Zirconia vs Metal Hall Crowns vs Conventional with Dr Tim Keys – PDP227

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 Pearl
Every 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 the point of recording this in February, I know it’s gonna come out much later in the year, but I’m recording this in February, 2025 and we’ve got 30,000 YouTube followers and I’m so grateful, honestly, like thank you so much.

But there is a percentage of these subscribers that are members of the public. They are non-dental. They are patients of dentists, they’re the public. And I feel a little bit uneasy about that because we need our little safe space. This is dentist talk like you’re a patient. I understand that you are seeking information and it’s good to be informed, but this is dentist speak like this is not the best place for you to get information.

And so what I worry about is some pieces of information that is like just dentist talk, getting through the wrong is. And so what I’m gonna suggest is, if you want the full experience of this episode, please check it on Protrusive Guidance, even the free subscription on Protrusive Guidance. It’ll be there, the full video without any interruptions on YouTube, you’re gonna get a little bit of an interruption where I probably censor about five minutes, and the reason for the sensor is a really appropriate and a really good recommendation that Tim makes and is totally appropriate, and I love him for what he says.

But if patients hear this, then I worry about them taking it to their dentist and it’s just not the right environment. So this is very much secret dentist talk that patients shouldn’t hear. It’s a fact of life. And what we do on Protrusive Guidance is that we have a systems in place that we will email you for proof.

So I know that Protrusive Guidance is a safe space because it’s not easy to get accepted. We ask you for proof that you are a dental professional. So if you’re watching on YouTube and you have access to our app, just switch over now so you don’t miss any of it. If you’re watching YouTube, still love you.

Thanks so much. You’re just gonna miss out a few important minutes, which make a very clear clinical recommendation that you should be doing, and me and Tim feel very passionately about that. But yeah, we’ll not go into it anymore. Enjoy the episode and I’ll catch you in the outro.

Main Episode:
Dr. Tim Keys so nice to meet you on here. Welcome to the Protrusive Dental Podcast. Your kids are asleep. It’s a great time. It’s morning here. It’s evening where you are in Australia. So tell me, my friend, whereabouts in Australia are you and are you a general dentist? Are you a pediatric dentist? I wanna learn more about you sir. 

[Tim]
Mate, I live in a state called Queensland, which is a very sunny place, one of the more sunny places in the world. And I live on a location called the Sunshine Coast, which is a nice, a beach area, very well known and it’s a beautiful, beautiful place. Absolutely. I’m a pediatric dentist, have been now for several years and obviously prior to that was a general dentist. And I love my pediatric dental job. I enjoy it and I love teaching too. 

[Jaz]
Would you call yourself a big kid? Would you refer yourself like you’re a big kid yourself? 

[Tim]
The best part of the job of working with kids is that you can have a lot of fun. You’ve got an important job to do, but you get to do fun things and you get to talk about all sorts of crap that you can’t talk about to adults, so you can have a joking time. They converse the worst part of our jobs, dealing with parents, which sucks. 

[Jaz]
And you live in the Sunshine Coast. There’s a book by the “The Almanack of Naval Ravikant” and great book. And then this really clever guy, he says that in life, we don’t spend enough time thinking about where we want to spend our lives, where we want to live.

So what I wanna know from you is, were you just born into there and then you just stayed in your Sunshine Coast? Or did you make a conscious decision to design your life so that you live in a beautiful place? 

[Tim]
Conscious decision, Jaz. Conscious decision. I live 800 meters from the beach, very close to little canal system. It’s beautiful here. Good surf. Good weather. And I’ve got my commute one kilometer to work. I go through two sets of traffic lights. So if it’s a bad day, it might take me five minutes to get to work. 

[Jaz]
That’s amazing. I’ve experienced that joy before. That has its downside as well. Like, you know, I know you’ve got kids and we’ll talk about that, but I’ve got two young boys and so when I used to work literally right next to the clinic and I’d be like home in like four minutes.

I never had time to read because I was always serving my children or whatever. And so therefore now I’ve gotta commute back. I’ve got like a 45 to maybe an hour commute now. And so now my audible credits are getting used up, which is great. So, you gotta take the ups of the downs. How old are your kids?

[Tim]
I got a 4-year-old, a 3-year-old, and a 1-year-old. 

