got three around Nottingham that I work with and one now in Lincolnshire, a couple in Sheffield, and one other in London. So these guys are fantastic. And they’re also good at emailing you back and saying, Andrew, I’ve done what I can, please can you put a bit of Botox into this muscle, because I think that’s something which is very good at breaking the cycle. The other thing with Botox is that it’s very badly taught to dentists by and large. So it’s injected suit, too superficially. It’s injected in the wrong places, it risks damage to the zygomaticus muscle, which runs from the front of zygoma, to the corner of the mouth, because one of the areas of major muscle spasm is the upper anterior masseter, just here. And if you try to inject that, it will leak into the zygomaticus, which is just next to it. And you’ll end up with a patient that can’t smile for four months. And so they won’t thank you for that. So when you’re injecting with Botox, you’ve got to find where your muscle spasm is. And what say to all of my juniors is muscle spasm. Teaching patients where muscle spasms, you get them to feel the muscle firmly. And if they can feel a speed bump, they go over the muscle spasm and it’s uncomfortable. And that is one of the keys to where the physio works is massaging that area of speed bump and running your finger over that speed bump for a minute, four times a day. It stretches the muscle. It helps improve the blood supply and it releases endorphins so that they get pain relief. Similarly, you look at muscle relaxant medications low dose, tricyclic meds, which a number of my colleagues are very quick to jump patients onto those meds. I think you’ve got to look at less invasive ways of doing it first, you know that they are quite difficult drugs to manage. And if you’re not used to using them, then really they should be managed by either the GP who are quite used to using them for a lot of things now, or a pain specialist. And I will try either low dose amitriptyline, nortriptyline or gabapentin, pregabalin. And if those aren’t working at that stage, I send them to my pain management team. And I have about three pain management consultants that I work with, that are very used to what I do. And similarly, they bounce patients back and say, Andy, could you put some Botox in this patient? I think that will help. In addition to what we’re doing in the medical management side of things, I think it’s very easy to just FOB patients off with muscle relaxant meds, when actually, it they need a more holistic approach to management.

[Jaz]

And with your pain management team, as well as cognitive behavioral therapy, what other modes of sort of intervention are available from the pain management side.

[Andrew]

So I think you’ve got to consider with these patients, I, in a lot of my lectures, I draw three circles interlinked. And there’s this internal derangement, there’s osteoarthritis, and there’s myofascial pain, and then there’s a double arrow feeding into all of that same psychology. Because if a patient has anxiety or depression, they’re more likely to clench and they’re more likely to feel pain. If a patient has pain, they’re more likely to become anxious, depressed, and clench their teeth. So it’s a two way cycle that you’ve got to look at. So you, there’s the occasional patients, I treat two consultant psychiatrists. It’s always interesting having that feedback with them about you know, you do realize that you need to see psychological management techniques and saying, Yeah, we do these things and blah, blah, blah. But yes, you’ve got to interact with psychologists with CBT therapists with psychiatrists on occasion and Kathy Fan from Kings produce a very nice paper where they have developed a tool, which works out all the patients that come into their TMD clinic get put onto this tool, and it says, This patient is high risk of anxiety, high risk of depression. And then they link in with their psychiatric team to manage that side of the problem as well. And then on top of all that, you’ve got the medical problems. So you’ve got the fibromyalgias, the inflammatory arthritis, which you’re linking in with the rheumatologists. So, it over the 20 years of working, I’ve worked with more and more colleagues and more and more colleagues work with me and it was beautiful working relationship in the end. I’m sorry, I left

[Jaz]

And that’s what it’s all about, you know, multidisciplinary care. So the definitely was all about and I’ll put reference again to the OPPERA study, which talks about all those other comorbidities. And I’ll put that in the link as well, because we discussed that with an episode with Kreena a long while ago. So we’ve talked a little bit about the kinds of cases that should be seen little bit sooner, the importance of conservative care, and you gave us some success rates. I love the 80-80-80 sort of rule if you have, Pareto principle comes to mind. When you talk about arthroscopy, please describe to general dentists, What is an arthroscopic procedure for with regards to TMD. What are you actually doing? And what is the sort of prognostic features or what are the features that will suggest okay, this patient has a good prognosis or a bad prognosis from an arthroscopy?

