Intro

[Jaz]
You potentially have an upset patient on your hands. This patient is potentially pointing some fingers. Now who should the finger go towards? Should the finger go towards the implant placing dentist? or the implant restoring dentist. It’s a bit of a medical legal minefield. So I’m joined today by Dr. Joe Bhat, who’s both an oral surgeon and a prosthodontist, so he’s in a great position to be our expert today, as well as Dr. Neel Jeiswal, who I rely on so much when anything, when it comes to medical legal, and indemnity

This episode is CPD eligible on the Protrusive app called Protrusive Guidance. I think you’ll learn a lot about communication, consent, and a proper medical legal management when things go wrong, how they work with each other. So we can benefit and really help our patients because ultimately everything we do is It’s for the benefit of our patients.

Dr. Joe Bhat, welcome to the Protrusive Dental Podcast for the first time. And Neel Jeiswal, welcome again, my friend. Neel, you are the representative of PDI and a clinical dentist that we love having on because your medical legal perspectives are absolutely fantastic, and also your years of clinical experience. But Joe, I don’t think we’ve met before properly, so it’s great to be introduced by Neel. Joe, tell us about yourself as a practicing dentist. What are your interests?

[Joe]
Thank you so much for the invite. I know it came via Neel, but I’ve heard a lot about you, Jaz. So good to be e-connected finally. I am a dentist. I’m a prosthodontist and an oral surgeon. So I started my life as an oral surgeon, did six, nearly seven years of Maxfax, did my, the old time fellowship, the FDS- RCS. And then I went back to dental school and did my specialist prosthodontic training. So I did my MClindent and MRD. We were the first batch.

I was the first student, my surname beginning with B meant that I was my first student ever to get a monospecialty training pathway in prosthodontics. So I became a dual specialist in 2001. So that’s 23 years ago. And we set up a specialist practice. The idea of the specialist practice at that stage was at that time, when I set up the practice more than two and a bit decades ago, was all the specialty centers were more specialty training pathway, more specialty clinics.

So, there was a periodontal clinic, or you could send it to Lister house for endo and so on and so forth. So we were the first ones to set up a multidisciplinary one stop shop for specialist referral center. We had nine specializations under one roof. So, 20 odd years ago, it was a crazy concept.

Now there are multiple centers, which are multidisciplinary specialty centers. We are proud still to have all nine specializations under one roof, which is great. They have a great team. So it’s a 10 surgery practice and we take about 1, 700 referrals a year from 370 dental practices. So it’s a well established practice.

We are less known because we are not on the social media very much. Everything is done through word of mouth. And we sold to Dentex about 18 months ago. So having run it for as many years as I did, I thought, I think I needed to offer the platform for somebody else to take you to the next level up. So we were successful practice.

We are very happy doing what we do. I’m a full time implant surgeon. That’s all I do for the last two and a half decades. And I’ve gone through various phases of placing and restoring to. Pretty much now I only place implants. So I have a team of prosthodontists with me who restore my implants for me.

[Jaz]
But this is a very unique show because I’m very excited now based on what you’re saying, because I didn’t know you were both oral surgeon and prosthodontist. And the reason that excites me because the topic we’re covering today, like I’m very grateful to have your specialist knowledge in both the prosthodontic restoring side, but also the surgical side.

I guess if I was speaking to someone who’s just an oral surgeon, there might be some bias. If I was speaking to someone who is just a prosthodontist, there might be some bias. Okay. But I’m really excited to see what, hear what answers you, have actually in terms of satisfying, from the perspective of both those individuals, if you like.

[Joe]
Yeah, we’re fortunate. I think five of us in the UK who are prosthodontists and oral surgeons. So it’s a small select group of guys who are nerdy enough to go back to dental school and doing one specialist qualification is bad enough. Doing two is a complete nutcase you know? So, I’m-

[Jaz]
That’s up to you, someone’s got to do it.

[Joe]
Somebody’s got to do it. So it was me, I had M U G written on my forehead.

[Jaz]
Not at all, not at all. I’m very excited to break down a conversation. Neel, my friend, just for those who haven’t listened to our previous episodes about indemnity versus insurance or the various scenarios that we’ve covered already. Just give us a refresher on who you are, Neel.

[Neel]
Thanks Jaz. And again, thank you, Joe. Nice to see you again. Joe is such a great guy. Brilliant at what he does. Understated, family man, always be there for you. Although we tried to arrange Sunday and you didn’t get back to me, did we? We’re trying to arrange a family day out.

I know you’ve been busy, but no I’m a practice owner. I practice in Hertfordshire, very much like Joe. My background was going to Frank Spear about 10, 11 years ago and realizing we need to link all these specialties together and there’s a pathway of doing it the right way. So again, we had probably not nine specialties, maybe four or five, and we’ve kind of developed that over the years, but still a small family practice.

And a couple of years ago, maybe five, six years ago, a lot of my friends were getting in trouble with the GDC for no reason. And indemnity was looking like they were letting people down. So I kind of fell into indemnity and it’s been a lovely pathway of helping dentists. That’s the way I look at it. And that’s what we do. We help dentists at PDI.

[Jaz]
Amazing. So I’ll put the links to PDI and everything as well, as well as Joe. Joe, again, I’ll ask you again at the end about any teaching, any resources that you have, but we’ll be sure to put your websites.

[Joe]
And a little plug that I’m also a client of Neel. So. You know, so I, myself am-

[Neel]
A good client. There you go.

[Jaz]
Someone like Joe is a client and that speaks volumes, I think, as a mind, as you guys know. But anyway, scenario. This is a really cool scenario that Neel has written. If there’s anything wrong about the scenario, blame Neel. But essentially a 55 year old male patient, night shift worker.

Now, every time I say something, I could let you, Joe, break it down, but there’s so much to discuss in this that I’m just going to, like, say what comes to my mind as we go through the scenario. So, I’m basically thinking, why did Neel put this in? And if I get anything wrong, Neel, you tell me. So, 55 year old nations, age is important always, the younger we are, the potentially the better we might also integrate, or maybe the decision making may change in terms of age night shift worker.