[Jaz]
How would you do it, man? 

[Tim]
Alcohol helps few bees, mate. Absolutely. 

[Jaz]
Lovely. Why paeds why did you go into paeds? 

[Tim]
I feel like it’s the last real remaining specialty where you can actually do a lot and try to still refine your skills within that. So by that I mean, it’s not just doing fissure sealants and crowns and fillings and extractions on kids.

You can do surgical extractions, exposures, and bonds of canines and teeth. You can do some pretty gnarly sort of auto transplants. You can do endodontic treatment as well. So there’s a whole scope of things where you can still focus on certain stuff. I quite enjoy dealing with children. I thoroughly enjoy the job.

It does get fatiguing, like I think three to four days of clinical peds, like in the clinic dealing with kids and anxious kids can get quite emotionally draining. So therefore it’s really nice to have that one day a week or a fortnight, under general anesthetic where I could just somebody else’s behavior managing ketamine and profile.

[Jaz]
Really fascinating. It reminds me of people I speak to whose spouse happens to be a chef. And so, when they’re cooking all day long. They don’t cook at home ’cause they’re just done with it. So how do you, right, this must be the toughest gig. Like that week we got like anxious children all day long and then you come after, you have to come home to your own kids. How do you make sure that the dad mode is on? 

[Tim]
Mate, it’s hard. Like I leave home and I have screaming children from 6:00 AM. I go to work and I’ve generally got screaming children for eight hours, and then I go home at nighttime and I’ve got screaming kids until seven. So I have 13 consistent hours of screaming children.

And you’re right. Look, it does get a bit sad sometimes that I can use up all this patience on other people’s kids. And you go home and you think, ah. But yeah, what do you do? Right? But I’ve gotta say, everybody that’s got older kids and Jaz, I don’t know how old your kids are- 

[Jaz]
Five and two. 

[Tim]
Five and two. So you would hear the same advice. Anyone that tells you, they say, you’re a bit in the trenches now, but these are actually such magical years. You got these little humans who all they wanna do is spend time with you. And sometimes you get a bit over that, but that’s all they wanna do. They just wanna spend time with you and I really do.

I don’t work weekends. I don’t work late nights other than doing podcasts after the kids are asleep. I think for all of us with kids, it’s just that really valuable special time, which you just, that’s that 20% you gotta think about while you get through the 80% grind of just screaming battles, right?

[Jaz]
It’s an absolute joy ever. I totally agree on the book I’m listening to the moment is “Hold On to Your Kids” by Gabor Maté and Gordon Neufeld. Have you heard of this book? 

[Tim]
I haven’t, no. 

[Jaz]
Okay. So I’m early into it, but I love it because it’s talking about the culture we have brewed as a society, we have created this culture of sending our children, encouraging them to have attachment with their peers.

And then children, it is like you can’t serve two masters. And so what happens is that because now they are attached more to their peers than to their parents, then this is why they don’t wanna hang out with their parents anymore. This is why they’re sort of moody at home. And we think this is a phase, but what the book argues is that actually this is a new phenomenon and we need to make sure that we hold onto our kids.

Their primary attachment and guidance in life should come from their parents, not from their peers, because otherwise the blind leading the blind. So that’s a really fascinating book. I thought it’d be nice to mention it in the pediatric. There’s lots of parents listening. The other one I’m listening to, thanks for a recommendation from someone in the community is the anxious generation.

How the newer generation and screen time is really messing up our kids’ brains. We know this already, but like it goes deep into the science. Any guidelines you follow at home just as parent to parent on screen use. 

[Tim]
Mate, we are very limited, but I’m fortunate that our kids are young. So we’ve got the point now where we can, to some degree, control them. Yes, there’ll be a big screaming fight and argument, but we’re pretty rare. Like we might do, there’ll be multiple days in the week where they get no tv, and then if so, they might get short periods, 15 minutes, like after they’ve cleaned up the playroom and things like that. So it’s used just as a reward basis.

Don’t get me wrong. Occasionally when it’s like five o’clock and you’re late for dinner. And you’ve got three screaming kids and it’s chaos. You’re like, we’ve gotta crack this. But we actually found about a year or two ago, we were finding that we were resorting to it too much. And I’m the same as you.