[Andrew]

Okay, so, arthroscopy is usually carried out under general anaesthetic. Patients don’t need antibiotic prophylaxis, orthopedic surgeons have not been using antibiotics for years and years and years for knee arthroscopy. The scopes we use, by and large, a 1.9 millimeter diameter and 30 degree angled, the scope I use now is a disposable 1.2 millimeter. And on viewing scope called an on point. It’s smaller, it’s easier to get into the joint, it theoretically causes less damage. But the risk is that sometimes you don’t quite get into the anterior recess, the majority of pathology, you see, an arthroscopy is in the posterior portion, or the mid zone of the disc. Arthroscopy realistically, unless you’ve got a disc test, you’re only going to see the upper joint space. So you will miss low joint space pathology. But you basically descend the joint, you then put in the telescope, and then you look around the joint, and you try and work out what’s going on, the commonest thing you’ll see is that this folding of the retrodiscal tissues because they’re stretched. And so when you open the mouth, you’ll see this kind of little wave formation flatten out as you move the scope through the joint. And then the next thing you’re going to see is, is there any inflammation on that tissue? Does it creep up onto the avascular disc, which is called creeping synovitis? And is there a hole in the disc, and you’ll see that a chronic tear has a nice rounded edge. And acute tear is a bit more jagged. And probably an acute tear is more likely to heal, and the patient get better than a chronic tear. Because what happens with a chronic terror is you get adaptation. You know what we’re doing as surgeons is facilitating the patient to get better. So if you like we’re helping God to get the better. We’re not God. You know, I know they say, you know, what’s the difference between God and the surgeon. God doesn’t think he’s a surgeon. But basically, what we’re doing or what we should be doing as surgeons is helping the patient’s body to heal itself. And so what you get from an arthroscopy then, and level one arthroscopy is literally putting the scope through the joint, looking around the joint and flushing it out, under pressure. You need to do it under pressure, because it distended the joint, you need to flush out enough fluid. So you need 200 mils plus a fluid to get rid of the inflammatory mediators or those free radicals. And what that 200 mils starts doing is getting rid of the free radicals in the lower joint space as well by diffusion through the retrodiscal tissues. That’s work that direct net San has looked at from Israel, that shows that less than 200mils. 200 mils is that kind of key 99.9% of all free radicals have got rid of. 100 mils, you’re looking at about 97%. 50 mils is around about 50-60%. So you really need to be flushing through a lot of fluid. The pressure distends the joint and breaks down adhesions in the joint that are forming. And it also what happens what you see with an anchored disc is like little fibrillation is where the joint surfaces have been stuck together and then pulled apart. And the way you can imagine that is if you put two surfaces of glass together with a thin layer of fluid and then you pull it apart. You can see those little strands forming. So that’s what you would see with an anchored disc phenomenon. Level two arthroscopy and there’s realistically only one person in the UK that It does this frequently, is putting a separate scope in and taking biopsies and freeing up tissues. Level three is putting three bits in and hiking the disc back. Now state that there is no good evidence that level two and level three given added advantage of a level one is categorically in the literature, there is no evidence that added procedures arthroscopically give any advantage. There is likewise no evidence that open disc plication, putting the disc back into position gives a long term relief of symptoms over and above dealing with any other pathology in the joint. So disc plication in the 70s and 80s was a common procedure. What happened was that five, six years later, the patient got clicking again, you did another disc plication, five, six years later, it comes back again, by that stage, the fact that you’ve opened a joint two or three times, you’ve got a degenerate joint. And so disc plication went out largely as a procedure through the 90s. There’s still people who will do it regularly. And state they get good outcomes from it. My own view is that I do it probably about 5% of my cases, I’ll do a dislocation. This is with open surgery. Of those, only about 50% of them get better. Whereas everything else I do, which is deal with, if there’s damage to the eminence, if there’s damage to the disc, if there’s damage to the condyle, I’ll deal with all of those at the same time. My success rate with doing that is 80%, bizarrely, as opposed to if you just do an emenectomy, your success rates about 60% If you just do a discectomy, your success rates about 60%. So if you address all the pathology in the joint with open surgery, then you’ll get a better success rate. But if you do disc plication, you probably won’t. And it possibly is because you’ve got the diagnosis wrong.

[Jaz]

I mean, that’s I’m sure there must be like there is dentists, difference in opinions amongst all surgeons. And this is where we need more evidence in our profession to know about these, you know, long term success rates, but very good insight now when it comes to arthroscopy, as you mentioned, and then you place fluid inside to distend the joint is that then classified as an arthrocentesis. So IE arthroscopy is the exploration. Is that an arthrocentesis? Fair term to say that that’s the flushing of the joint?