So quality of sleep that might be a detriment here, non smoker, which is important. Obviously smoking, we know has an impact on your osseointegration, but Joe, you’re the expert on that, upper right first molar, upper first molar. So Joe, I’m setting the scene for you seen this already, but I’m just reminding the guests, you guys, and also the audience about this.

So upper right first molar on this 55 year old male, there’s some crowding. The perio is stable. The patient is a snorer. Okay. And there is bruxism. So potentially higher occlusal forces, potentially. Now I’ll be interested to ask you, Joe, later about how you may or may not treat a bruxist differently to a non bruxist kind of thing, if they exist, et cetera.

But we’ll talk about that. Now, the dentist refers the patient out to an implantologist. Doesn’t exist, but let’s go with that. Who successfully places the implant without complications. Okay. Patient returns a few months later for the crown fitting, okay, with the referring dentist, okay. However, six months after the crown fit, because there’s two ways you can do this, so the surgery’s been done, we’ve waited some time, a few months later for the crown to be fit, and then six months after the crown’s been fit, okay, the implant fails due to peri-implantitis, leaving the patient dissatisfied and wanting compensation. Anything do you want to probe on so far before you go for the individual questions, Joe?

[Joe]
No, I think it’s pretty, pretty explicit. It’s quite well written, case study.

[Jaz]
Well done, Neel.

[Joe]
So, there, and the good news or the bad news, I suppose, is that it is not a scenario that is alien. It happens quite often. And it only comes to surface, I suppose, when things go wrong, because a lot of the training of pretty much all the dentists that we do in implant dentistry is training how to do things right. Not a lot goes into what happens when things go wrong. So when you are sitting and looking at these kind of scenarios is obviously something is going wrong. Where do we go from here? So from a question, but if you know, I don’t have any more to probe. I kind of understand the scenario because I’m well versed with it.

[Jaz]
Brilliant. And I think the way to think about this, the rest of the episode is, whilst it’s good to have some clinical gems in there, like what kind of restoration was done, screw retained, cement retained.

I’m sure we’ll go into that and have those little clinical nuggets to reduce our complications. Really the crux of this episode is the medical legal side, the communication. Ultimately it’s communication, ultimately it’s consent, ultimately it’s how do we liaise and communicate with our colleagues when something like this happens. So that’s the mainstay of it. Neel, anything to add now that I’ve read out this scenario? Is my interpretations correct in terms of why you included certain factors?

[Neel]
Well, I think definitely, we’re all seeing bruxism on the rise. We’re all seeing sleep apnea on the rise. We’ve seen a modern diet is appalling. So glucose control. So what I’ve seen shift workers, they don’t sleep well. And we know this for a fact, generally they don’t sleep well. And that leads to AOSA, you’ve touched on this in the past, Joe and Jaz. So I think there’s an element of bruxism, but there’s also an element of glucose control.

I find shift workers eat very erratically and all at the wrong times. And I’m also going to ask Joe later, he’s like, in terms of what does he feel about glucose control and pre diabetes in terms of managing these and evaluating these patients.

[Jaz]
So it’s good you planted those things in there because this is all systemic health, which is related because ultimately surgery, the results of surgery will be impacted by the patient’s health. And the other one commonly is vitamin D, how many of us are lacking vitamin D, which I’m sure Joe is going to talk about kind of thing in terms of when we look at the patient factors and medical factors associated with failure, which I’m sure are so vast. And because we don’t know, even more details.

We don’t have radiographs. We kind of have to infer and come up with our own scenarios, but ultimately to answer the following questions, which are number one, how should the dentist deal with the situation of the implant failure and the patient dissatisfaction? Number two, discuss where the responsibility lies of a case of implant failure and patient dissatisfaction, i. e. Do we point the finger at the surgeon? Do we point the finger, he who touched it last kind of thing, right? If you touch it, you own it. So is it the fact that it was, once it was restored, is it now the prosthodontist or the dentist who placed the crown?

Is it their fault or question three, which is what considerations should a referring dentist look out for regarding the choice of an implant surgeon based on this scenario? Very fascinating, actually. So, one at a time, you have an upset patient, Joe, in front of you, not in front of you, but the referring, the dentist is the patient’s upset because their implant, which they paid some money for and had some surgery for, had some time and money invested into, is now failed. How do you want your dentist to manage the initial part of such a scenario?

[Joe]
I only but presume that the patient is obviously going to go back to the referring dentist or to the restoring dentist rather to start with. I’ve not made any notes about this because I think I want it to be a free expression of how I feel about this case.

With regards to dissatisfaction, unsatisfied patient, one of the primary reasons is they were not informed in the first place of the scenarios of what is possible. I wouldn’t mind a patient being saddened by an event of an implant failure. A dissatisfaction, meaning the satisfaction has been dashed. That means the communication fell apart to start with.

Patients often ask us, will this last forever? And my last response always is you and I don’t last forever. Everything has a finite life expectancy. So one has to manage expectations. And this is where we go wrong so often, a statement I make sometimes saying, don’t promise them the Earth and give them Uranus, it’s very, very important for us to make sure that we promise the right things.

Do not over promise and under deliver. You’re better off under promising and over delivering because that is where the issues tend to lie because the patient is dissatisfied because he did not even expect it that it could fail. at this early stage did not have-

[Jaz]
Joe, can I just stop you there? Because firstly, I’m loving what you’re saying. And I love that distinction between being saddened, which you would expect anyone to be sad when this fails, right? But dissatisfied has different connotation. It means there was a problem with the consent. It was a problem with the communication. And so the next question I will be asking you on this vein is, okay, just like you said, you under promise, over deliver, but what kind of actual verbatim do you use your patients in terms of, okay, how likely is this to happen?

What happens in the event of that? What kind of conversations you have beforehand, before it even happens. And the reason I say this, because the theme we’re talking about now, you can apply it to a lot of other things in dentistry. For example, specialists and endodontics. A patient can have a fantastic root canal under a microscope and six months later, they need a tooth out because the root canal failed.