I just feel like, particularly where I live, like our winters at worst are like 12 degrees to 25 degrees. That’s how cold winter. So that’s excuse. 

[Jaz]
Excuse for those Americans out there. It is pretty good. 

[Tim]
Yeah, absolutely. So we’ve got no excuse where I leave not to be outside and playing. And we’ve got a fenced house so they can have a good time. But yeah, I agree. Absolutely. I think there’s a few things, there’s a lot of ultra processed foods and that sort of stuff. A lot of sugar, a lot of tv, and I’m so happy that Jaz, you look similar sort of age to me that we grew up prior to social media. 

[Jaz]
Big time. And so the book argues, and I’m glad you mentioned this because I remember growing up and I would be away from the home. Like I’d be like nine, 10, and I’d be like, in a distance park, maybe 500 meters, maybe in a kilometer away from the home, and I’d be in the park, no phones, no contact, and I would just come home six hours later or something.

Okay. And parents were accepting of that. Nowadays we can’t bear to not know where our children are at such a young age and for them to just go and walk off. And so this is what the book argues is a real one. The biggest tragedies of our time. So it’s interesting to talk about this. 

[Tim]
Absolutely. I agree. Yeah. I mean, to be honest with you, but I think I would struggle to let my kid, I did the same. I used to go for a bike ride, 15 K away, but I’ve still got young kids, but I struggle to feel like I would let them do that. It’d be emotionally tough for me, but I don’t know. We’ll see what happens when we get there.

[Jaz]
Yes, exactly. So it’s society, but I enjoyed that pre-check. Thank you so much, Tim. I’d like to learn about why someone goes into this particular specialty and learn a little bit more about the individual. And I know it’s nice to learn about you and your family and just parenting advice is nice to talk about as well as books.

But the main crux of today is hall crowns or rather formally, we used to call them stainless steel crown technique versus hall crowns. But now the new player zirconia. And I was saying to you before we hit record, actually my wife, she did a MSC at Eastman in pediatric dentist. And her thesis, a master’s thesis was on zirconia hall crowns versus stainless steel hall crowns, basically. So, very interesting. I believe the only supply, and you correct me wrong, is it new view or new smile that zirconia- 

[Tim]
New smile. So there is another company called Sprig, which came later to the game, but the predominant market in the world is a company called New Smile. So they’ve made the zirconia crowns, which I think those particular crowns are not suitable for a hall crown, and we can go and discussing that why. But they’ve created another crown, which is like a resin base, is acrylic crown called BioFlex, which they’re trying to say is a bit more like a hall crown.

But I think what we should do Jaz is let’s go through the pros and cons and things of stainless crowns and zirconia, and we’ll talk about the pros, cons, limitations in how we can do it. But I’d be very fascinated to read this. This thesis. 

[Jaz]
Yeah, I’ll send it to you. I thought I just mentioned that as a little background, but yeah. Where I want to start this podcast is for our younger colleagues, and actually, you know what, for our older colleagues, because they probably qualified at a time where the technique wasn’t being used so much, or not in the way that the whole crown suggests they were still prepping perhaps. And so let’s talk a little bit about the history of using stainless steel crowns from pediatric molar teeth and how that’s evolved and where, when, and why the whole technique and what it is. 

[Tim]
Yeah, so Jaz, essentially the way we have managed decay, as many of us are aware, has changed, right? And the reason is we are moving away from this infected and affected dentine and things. So dental caries, the outcome is a cavity. Okay? Once you’ve got a cavity, you can’t tend to remineralize it without plaque control it will continue to progress.

And that’s our justification for putting fillings in, right? Restoring form, function, and aesthetic. So for pediatric teeth, there’s significant limitations to putting intracoronal restorations in teeth. So my thesis was a part of a series of surveys of dental protection is nation, so nations wide, so internationally, and so for us practitioners in Australia, what do they use to treat kids’ teeth?

And the dominant material used for primary teeth was GIC followed by composite resin and then some RM GICs and some stainless steel crowns. And you’d find the variability was significant. You’d have 25, 30% of people using this, 30% using this, 20% using this. Well, if you asked for permanent teeth, it was 85% composite resin, right?