[Andrew]

Yeah, so arthrocentesis, by definition is putting two needles into a joint. And that can be one needle with two lumens. But two needles into a joint, and flushing the joint fluid through under pressure with a volume of fluid. Arthroscopy is exactly the same type of that, but one of those needles is an arthroscope.

[Jaz]

Got it. And those patients who have a acute disc displacement without reduction, who maybe is in their 40s or 50s. And conservative care is not working, they’ve come to you. Is arthrocentesis or arthroscopy the next step for those patients largely and then if so, is it again, an 80% success rate? So unlock them.

[Andrew]

Yeah. So when I’ve looked at my outcomes, you know, I’ve got now a series of roundabout 2500 patients where I’ve got the prospective data of an even when you look at that group, and you classify them according to Wilke stage and Wilkes is still, it’s the only classification system we have. But it’s controversial. There doesn’t seem to be a very clear correlation statistically, that a patient with a Wilkes V, which is a severely damaged joint or deranged joint does significantly better or worse than a patient with a Wilkes II. The trend is that Wilkes II does better than Wilkes V, but Wilkes V is like a disc tear. And so 50% of my patients with a disc tear get better. Whereas if they don’t have a disc tear, and this is again, a study, which we’ve looked at 596 arthroscopys, their risk of or the success, if you’ve got disc pathology, means that about nine I think it was 9% went on to needing open surgery. Whereas if there was no disc pathology is about 2%

[Jaz]

That I’m gonna have to boil that down again, and look at all these percentages because they’re very fascinate because essentially, it’s about helping our patients. I think the first port call is to get them there, right help with you, or someone who’s experienced with that. And then these Micro sort of diagnoses that are made with surgical interventions, it’s about getting the right treatment because I’m sure you know, like you said, every surgery is unique that you do and Every patient is unique and you will not just do one thing you’ll address all the things in there. That’s what I was thinking in my head. Okay, these percentages as a general dentists, I mean, if you don’t mind me asking and this can be off the record if you want me to, as and when we send patients to colleagues like yourselves who are very experienced in this and this is exactly what we want we you know, I think we want to send, I mean in my group of hundreds of delegates, right, we are desperate for people who can help with this at the next level when conservative care has failed because because my group of dentists are really good at conservative care. So I’m actually really glad to have found you as someone to recommend who has experienced in this what are the kinds of things that we say to our patients terms of budgeting and fees because you know, this is something that you know, with NHS is massive waiting lists and whatnot and you don’t know you’re gonna get I’d love for them to be seen by us, more complex cases who conservative cares failed, what kind of because I want to set my patient up. I don’t want them to come to you and say I can’t afford this. How’s it work with insurance as you charge and and what other kind of fee structures?

[Andrew]

So most of the private health care insurance companies cover all of the stuff to do with TMD. So a lot of my patients Bupa or AXA. AXA are a problem for me because I’m not fee assured with them but Bupa, Aviva WPA, vitality, etc. All of their fees are covered. Some companies you’ll have an excess to pay, some companies don’t cover the surgeons fees. So for me AXA cut the fees that they pay by 40%, five years ago. And I didn’t want to accept that fee cut, but that’s my choice. Other surgeons will accept their fee rates so. But if you’re privately insured, it is covered by and large, and the surgeon should tell you, if you’re likely to have an excess to pay. You can find out who they’re insured by on the PHIN site, which is a government site which all surgeons have to submit their data on to and it says what they’re doing and what they have. The problem with the PHIN is that there isn’t a strict code for TMJ arthroscopy until recently. So on that site, I do a lot of ankle arthroscopy and a lot, a lot of knee arthroscopy, because it’s been coded as that. That’s changing. And, you know, hopefully it will become more apparent, but self pay, again, it varies between regions, so you will pay a lot more London prices, in Nottingham, for a unilateral TMJ arthroscopy, it’s around 3000 pounds, bilateral about four and a half. And it’s usually a day case procedure. So you come in,

[Jaz]

That includes the anesthetist fees?

[Andrew]

Everything in. Every cents.

[Jaz]

That’s retty good. That’s what I think that’s pretty good. I’m sure the figures are much meatier in Australia in the States.

[Andrew]

Yeah. They are.

[Jaz]

Okay, that’s a really good insight to have, you know, because sometimes patient unsought, to give them a ballpark figure that’s really useful. Prof. Thanks so much for that. And

[Andrew]

Consultation fees will be on the PHIN site as well, of course. You know, Mr. Sidebottom charges 200 pounds for his consultation, or Mr. Evans charges, 250 pounds for his consultation and whatever.