It can be in all sorts. So we can actually use a similar theme. The patient was saddened, but maybe if the patient wasn’t told that there’s a risk of failure, and then that wasn’t made tangible enough for the patient, then they would be dissatisfied. So tell us about what kind of conversation do you do so that you don’t have a dissatisfied patient, but you have a saddened patient.

[Joe]
Yeah, I think when people ask me, will this implant fail? And I will always say in my experience, everything that a human being does on another human being has a failure rate. The question of failure is if it’ll fail or not. It is when will it fail and how much of longevity will I get out of this in my life expectancy.

I use all kinds of analogies, including saying the Lord created the teeth for you. If they could fail, what are the chances of something that a human being is doing for you? So we have lots of little, little things I use to make sure that nothing is more healthier than a natural tooth. Remember an implant is not being done as a replacement of a tooth.

It’s being done as a replacement for a space. Okay, so there’s a big distinction between the two. You’re not giving a like for like replacement for a tooth. You’re just providing the best replacement for a gap. In all the choices of having either dentures or bridge work or implants, this is my favorite choice.

So we have literature, we have data, and one of the key things that I always show my patients is my own data. I have an Excel spreadsheet going back to 2001 to 2024 of every single implant that I have placed. I placed implants since 1996, but from 1996 to 2001, I did not own a computer. So I didn’t have any data set.

So it was handwritten notes, which I still have it somewhere, but I’ve lost most records. But so I’ve got data stretching back 23 years of every implant that I have placed. And therefore, when I give data, I can’t quote my own data. I don’t quote literature because that is irrelevant. It is probably done in test conditions in a teaching hospital and so on and so forth.

So I always make sure that I manage their expectations realistically. I say it will fail. What are the things that may make it fail? Is if just like your teeth failed because of either lack of maintenance or things that have gone wrong in dentistry, et cetera, same things can happen with implants.

In other words, If you’re not taught how to clean around implants, it will fail. If you develop gum disease, it’s bound to fail because as you progressively get older, your manual dexterity will fail you. When your manual dexterity starts to fail you, your ability to clean around the implant will start to fail. That’s when implants starts to fail.

[Jaz]
Let’s talk about your data. If you don’t mind, Joe, what is your data showing since 2001 to now? Firstly, is it success and survival? And then how do you make those distinctions? And how do you, what do you communicate to the patient?

[Joe]
Currently, the data is only on survival rather than success because we have, if you look at success, there are so many parameters, so many parameters, even a loosened crown is considered a failure.

[Jaz]
Or porcelain fracture could be a failure.

[Joe]
The parameters are too huge for us to record it in a clinical environment, in a dental practice, in teaching hospitals far easier. Because they’re providing the implants for free for patients so they are willing to come back for their checkups. Here it’s a bit more challenging.

So it’s more to do with survival rather than success and the data for us that we have in non smokers, in non periodontal disease patients is 99. 6 percent. So it’s very, very high over a 10 year period. Do we follow up all our patients back in our clinic? The answer is no. But we follow it up with a telephone call.

So we have a recall set up. So we do our recalls at yearly for the first five years and then five yearly from that point onwards. But of course, those five year appointments, sometimes patients turn around and say, I don’t have any problem, so I don’t want to come. So we record that as patients saying that there was no problem. In other words, the implant is still there. So you have to find your own mechanisms of recording your data. There is no hard and fast rule. There’s literature and there’s literature.

[Jaz]
Well, the next question I have then is, this scenario that we’re talking about, this 55 year old male, peri-implantitis. And so I’m going to go back to the scenario and I’m going to pull it up, right? So he said the implant fails due to peri-implantitis. Now, according to the survival criteria, would this go down as actually it’s succeeded because it will be a positive in the survival data or was this count as a negative because the implants still in the jawbone? Interesting distinction here.

[Joe]
For me, if the patient got peri-implantitis and has a problem as practically the removal of the implant is imminent, then that’s a failure. That success has turned into a failure. That’s it, zero. If that’s the only implant you’ve placed, you have a 100 percent failure rate.

So, this is important. The reason I’m saying that is because people make a lot of promises on their implant success rates. The people who say that they don’t have implant failures, they belong to two categories. Either they don’t place any implants, or they lie. Because anybody who places implants knows that there will be failures. It’s just how to manage them. So-

[Jaz]
It’s the same with any part of dentistry, right? Anything with this endodontics or occlusal appliance therapy, whatever it could be, there’s no one going to have a hundred percent. And so always be careful to people who claim anything is a hundred percent. So we’ve already established the whole thing about dissatisfaction and saddening, which I think is this brilliant distinction.

Neel, anything you want to add in terms of in the medical legal space, have we seen a trend that a lot of the complaints that are coming, are they implant related or are they not so much in terms of the, because it’s a heavier fees involved often people might think that, okay, there might be more litigation.

[Neel]
From what I’ve seen is the people doing lots of implants, and when I started doing implants, I was jack of all trades. So I placed maybe 50 in my life and I got to the point where is I need to invest all my time to do this well. So I cut back on it. So we’re finding a lot of people like Joe who do lots and lots of them.

We don’t have really any problems with them. And to be fair, they pay a low premium. They’re a great risk for us in terms of we don’t hear from them and they know how to manage their patients with great communication skills, all those kinds of things. You do get the odd blip where there’s suddenly a couple of hundred grand payout, for big implant cases, all on fours and that kind of stuff.

And what happens in those cases, those dentists then become uninsurable. Some dentists aren’t as nice as others and they just think, fine, I’ll take one on the chin and I’ll just keep going down the route I’m going. But actually, they’ll get to a point where nobody wants to insure them and they’re sort of forced out.

So in a way, the system encourages good dentists to keep doing what they’re doing and it drives out bad dentists. So I generally think if you look at ADI, if you look at ITI, if you look at some of the people doing courses, we’re really taking implants seriously as a profession and not just dabbling in it so much.