So why is there so much variability for primary teeth? And I think the reason comes is that there’s not a great deal of research on this. And essentially everyone’s just having a crack at it. My supervisor’s using fuji and, but a fewer GICs, and that works really well. The issue that we’ve got primary teeth takes six months to form, not three years.

The enamel that’s present is much thinner. It has a much lower mineral content. Now we use predominantly resin based or a chemical adhesion. Yes, GIC has that ion bond, but the vast majority of our resin restorations. They’re just glued in and we don’t have, even, despite trying to go for that, still, our best bond we can form is with enamel.

And so you can imagine if a primary tooth begins its life with less enamel. And the enamel that says, got less mineral content, it’s much more difficult to glue a intracoronal restoration into the tooth. Our main drawback with GIC based materials is that they’re structurally weak and children, because they’ve got their flat occlusal plane, can actually have higher bite forces on their marginal ridge than weak can as adults.

So, but why therefore do we use a inferior strength material to restore primary teeth? And so the failure rate for tooth surface intracoronal restoration at three years sits at about 35 to 40%. That’s what our evidence shows us. So that means if you’ve got a child in your clinic- 

[Jaz]
And that’s any restoration that’s GIC or comp, any direct restoration? Yeah? 

[Tim]
Much higher failure rates of GIC. Like if you look at the American Academy of Pediatric Dentistry and other guidelines, a lot of them are recommending, once you get past a single surface for GIC. It’s really not indicated. It’s contraindicated, it’s a temporary restoration- 

[Jaz]
But while RMGICs does that make a big difference? ‘Cause you know they are two different materials. RMGICs, you know, far mechanically superior. 

[Tim]
Yeah. But it still can’t put up with the years. If you’ve got a 5-year-old and you’re putting a DO in there first primary molar, you got six years of occlusal forces on that. I guess the question Jaz to you is would you expect six years to survive in an adult tooth with an R-M-G-I-C as a tooth surface restoration? 

[Jaz]
Put it this, say it’s not predictable treatment. You wouldn’t say to a patient, ah, it should be fine for many, many years to come. Whereas with a composite, you definitely could say that, yes, I expect this to last long, whereas your reducing the predictability for sure. 

[Tim]
Correct. And so the same thing applies to kids and so therefore, composite resin has a higher success rate when it’s small. The moment you move past the contact point, so it gets wider and extends onto the buccal or lingual surfaces, you’re actually now moving into a three surface intracoronal restoration and it is a contraindication of placing in intracoronal restoration and that for longevity. Why else? If you wanna put an R-M-G-I-C in what’s in it, what makes it stronger? 

[Jaz]
So it’s the silica. 

[Tim]
Well resin, right? It’s a resin modified glass, ominous cement. Is resin moisture resistant? 

[Jaz]
No, it’s not. But there’s the same issue with the composite. 

[Tim]
Correct. So if you want to do an intracoronal restoration that you want to survive, you need local ’cause you’ve gotta drill. And you need rubber dam on ’cause without rubber dam your failure rate increases by 200%. And then even then, even if you’ve got a tooth surface resin put in those areas, your composite failure rate can still approach about one in five. So if you’ve got a kid, you put four fillings in, you would expect at three years at, to be getting close to one of them failing at least.

Keep in mind that’s an average place under rubber dam with local anesthetic. Can’t be hard to do, so therefore we move to stainless steel crowns. So a stainless steel crown on a primary tooth was traditionally, as you said, the conventional technique, and it was reserved for those teeth that were heavily compromised.

Large multi-service areas, decay or pulpotomy based teeth where people were scared to put a filling. The success rate at 10 years sits between 97 and 99%. I would add- 

[Jaz]
The traditional conventional approach, yeah? 

[Tim]
Conventional crown. 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 in the UK there was a particular dentist who was audited because she was claiming a lot of NHS think it is, a lot of the rebates but she was doing so many stainless steel crowns.

It was just like this can’t be right. This girl’s lady’s doing too many and they went and ordered her records and found out she was putting them on non-invasively. So this goes back to that decay scenario. If we can deprive the bacteria of a food source, they’ll die. But it has to be well sealed and that’s where standards of chronic overcomes that.

As long as you have sealed the decay. So they ordered her and actually found out her success rates were brilliant, and this is what became the hall technique. Now, pediatric dentists were actually one of the more resistant groups to adopting this technique. So they said, this can’t be right. We’ve gotta sit down and drill it and put a conventional crown on.