[Jaz]

Got it, got it. And then that’s really useful information for us, general dentists listening to this. Last thing to ask you generally is, obviously I’m really looking forward to meeting you in the flesh in May and June to do the live lectures and you get to meet the delegates who are passionate about treating the TMD patients in general practice with good conservative care. And maybe even you’re slowly inching with more complex intracapsular cases as they develop the practice which would be a great help to you I’m sure you’re desperate for dentists who are good at providing conservative care. So I look forward to meeting you live and geeking out all about that. And you get to see what we teach the dentist as well. What is the main message you want to send out to general dentists or general dentists when it comes to the successful management of temporomandibular disorders?

[Andrew]

Okay. Without swearing don’t believe a lot of the BS that there isn’t the internet. Simple management measures are largely beneficial for the majority of patients. So on my website, andrewsidebottom.co.uk, there’s a free to download information leaflet which I recommend all my patients download, which covers pretty much what I tell them in the initial appointment, which is, you know, first of all, it’s not likely to progress the surgery is not likely to develop to arthritis. The majority of patients can get better with simple conservative measures. This is what how, what’s happening, this is what causes a click. The only things realistically we should be treating in secondary care are patients with persistent pain restriction, or locking and locking is kind of gets stuck as you open or you get stuck as you close. And that is happening relatively frequently. So I wouldn’t tackle anyone with just a clicky joint, I don’t want to know, they should just be told, yeah, you’ve got to clicky joint, that’s fine. So 30% of the population, the vast majority of people don’t develop problems with that. But you are slightly more prone to develop problems because of it. But just because you’ve got it doesn’t mean that you’re going to have problems.

[Jaz]

Yeah. Are you more in demand after the pandemic, in the sense that do you think there is because of the stress and the change and the lifestyle changes and the work from home and you name it? Do you feel as though in your practice these are resurfacing now?

[Andrew]

Yeah, I think everyone has seen an increase in TMD type issues. Because as you say, of the clenching and what have used the stresses of it all. Obviously, my viewpoint is somewhat skewed, because I’m dealing next door to a trust, which has a 40 week wait. So before the pandemic, 10% of my patients were self pay. Now, about 50-60% of my patients are self pay, because they don’t want to wait for two weeks to get a diagnosis. The other interesting thing, which is just an anecdotal aside, I’ve seen more facial cosmetic surgery in the last year than I have done in the last eight years.

[Jaz]

Is that you mean like facial cosmetic surgery gone wrong.

[Andrew]

Zoom faces. No. Looking at their face on Zoom and thinking, Oh, my chin looks a bit fat, my chin looks flat, what my wrinkles

[Jaz]

Indeed the zoom, boom. Thank you so much, Prof, for giving up your time to come on the podcast. I really appreciate I think we covered a lot of ground today. But like I said, I look forward to meeting you. And going a little bit further for those dentists who are already a little bit inclined towards this. This will also help them but we’re gonna go a little bit meatier and a little bit get again to the nitty gritty. So thank you so much for giving up your time today.

[Andrew]

Not all, cheers.

Jaz’s Outro:

There we have it, guys. A interesting perspective there about what happens if conservative care fails. What about those complex intracapsular issues. Thankfully, they’re not as common as muscular. Muscular issues are far more common, which is why the splint course can help so many of you who are looking to delve into a world of TMD, but you don’t want to go limited to TMD. That’s what I do. I’m a restorative dentist. I like to do my rehabs and stuff. I like doing Invisalign. But I’m confident when it comes to TMD consultations, and I refer the really complex ones which are intracapsular on because their success rate is lower in those cases. So I’m very good at screening about success and how it can help the majority and majorities patients just need a bit of TLC, education, physio and a splint. That’s it. Now if you’re looking for a live in person version of this, it will take like three days for it to happen. But if you want a one day introductory live course, I’ll be teaching with Kreena Panchal, our physiotherapist at the Dentinal Tubules Congress in October 2022, later this year in Heathrow. So if you don’t learn more about that go to protrusive.co.uk/congress that’s /congress. That will take you to a page more about our course how to do a TMD examination, how to palpate the muscles, how to come up with a differential diagnosis and how to work alongside your physio and which occlusal appliances to consider when, that’s what we’re covering throughout that day and the Tubules Congress if you’ve never been to it, it’s electrifying. Such a great atmosphere of dentists, the energy is just through the roof, you’ve got the best educators, you got the best parties. So wherever you’re on the world gonna come to Heathrow London in October, join the Congress. It’ll be amazing to see you and if you want to book onto my workshop, it’s seven places left only so check out protrusive.co.uk/congress. I’ll catch you in the next episode, guys. Thank you so much.