So I don’t think it’s a higher risk. I don’t think placing or restoring is a higher risk either way, and we don’t charge more for restoring. So I actually think it’s a good thing to get into, but I would do it well and devote your time on it. And what I wanted to ask Joe really was, do you have referrals from restoring dentists?

[Joe]
Yes, but in my experience of 20, now 24, 25 years of staying in the same center is the number of dentists who restore my implants has significantly gone down. So-

[Neel]
Why do you think that is?

[Joe]
I think the initial influx of dentists restoring and somebody else placing in a different center, I’m talking about a different center, I suppose there has to be a distinction as well on is it being done by visiting surgeon and restoring in the same center.

Are you talking about two separate centers? So let’s start with two separate centers first. I am placing it in my specialty center and they’re restoring it in general practice is the dentist kind of feels now that the initial drive came from implant companies, implant companies wanted, oh, we’ll get all these dentists to refer to you.

So, and we’ll teach them how to restore in their practice. It’s literally like, I think there’s a rule. Not that I know much about NHS dentistry, but you cannot have two lots of treatment, or it can be an NHS and a private treatment on the same tooth.

[Jaz]
And the mixing component.

[Joe]
Exactly. So if you’re treating the same missing tooth rather with an implant, and then one person is doing the surgery, one person, where does the responsibility lie? Hence the discussion, this whole discussion is all about that. So as time has gone on where people have not had a distinction of where the responsibility lies, my referring dentists are more and more opting to not restore. Okay. Is it right? I’m looking after their general dental health. Please feel free to place and restore and when it’s done, let me know the number of restoring dentists in our practice out of 370 referring practices, not practitioners who refer to us.

The percentage has fallen substantially. I would, if I were to give you a number today, I would say less than one percent of the implants I placed are restored outside of my practice. To give you a comparison, as recently as, well not recently, as, as 10 years ago, that number would have been closer to 10 percent. 10 percent down to one percent in 10 years.

[Neel]
And do you think that’s a good thing, Joe? Do you think that’s a good thing? Do you think it’s safer?

[Joe]
I personally think it’s a good thing for one person and one person alone, which is the patient. Because I think at the end of the day, he’s the one who’s putting his hand in his pocket and paying us for our services.

As I say in most of my lectures, when a patient can place their hand in their pocket and give us three grand or four grand for an implant, they can put the same hand in the same pocket and give a grand to a solicitor. So if they can afford me, I promise you they can afford any solicitor. And therefore I always look at any case as a litigious case just to make sure that I can provide the right level of care.

[Jaz]
Chaps, for the summary of this question one then, really it’s all to do with the initial consent and the initial discussions that you have and that’s what’s good communication.

[Joe]
Communication key.

[Jaz]
Now let’s say the communication was, obviously it would have to be not good enough to get to a stage where someone is dissatisfied. And so now we have a scenario where the patient is dissatisfied, not just saddened and dissatisfied. They want their money back, something they’re like, this is ridiculous, I’ve only had it six months, and now you’re telling me that this, I spent so much time and surgery on this tooth, it now needs to come out because there’s been this gum disease around the implant.

There’s a question too, as Neel wrote, is, where does the responsibility lie in such kind of an implant failure, i. e. is it with the implantologist in quotation marks who placed the implant or the restoring dentist? How do you tackle this?

[Joe]
From my perspective, it is very, very straightforward. So that before we even communicate with the patient, there should have been absolute perfect communication between the surgeon and the restoring dentist. So before even a first patient is ever seen, we got to establish the responsibility protocol. Who is doing what? And any case like this scenario that you just posted, I have no doubts in my mind that both are responsible.

Because there is no way an implant surgeon could say, I gave you a fully integrated implant, now it has failed. Surely it’s your responsibility. An unrestored, an unloaded implant, placed into either poor quality of bone, or even into bone which has no buccal shell, for example, it’ll still integrate.

But the tooth will only surface when you then start loading it. So as soon as you start loading it, that implant fails, not because the loading was poorly done, but the implant was poorly placed. So, the responsibility can lie straight from that corner of initial assessment, right up to the final fit, in a bruxer.

You know how is the occlusal platform of this tooth maintained? There is nothing other than shared responsibility that I would accept on a case like this. Because I think, just because the implant was integrated at the time of start of restoration, implies that the implant was well placed.

[Neel]
What would you do, Joe, if I rang you and said, Joe, the upper right six that I restored, the patient’s kicking off now. Can you help me here? Because obviously, I can’t place the implant, so. Even if you felt it was my responsibility, I’m relying on you. What would you do as my referring implantologist to help me out?

[Joe]
This is unfortunately when we stop working with our head and start working with our heart and we start feeling, and so we should, we are a caring profession. Why wouldn’t we work with our heart, you know? So we need to work with our heart because we want to convert the dissatisfied customer or patient to then being singing your praises. So taking them under your wing, say, you know what, I will give you my time for nothing. I’m very happy to replace that implant at no additional cost to you.

But of course, I’ll communicate that with the referring dentist to say that, you know what, as long as you are happy to then do the crown on top of that, so have I done mistakes? You bet, there are tons of mistakes that I’ve done over the years, but then I’ve been placing for so many years. I have looked at my own cases that I did 15, 18 years ago, I looked at the case thinking, Oh my God, Joe, Bhat what were you thinking?

Because at that time, the teaching protocols were different compared to what they are today. We were very, very small handful of people who were placing implants. When I placed my first implant 28 years ago, I think there were about 10 of us in the UK. We were placing implants. So it was a very small number. So, but the responsibility has to be joined, but I think that also kind of a failure needs to be used as a trigger for the two dentists to get their hands heads together to sit down and have an honest heart to heart chat to say you know what this shouldn’t have happened.

This implant shouldn’t have failed here are the protocols that I followed here the protocols that you followed what could we have done differently remember we do not comment on what went wrong. Whenever I do my teaching I always talk about what did we do right? And what will you do differently? It’s a more positive spin to a negative result and what we do differently, we could have done this, we could have done this and we learn from it.