Otherwise it’s gonna be too uncomfortable. It’s not gonna work. They were two, there’s actually a studies done, and there was two comparison postgraduate pediatric groups in the UK that did this. They treated 836 teeth and had a 77 month follow up. One group did conventional crowns and one group did hall crowns.

[Jaz]
Before we talk about the success rates there, because I just wanna just clarify to our audience, what actually does a conventional technique entail and what makes a difference to a hall technique? 

[Tim]
So a hall technique is no preparation. So you put two separators between the tooth. So you’re leave there for a couple days, then you come back and take the rubber bands out, and so now you’ve got a little bit of room to fitch ground.

Then you just size up. The best size you can and the more you do, the more comfortable you get it. Doing the size, you still gotta crimp and adjust the crown. So crimps like bending the crown to make it tight. Then you fill it full of glue and this is probably the best place to use. GIC in kits is within a stainless steel C crown and you squish it on over the top.

Okay, now it’s heavily reliant on your diagnosis. And investigations prior, which I think we’ll cover, but in comparison to a conventional crown. And a conventional crown is where we used to just, you’d numb a kid up and you’d take about a mill and a half off the top. Then you get a bur, like a stiletto, or what’s called a flame bur sometimes, and you just sort of open the contacts up and round it all around a little bit.

Then you get a crown, try it on several times, bend it, adjust it, fill it full of glue, and stick it on. Okay? So they’re your differences. Now, you still need to do conventional crowns in circumstances where hall crowns are contraindicated or following a pulpotomy. Okay? So you still need to know that skill set.

But going back to this study, the hall crowns are non-invasive, filling full of glue, squishing on when it met the guidelines, which we’ll go through in a second. The success rate for that was 95. 0.8% for the hall success rate. Hall crown success rate for conventional crowns was 95.3% statistically insignificant.

So that converted us. So you got, yeah, that’s a lot of kids. That’s 400 kids. And that’s like, okay, this technique works. So in my clinic alone, I think we probably pace about 1200 hall crowns per annum. So a reasonable number. And your failure rates are not significant if you place ’em in the appropriate situation.

And just to be honest with that, we’re beginning to see a much larger number of failures is where they’re probably placed on teeth that weren’t suitable for this technique. 

[Jaz]
So like in everything in dentistry, right? Case selection is so, so important to actually doing the technique well and correctly and to get the success rates. 

[Tim]
Yeah, spot on. So, to know how to treat kids, you’ve gotta have done a comprehensive clinical examination. And arguably, even more importantly, you’re gonna have x-rays. So it is medic legally indefensible to do a restorative procedure on a child without an x-ray. I mean, we wouldn’t do it on an adult. We see a lot of people doing it on kids ’cause it’s hard to take x-rays on kids. 

[Jaz]
But have you seen a big friction here, Tim? On social media perhaps with dentists where I’ve seen dentists openly say that, listen, I don’t radiograph children until they’re 12. Like, and they’re very adamant about that, right?

And so whereas I was taught by Professor Helen Rodd in Sheffield, and so when I saw children, I would take radiographs at the soonest opportunity. Maybe age four if they’re looking like they’re gonna be high risk if I can do it. But definitely age five and beyond. What guidelines do you suggest in terms of, okay, when should you start? Basically, I just want you to encourage the listener to remember that actually it’s okay. We should be taking graphs for children. 

[Tim]
Absolutely. But these people that are saying they don’t take x-rays on kids to 12 should probably cease practicing on children. To be realistically, ’cause they’re causing more harm than good.

When you should take radiographs on children, let’s say you’ve got a child who’s got no clinical issues, you’ve done a clean exam, it looks good, but you’ve got closed contacts. It should be taken 18 months after closed contacts. So Jaz, well done. Four years of age, that’s about when we should start taking them.

It’s hard. There’s lots of variations you can do to the technique to still achieve it. Keep in mind, each x-ray is the equivalent of around six bananas. ‘Cause six bananas got radiation in right? So the radiation test is insignificant, really. Now, if you’ve got a patient who’s got 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 to treat them. ‘Cause if you can’t get an x-ray on them, how do you expect them to sit through an extraction or a restoration or even a bit of putting a bit of Fuji2 over the top of it, right over RMGIC.