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I’m so excited to bring you another one of my favorite people today: Prav Solanki. I’ve said it before and I’ll say it again, “for every CLINICAL course you do, do a NON-clinical one”. This is super important. We talk health, relationships, business growth – and if you listen all the way to the end, you’ll learn a BRILLIANT way to build social proof in to a consultation that is elegant.

https://youtu.be/zmQsC99_MoU

“The definition of success for me: To be able to do what you want, when you want, with whom you want; without any financial constraints.” Dr. Prav Solanki

The highlights of this episode:

8:46 How Prav became a Dentrepreneur
17:28 Work Life Balance in Dentistry
31:50 Importance of Pitching
43:57 Importance of Social Proof on a Consultation Appointment

All of the Protruserati clan get 10% OFF the Business and Mindset Mastery with the code ‘protrusive‘!

Check out this blog with Dr. Prav and his 21-day fast experience

If you enjoyed this episode, you will also like Being Unstoppable with Ferhan Ahmed

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Zirconia Veneers!? eMax vs LiSi? Which type of Zirconia should I use (and yes, there are 3 main types of Zirconia!) and is there still a place for Feldspathic veneers? These burning questions is why I brought on the OG: Ed McLaren. What Dr Ed McLaren does not know about dental ceramics is not worth knowing, and he gives it all away on this cracker of an episode which is sure to go down in Protrusive Hall of Fame!

https://youtu.be/ZR-V-ekhMv0

Protrusive Dental Pearl: How to mask a metal post? For me, a post-core is just a space-filler, it’s a way to retain some sort of foundation/core restoration. I do not mind cutting it back a little bit – below I share a video of how to mask a metal core using Paracore White Opaque, to help my ceramist. You can also use an opaquer resin such as Ivoclar Direct Opaque – it’s like Dental Tipex!

Want to download the 1 page summary of all the indications for free? Click here to access the download.

https://www.instagram.com/reel/Cd0P2mJqNUn/?utm_source=ig_web_copy_link

Enlighten Smiles sponsor this episode. I know some of you feel that we can’t make composite look as good as ceramic. Well, you need to check out the work by Dipesh Parmar. His course is called Mini Smile Makeover where he teaches his techniques using Renamel Composite and other brands to give you some amazing results working with composite resin.

Highlights of this episode:

11:07 Feldspathic Ceramic in terms of Patient demand and Dentist skill set
18:26 Shortage of skill set from Technicians in the future
20:41 Composite vs Ceramic Veneers
23:11 APC Protocol in Zirconia for Veneers
29:10 Posterior Zirconia Onlays
31:42 Decision Making regarding Biomechanical status of the patient
37:29 Ivoclar eMax vs GC LiSi
39:57 Different types of Zirconia
50:00 Restorative protocol for wear cases

Check out these studies as mentioned by Dr. Ed McLaren – if they are not showing up on your usual podcast player, be sure to visit the show notes on the protrusive website.

Influence of Enamel Preservation on Failure Rates of Porcelain LaminateVeneersDownload Check out the Hands-On Courses by Dr. Ed McLaren

If you like this episode, you’ll also like Dr. Chris Orr’s Composite vs Ceramic

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How much money is enough? Let’s face it, General Dentist is one of the most challenging jobs in the world – what level of income is worth the stress and health risks? This is a very personal question and will vary according to each Dentist’s money mindset and personal values. Dr. James Martin joins us again to discuss personal finances for Dentists.

https://youtu.be/QwtQ43cU2uY Check out this full episode on YouTube“Your rich life is determined by your little network, your family, your friends, your nearest and dearest – THAT is worth more than any amount of money.” Dr. Jaz Gulati

The highlights of this episode:

4:28 How much money is enough for Dentists?

11:42 How does one decide how much money is enough for them?

15:16 When do you envision Retirement?

18:57 Financial Independence

23:23 Importance of Saving

36:40 Should associates look towards practice ownership?

41:41 Summary Points

Check out this book recommended by Dr. Jaz: I Will Teach You To Be Rich By Ramit Sethi

If you enjoyed this episode, do check out Money – 5 reflections to help you get started with Investing

Full episode transcript available within 72 hours!

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