If you have a failure and if you don’t learn from it, you might as well have not have bothered. So I think learning from, from your experience is so, so critical and have I placed in word commas, free implants for my patients over the years? You bet. You know.

[Jaz]
Because that’s been the right thing to do with that because you genuinely care for the patient. But here’s the interesting distinction playing devil’s advocate, right? The scenario we’ve pitched you is the dissatisfied patient because obviously something down in the communication didn’t go so right.

Imagine you do as you do now with the years of experience you have, you think you’ve nailed the communication. You’ve told the patient, look, you’re a shift worker and you’re a bruxist, although you don’t smoke, which is brilliant, but there is a real chance that this could fail here, right? And there aren’t any refunds here.

You’re paying for my time and expertise. And then when it does go wrong, the patient is perhaps unjust, unjustifiably, dissatisfied. They’re saddened, but they’re converting that saddening into dissatisfaction to try and reclaim some funds or just this is their way of coping with this scenario now. In that patient, would you then also be like, oh, come on in. Let’s see if we can sort you out. Or is that now a different scenario?

[Joe]
Let me understand this question better. So you’re saying what additional thing would I do just because he is dissatisfied to try and win him over or, what is the-

[Jaz]
I think the difference here is I love what you said that from the heart you’re going to do an implant, I have to restore a dentist, and that’s a great way to, to help someone, right? But, and thankfully our success rates are high, failures are low. And so when that failure happens, we learn from it and we help the patient out. But the whole thing is that you did your consent and your communication so well at the beginning, such that the patient should not have an expectation of a free implant.

And so you expand it and the patient should pay again, really in an ideal world. If it’s going to be like, lawyers and that kind of stuff, like, okay, you pay for my time, you pay for my time kind of thing. And so I guess what I’m trying to ask is, is the implant surgeon and the dentist justified to say that actually it’s failed?

We’re sorry, but it’s failed. But this is out of our control. If you’d like to have the procedure again, it will be a fee to remove the implant and it’ll be a fee to do a new one. Would you like to go ahead or not kind of thing. So someone who doesn’t want to get involved in that.

[Joe]
I think part of it, Jaz and Neel, also depends upon your loyalty to the center or the business where you’re working in. How much of goodwill do you want to create? Being in the same center for as long as I’ve been, of course, my whole ethos is to create goodwill. And if I’m a visiting surgeon to a center, would I have the same goodwill? I would do, I should do. But is it across the board that every visiting surgeon has, the keenness to develop goodwill within a center, perhaps not and that’s when it comes to roost, why do sometimes practices get visiting surgeons come and visit their center because they want to keep the money in the house.

Why is a visiting surgeon coming to visit you? Of course, to earn money, does he have loyalty to that one center when he’s going to say 15 different centers? Why would he? So the loyalty, in my opinion, with those kind of visiting surgeon, genuinely tends to lie with the practice owner while in the center.

Where the surgeon is see, embedded and concreted into the floor and the wallpaper of the fabric of the building. Then, so the answer is very simple. I would do that free implant because I want to maintain the goodwill within my center. I want it to go back, God forbid, if the good news spreads from one person to another person, bad news spreads from one person to 10 other people, you know?

So I want him to go back and say, you know what, Joe Bhat’s practice, yes, there was a problem with the implant, but he sorted it out for nothing, you know? I would rather take that gesture all day long. I’ve always, always learned very early in my life, you can’t win them all.

[Jaz]
That’s fantastic. I appreciate again, the human side and the care that you’re showing is fantastic. I think we can all learn from that and take a leap from that. Neel, what do you feel about the medical legal aspects that when something like this happens, do you think someone with a Joe’s experience and let’s say Neel, if you are the referring dentist, for example, you both experience your great practitioners, in my opinion, and therefore, are you happy just to crack on with it and manage the patient like this just in the textbook way?

And let’s make it right for the patient? Or do you think this needs to be done as well as informing the dentine ad by the way, this has happened, but we’re going to crack on with it. We’re going to look after the patient. Don’t worry. So is there any role and responsibility of any of the individuals to actually inform their indemnity insurance provider at any point? Is this something that surfaces?

Interjection:
Hey guys, it’s just Jaz interfering here. Hopefully you’re enjoying this episode so far. I just want to remind you that if you’re in a situation where you’re renewing your indemnity or your insurance. Do take a look at what Neel has to offer with PDI, that’s Professional Dental Indemnity.

Both me and Joe Bhat are clients of PDI, and I’ll be honest with you, the main reason I switched at the beginning was I need to save some money. I mean, indemnity was getting really expensive and I never even had a complaint. So when I discovered the thousands I was saving with insurance, it kind of appealed to me.

But I trust Neel a lot and he guided me through the whole process. Including when I jumped between different insurance products. And what Neil’s taught me is that there is a difference between every insurance product. And to be careful not to fall into a trap whereby your previous years may not be covered if you’re with the wrong type of cover.

Now, if none of this is making sense to you, please understand the difference between indemnity and insurance. And listen to episode GF019, that’s Group Function 019, where Dr. Neel Jeiswa will fully explore, he educates me on insurance versus indemnity. And as part of the episode, we encourage you to get a quote.

Get a quote using protrusive.co.uk/insurance. That’s protrusive.co.uk/insurance. And see how much money you could save by switching to an insurance product. And on top of that, you get a hundred pounds off. This is an affiliate link, which means it does support Protrusive. But you’re doing it in a way that it saves you thousands as well. And of course, Neel is always happy to help and guide you. He’s even on the Protrusive Guidance app. And you can totally just DM him. Let’s now rejoin the rest of this episode.

[Neel]
Good question. Yeah, I think that was my, you know, patient and in the kind of patients we have in our practice, we try and develop long term relationships with them. So you would hope that yes, it’s failed and this is what we’re going to do. And Joe’s going to come and help me and we have Joe is going to come and help me because he cares about the patient, but also he cares about our friendship and he’s not going to let me down. And also commercially for him. You want to get more referrals, and I’m not going to refer to him again if he drops me in it.