So you need to get x-rays and sometimes you gotta vary the technique. So you might do like instead of getting a set of bite wings, you might get, like, you might capture like a quadrant with a little crocodile. So you get your little sensory, your plate in the crocodile, get the parent to hold it, just angle it up, try and get the contact points.

And the benefit of doing that early is that you can also do prevention such as silver diamine fluoride and things like that to prevent lesions from developing. But then you’ve got a firm diagnosis, and I think I need your listeners to really understand that we don’t treat children differently because they’re children.

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, it’s completely wrong.

[Jaz]
I mean, what got me from memory, and I appreciate you saying that. And I think we need people just sometimes to say how it is. And I wholly agree with you, except, what I see on social media is reluctance of dentists. So I’m glad you’ve really been very clear about that and I appreciate that.

It can be challenging, but we must do it. And the piece of research that always stuck with me in final year dental school and now, I dunno, it’s been like many, many years since then, but it was like, you are likely to diagnose eight times more caries when you have radiographs. So if you think you’ve got two lesions or two areas of caries, it’s probably a lot, lot more than that basically. And so you’re missing a lot of diagnosis. 

[Tim]
Correct. So, Jaz, if you can see a cavity in a primary tooth, let’s say the five, the upper right. First primary model, what we would call five four. What environment is the six four sitting in? Same environment. Where’s the seven, four, and eight, four sitting?

Same environment. Maybe they’ve got a tongue, a bit more saliva, so maybe less, less effective. What’s happening to the five five? By the time you can clinically see a cavity in the mouth, it’s been there for a long 12 months. How close is it to the pulp? I can guarantee you if you just go put a food, just bog up that little five full, A) it’s not gonna last. B) the kid’s gonna come back for probably an extraction of that tooth. And C, you’ve probably missed the three or four other holes that are there. 

[Jaz]
Totally. I’m glad that’s nice and clear. So the message here is, let’s start taking radiographs in children. And then it’s imperative, I mean, to any treatment modality you do, but in terms of how could this sway you in terms of, okay, is this now suitable for the stainless steel or hall crown approach? Or actually we should be considering another way of treatment. 

[Tim]
Let’s say you’ve done a beautiful clinical and radiographic examination and you picked up a couple of holes in the mouth. With the hall crown, the main key is at this point, according to the guideline for this, which is once again published UK, you need to be able to have a clear, radiographic band of dentine between the cavity and the pulp.

So you’re looking for about a mil. It shouldn’t be something where you like, ooh, I think I can see it. It should be, yeah, I can see hole and I can see decay. And what we’re thinking there is that you’ve got like a bit of insulation, okay? At that point, hall crown is eminently suitable. You can treat a single surface. Two surface, three surface doesn’t matter as long as you’ve got a radiographic band to- 

[Jaz]
And if it’s cavitated or non cavitated, does that inform the prognosis? The broken marginal ridge. Okay, good. Good. 

[Tim]
No, doesn’t change it. So we’ve moved away from that thinking that a marginal ridge involves pulpal involvement, therefore you require pulpotomy. You only need a pulpotomy if radiographically the decay is into the pulp. Or if the symptoms are guiding you to question the health of the pulpal status. But if you’ve just got a standard hole, whether you can see it clinically or not, with on your x-rays and you’ve got that radiographic barrier, and the kids just say, oh, it hurts when I eat.

Happy days hook in. Now, where would you do a hall crown over an intracoronal restoration? I would probably encourage you to do a haw crown in most circumstances. Why? Because you don’t need local, you don’t have to drill it. Your success rate’s higher. And so it’s cheaper, quicker, and easier to place happy days.

What’s your big drawback? Aesthetics. And what is becoming increasingly more important for people these days is aesthetics. And that’s obviously why we’ll talk about the zirconia crans shortly. Now with the hall crowns, you need a vital tooth with decay not involving the pulp. Two other things I want your listeners to look out for because you are not adjusting the occlusal surface.

The ability for the crown to sit down towards the gum level, it can only sit down as much as the crown will go down, right? And when it hits the top of the tooth, it’ll stop. So if you’ve got a really deep hole, not towards the pulp, but down like under the gum, I need you to think. If I put the silver crown, the Staines stainless steel on this without taking anything off the top, will the crown actually seal the cavity?