So, generally I would agree with Joe that we would do the right thing, we’d always want to do the right thing. If we’ve consented everything and done everything beautifully, should the patient pay? Probably? Maybe? But, you’re opening up a can of worms, because if it becomes litigious. The amount of stress you’ll go through, the amount of issues it will cause with your family life, with your practice, with all these things.

Some of us have very thick skin, I don’t. And I just want to get this sorted, let everyone move on and everyone be happy as quickly as possible. But when you’re starting to get involved with lawyers and you’re waiting for that letter or they’ll use a GDC as a weapon, and we’re going to start looking at everyone notes, and in this scenario we would be looking at the implant notes to say, was it placed buccally, lingually?

Was the emergence profile correct? Did they report on their CBCT? Did they get a medical history? There’s somewhere there could be a flaw that’s going to drop Joe in it. Or, same with me, they’re going to look at it and say, well, did you discuss whitening? Did you discuss ortho before this implant was placed?

Did you, well, you’ve been remiss, you’ve been remiss there. So, it’s not going to end up well for either of us, I don’t think. Even if we’ve done nothing wrong, there will be something in there that might be pervasive. So we want to look after our patients. I, we work in a small village where Joe works, it’s, it is London, but it’s a community, it’s rural, and with all those referring dentists, as you said, Joe, word gets out.

So you want to do the right thing. But yeah, if it became medical legal, there would be a dissection of the notes. And it would be me versus Joe on where the blame lied, or we would share the responsibility. And that’s really a matter for the indemnity to get together to figure out how they’re going to deal with it. But it’s not nice.

[Jaz]
You two, you wouldn’t need to necessarily approach, you’re very well capable of managing this patient. And there’s no need to bother in them and say, oh, by the way, this is happening because you guys are very happy to help this patient out.

[Neel]
I would, I would. One, there’s no complaint letter. There’s a dissatisfied patient and we’re managing it. And if I rang my indemnity company up, which is the same as yours and Joe’s, and I said, I’ve got this patient, this implant’s failed. We’re managing it really well. I think the patient’s on track. If anything happens, I’ll let you know. They’ll go great, they’ll log it, they’re not going to hold it against me.

They’re going to probably think, actually, Neel’s a decent chap, he’s being really honest with us, and he’s letting us know what’s going on, and we’ll log it. And if that does develop, there’s no issue of me not telling them, or, you’ve handled it the wrong way, or, why did you not do that and not do this. And not to say that they would do that.

But informing them, it just makes you look like a better proposition to be honest, you look honest because as we know Joe, we all have failures. So you’re just saying I am human, this has happened and we’re dealing with it and they’ll go brilliant. And it won’t come to rise at all if nothing happens.

And if it does happen, they’ll be like, Neel’s been really honest with us from the start. We can do everything we can to help him. So, you have to play it by ear. Now, if it’s a broken filling, I might not tell them, because we’re managing it. But implant has more consequences, medically, legally, and cost wise, and and two people involved.

[Jaz]
And also, I guess it depends on the tone of the patient as well. If they’re a newer patient, not a long term patient. If they’re particularly disgruntled, if it’s heading towards potentially a complaint, even though you feel you’ve done everything right, I guess it depends on the character of the patient as well, where you think this is likely to go.

[Neel]
Yeah, you know your patients, you know how they are, you know if you can communicate with them. I’ve had some horrible patients where I’ve told my indemnity. I’m not happy about this. We’re managing it, but I just want to tell you, I don’t feel good about it. And luckily nothing happened. So I think you’re absolutely right.

I’ve got patients for 10 years who are my neighbors. They’re not going to be different to working in central London, you’ve only seen them once and they’ve flown in from Azerbaijan. It’s a different rapport. So I think that’s why I like staying in one place and getting to know, it does make you safer when you know your patients.

[Jaz]
Great. So last question then is, I think you guys covered this already, like what should a dentist look for in the choice of an implant surgeon to work with? And I think you guys talked about it already, that relationship, that communication, that rapport with your placing dentists and having an understanding like Joe mentioned about each other’s protocols and helping each other out. Is there anything else, Joe, that you want to mention about that relationship between the referring dentists that may be restoring and the placing dentists that may be visiting?

[Joe]
I think it’s two separate In either way, in either case, I think communication or meeting the person per se and spending time with him, understanding his experience, what he does, can this implant surgeon guide me because I’m still new in the restoring world.

Is he there available for me to communicate with and chat to if there was a problem? And then God forbid if there’s a problem, is he there to help. I think as a referral practitioner, where 95% of the patients I see are referred to me by a dentist, 95% as high as that. So my client is not a patient.

My end product is a satisfied patient. My client is a dentist, so it’s quite different. I belong to a very small cohort of. or specialist whose clients surprisingly are dentists much more than they are. So my delivery is at this side. My input is from a different source, so the communication channels.

So when this patient implant fails, I would invariably write to the patient saying, we’re so sorry that you feel, that you’re unhappy about the implant failure, but we are here to help you. Nice kind words to that effect saying please do not worry. I appreciate that you’ll be giving us your time but we will make sure that there are no financial implications to this aspect of the surgery.

I would done that after having communicated with the restoring dentist to make sure that patient is being looked after, so what does one have to do? Is it essential to be a specialist compared to a non specialist? That’s the other thing that I get asked quite often. The answer is no, there are very, very, very skilled implant surgeons who are non specialists.

I don’t have a problem. I think, as long as they are in ‘well read’, well trained in the art of implant dentistry and are able to manage complications. I think it’s all well and good. I know implant surgeons who go place implants. But when the failure starts to happen, for some reason, the dentist is not calling on that implant surgeon.

They’re sending it to a specialist referral center. So in other words, they were there to take on the good bits. So nearly two days a month. Two days a month, Jaz, I am not an implantologist, if there’s a term like that. I am a more peculiar term. I’m an explantologist. Two days of the month, I’m explanting implants because we are, ‘the dumping ground’ for implants that have gone wrong.

So we are explanting faster than I can blink now because we are the center in the Northwest of London, which are taking on so many cases. The number of failing implants being sent to us is, let me rephrase that. The number of failed implants. I remember doing a lecture I think it was in Berlin many years ago with Andrea Mombelli, who’s Mombelli, Professor Mombelli has written the most amount of papers on, on peri implantitis, ever, researched, and he was sitting next to me and I said, oh, how are you handling your peri implantitis?

And how are you handling your failing implants? And his statement to me was, Joe, there is nothing called a failing implant. There’s no present continuous tense, either there’s a successful implant or a failed implant. So there’s only a past tense or a success, but there is no failing implants.

Because if once an implant starts to fail, it will only but progress. All you’re doing is reducing the progression of it. But handling, this is what I said earlier, you need to make sure that you are with the person. Who does not only know how to do things right, but also knows what to do when things go wrong.

That’s where the issue is. Is he able to handle? Because things will go wrong. It’s surgery, it’s a human body, it’s blood, it’s tissues, it’s bone grafting, it’s anatomical structure, the sinuses, nerves. There’s so many factors to take into, and so things will go wrong. Anybody who says otherwise is lying. Is he able to handle that?

If this visiting surgeon comes once a month, I just don’t get it when visiting surgeons come once a month. What happens to those patients for that whole month? If there’s a day’s sense of wound, if there is a graft that’s failing, if there’s an implant that is separating, if the, who is there to assess that patient?

Nobody. Or the implant surgeon, if at best, would say, okay, you can send him to my other clinic somewhere else on the other side of London, so that I can have a look at it for you. That is not quality of service. Not for a patient who’s paying an awful lot of money.

[Jaz]
That’s a really good point to watch out for in that relationship when you’re picking an implant dentist. Now, one reflection is something that I learned from listening to Frank Spear. So Neel, I know you’ll be able to resonate as well, is that when something goes wrong, you just want to literally just want to go in there and fix it. That’s your number one aim. It’s really like a typical bloke. You just fix it.

Okay. What’s the problem? When my wife tells me a problem, I don’t want to listen. Which that’s what she wants me to do. I want to go in and fix it. And I think that serves us well in dentistry. You should go in and fix things. And that was very clear from our conversation.

So that’s good. But talking of failure, I think it’d be, and I’m really happy with how this episode’s gone, I think we covered some great points, but those two bits in the history, I think now we can go a little bit more clinical for the next five minutes, is let’s talk about, Joe, your opinion and experiences in bruxist patients and how they do to your implants, long term, and also the impact of obstructive steep apnea on such patients. Any insights you can provide us on those?

[Joe]
My philosophy with Bruxism is, historically, the failure of implants in bruxists used to be much higher. Not necessarily from loss of integration, but mainly because of fracture of components. Abortments you would fracture, screws would fracture, sometimes implants would fracture.

Those days are now behind us, because the components are made stronger, the connections are better, the screws are taking much more tensile forces on it. So, Things are getting stronger. So the number of incidents of fractures compared to even 20 years ago, 15 years ago, has reduced dramatically. I tend to do two very, very fundamental, basic things.

One, keep the cuspal inclines as shallow as I can. Two, I reduce the occlusal table to narrower than what natural, the natural teeth are, and three, a bite guard of sorts. Okay. Those are the incidents of implant failures in bruxist. Pretty much these days should be or needs to be close to zero or should be equitable to what a non bruxist patient would be.

Because there is so much data on it that we have so many clever things one can do to make sure that it is not even a factor. With regards to other factors, the sugar contents of your blood, the sleep apnea aspects of it, all those are factors that have a very, very small, but sometimes significant, but very small impact on implant health.

I think the generic health problems of proper full fledged diabetes, full fledged, immunosuppression, full fledged bisphosphonates. So my analogy for any of those patients is anything that is uncontrolled is a no no. Walk away, or at least make sure that you treat. In other words, do I treat patients who are diabetic?

Yes, I do. Hypertensive? Yes, I do. I do all, but none of them which have a prefix called uncontrolled. If it’s uncontrolled diabetic, I don’t treat. Uncontrolled hypertensive, I don’t treat. Uncontrolled psychosis, I don’t treat. Because they’re patients who come with mental health issues. Uncontrolled, so anything that has the prefix uncontrolled-

[Jaz]
Even the Bruxism, if you leave it uncontrolled in a way, you are shaping it with the bite guard. You’re shaping it with the restorative design to get some degree of control over it. You can’t stop the behavior, which is bruxism is a behavior, but you are influencing how it’s perceived by the implant.

[Joe]
So the word uncontrolled is critical. So if a patient comes in, look at the medical history, this is diabetic. Mrs. Smith, how well controlled is your diabetes? Oh, it’s really well controlled. When was the last time you had your blood sugar checked? Because these are all standard questions that we should be doing. We don’t need to be super clever and start micro dissecting medical conditions. Fundamental stories is plenty. And your success rate will shoot off the scale because you’ve asked some really basic questions.

[Jaz]
Fantastic. I’m very, very happy with that. A nice little concise summary. I’m very happy with that. Neel, anything you want to add to our discussion that we’ve had about the dissatisfied patient? I think we covered a lot of the communication stuff, which I think it’s the crux of all of our episodes that we do in the medical legal series, Neel, isn’t it really?

But we had this little blame game thing, but I just love the direction it went in. And I think it speaks volumes about, Joe as someone who places implants for the referring dentist and how that really works. relationship. If you take anything away is to work with someone with that kind of relationship, kind of like what Joe has with his dentist.

That’s a beautiful thing to have and someone who can rescue you because when the failure happens, it’s really nice to have confidence in the implant surgeon that A, there’ll be present and B, there’ll be on your side when that happens, basically any additions to that, Neel?

[Neel]
I think generally, as we all covered it’s communication. It’s the relationship with you and the surgeon and the patients. If you are trying to find a peripatetic surgeon, Or if someone else is placing implants for you, ask them to have a look at their notes. Just do what we would do from an indemnity point of view. Are they writing ISQs? Have they taken PAs, grade A’s as they now called, you know.

What are the notes like? Are they recording everything? I’ve seen lots of notes, CBC taken, no justification, no report. And you just start thinking-

[Jaz]
I didn’t even think about that. That’s a really good, about saying I forgot who it was, but how you do anything is how you do everything. So when you see that their notes are really good, then maybe that’s a surgeon is going to be really good and precise and stuff as well.

So how detailed are they going? Who knows? But this is something, if you’re working with someone and you know, when the proverbial hits the fan and P and people’s notes are being looked at, you want to see that, okay, that my dentist was like a partnership that their notes also carrying the weight that are worthy of.

[Neel]
I mean, and then that’s what it will come down to and it may not be you that gets dropped in it because their notes might be bad. But it’s a team and you don’t want to you want to work together for a better outcome. Joe, would you be offended if I asked you to just do you mind sending me the patient’s notes?

If I asked oh just you placed enough for right six for me, do you mind if you just send me the notes so I can have a look?

[Joe]
I do it, no, I do it all the time.

[Neel]
There you go.

[Joe]
I do it all the time. Nothing to hide. There should be nothing to hide. I think even when you’re picking a visiting surgeon to come in and help you through your surgeries, please do some research on that person to find out what kind of portfolio of cases does he handle?

Does he handle the whole spectrum, including all on four? What kind of experience has he come in? Who has he done work for before? Let him give you the 10 names that he’s been to. You’re bound to know one of those 10 people. Don’t be embarrassed to ask questions like oh is there a clinic that you worked in where you have left and not don’t work there anymore?

You said yes oh, yes. I have two clinics, but I don’t go anymore. Why did you leave those clinics? We want to know what broke down for you to go to a clinic, two years later after having placed 30 implants you have walked away what made that this is crucial. Because the patient will only ever come back to your practice to ask you for your problem for their problem to be solved. But the surgeon if he’s not there, so you’ve got to do some research You’ve got to be able to speak to some of the other clinics that he goes to to say can you please if you don’t mind?

He’s trying to come to my practice as well. Can you please tell me a bit about him? How is he with his patients? Why do you want him to come and place your first implant without even asking? I see this routinely. People don’t even ask other dental practices, so how is he with your patients? No, they’ve got him in on board because somebody may have mentioned a passing name and they want to keep the work in house. That is the only criteria.

[Neel]
Very good. Due diligence.

[Jaz]
Due diligence, be selective and, really know the person who’s placing implants. Joe, I’m so, so privileged to meet you today and just hear what you have to say. Your sayings, your verbatage, you’re already from this conversation. If I ever need an implant, I know where I’m going. But tell us, where can we learn from you, my friend?

[Joe]
Oh, you know what? In all the years that I have been doing implant dentistry, my door out here, is an open door. It’s anybody and everybody is welcome to spend time with me. I have never in my life charged for anybody to come and look over my shoulder, ever.

All they do is, Joe, they say specific, Oh, I’m just starting off my implant journey. Can I come and see some simple ones? Or I’ve been my implant journey for many years. I want to take it to the next level. Can I come and look over your shoulders, see you doing a sinus graft or, or, you know, or anything a bit more complex.

I do run a foundation level modular course at our practice, it’s run over five modules. Four of the modules are run in Moore Park Center here. We are a 10 sergeant practice with a training center upstairs. And one module is normally run abroad. For the last couple of years, I’ve been running it in Sarajevo, in Bosnia, because we have a massive international strawman and neodent training center there. In the university, the main government university hospital. So that’s where we normally run it out of, and we run it normally.

[Jaz]
Any website we can check. I mean, I’m going to, I’ll put everything in the show notes anyway. So you have to tell me now, but if you know it by heart, I know lots of people are looking for great implant mentors and you’re in that category. So if you know the website, I’m happy to just direct everyone.

[Joe]
Sure, sure, sure. www.moparkdental. com is the best place to reach me at. And then I have a modular course brochure, which I’m very happy to share. I take a very, very small cohort of people, because I think anything more than six or even eight is a crowd. When people run modular courses with 14, 15 people, I generally believe quality of education is not as intensive. But if anybody wants to learn anything, I’m here to help.

[Jaz]
Certainly. And I’m always there to shine a light on great educators and people who are any profession got so much experience. So that’s my role to get these people pick your brains. And so we certainly have done that today. Joe, so much for your time. I really appreciate it. I’ll put all those links in the show notes and Neel had to go because his battery died, but Neel guys represents PDI Professional Dental Indemnity.

If you need to contact Neel, check him on the protrusive guidance app. He’s there. You can DM him, but also it’s a neel@professionaldentalindemnity.co.Uk. But again, we’ll put all that in the show notes. Joe, thanks so much for your time.

[Joe]
Pleasure is all mine. Thank you Jaz for the invite.

[Jaz]
Well there we have it guys. Aren’t you so impressed by Dr. Joe Bhat? Super knowledgeable man full of wisdom. Now if you want a certificate to prove that you’ve gained from this wisdom today, this episode is fully verified one hour of CPD. You just have to answer a few questions on the Protrusive Guidance app. And our CPD Queen Mari will send you a certificate.

She will send it to you the Wednesday following once you’ve answered the quiz. And then also quarterly she’ll send you a summary of all the CPD you’ve gained through Protrusive. And that includes the masterclasses like Vertiprep for Plonkers and Sectioning School, all the good webinar replays and topics that we’ve covered before.

Do check out www. protrusive. app if you love the podcast. And if you want to now formalize the learning that you’re doing. I want to thank Neel and Joe once again. I put the links in the show notes. So check out these courses from Joe Bhat and also the indemnity PDI with Dr. Neel Jeiswal. That’s protrusive.co.uk/insurance. Thanks for listening again. I’ll catch you same time, same place next week. Bye for now.