Because what happens if it doesn’t? Well, the decay continues to tick away, and then you end up getting sent to me. I pulled the tooth out. Okay, so that’s tip number one. If you can see decay, that is about the gum level, I would start thinking my crown is gonna struggle to seal that. Okay? If it’s above gum level, you’re probably gonna be sweet if it’s well below gum level. You’re gonna struggle. 

[Jaz]
So well below gum level is obviously okay, as long as A is vital and B, it still has that band of dentine, it’s still okay to treat with the whole pan approach. Except what you’re suggesting here is perhaps consider some occlusal reduction? 

[Tim]
Yeah. The problem is, I don’t know why Jaz, but if I pick a little flame will still let the bur up and go in proximally without local, the kids don’t tend to feel it. ‘Cause there’s reasonable enamel there. The moment you seem to pick a footy up and touch the top, the kids do seem to feel it. So when I’m looking at my x-rays and clinically I’m looking at how deep down towards the gum the decay goes, and if it gets below gum level, despite meeting the other criteria.

So plenty of space to the pulp. Symptoms are sweet. I might say to them, hey, we need to do a conventional crown here because I need to numb ’em up. Take some off the top to get the crown to sit down far enough to seal decay. The second thing I need people to look out for is when you’ve got a clinical cavity that’s present usually on the D, the D blows before the E or for the other people that know that the first primary molar goes before the E.

The second primary molar reason is it’s been there longer and it’s got much thinner enamel on, so it tends to blow first. What can happen is you get a clinical cavity on the first primary molar and then the tooth behind it tips into the hole. 

[Jaz]
Hate that scenario. ‘Cause it just makes everything so awkward and tight.

[Tim]
Correct. And then how do you get a crown? You need to do like an S bend, it’s gotta get like a dog lick to get around the second primary molar to seal it. And that’s once again where you might look at the scenario and say, actually I need to numb the kid up into a conventional crowd. But they’re your two main ones.

They’re the two things. Just for tips for young players, you’re getting started. I would say don’t pick a D, pick an E. So second primary model, they’re easier teeth to manage. Pick obviously a very compliant child. And if you’re a bit concerned and you’re worried, like you’d think, oh, I dunno if I actually sealed that decay.

Take an immediate x-ray. So before the cement sets. So if it has, and you haven’t sealed it, get the crown back off and reassess your plan and maybe you need to numb ’em up and take a bit off the top. 

[Jaz]
Okay, that’s wonderful. And so the questions I have clinically on the back of that is just some common questions I actually see on forums on this technique is, let’s imagine a scenario where you have a, let’s say 5, 6, 7, 8, and eight.

So lower right D for some of our listeners, it’s clinically cavitated, but it’s equigingival caries, and you have, or, it’s vital. You have that band of dentine, so it’s suitable for a whole crown and you don’t have any space issues per se in that scenario where, because it has got an an obvious cavity, the guideline says, obviously if you can get a seal, you don’t need to remove the caries.

But in that scenario, it’s so tempting to just pick up an excavator and just scoop out some of that the most superficial decay. Is that something that you do because it’s just so easily accessible, just scoop it out in case there’s some bread or cookies stuck in there or something? 

[Tim]
Oh, absolutely. You gotta get the food out. Yes, please. So definitely give it a clean, but you don’t need to scoop out tooth structure, because once again, that boils back down to the understanding of decay. Decay is not an infection, it is a biofilm related disease. So if we can, so plaque bacteria related, right?

So if you can kill all the germs there because they’re deprived of a food source, don’t worry about it. Don’t pick anything up. Just make your life easier, quicker. Don’t pick a drill up. Just squish it on. 

[Jaz]
And then just the point there to make is if you see an obvious bit of food there, just get rid of that, cleanse it in that way basically, and get rid of it. And then the other scenario is when you are a bit more experienced, and then I’ve done a fair few hall crowns in my time, don’t see children anymore, but I used to love doing them. And when I did them, sometimes when it’s a bit tight. We need to then, yeah, zip the contacts just to allow it to seat a bit better.

And in that scenario, like you said, I also experienced that, okay, children were okay with that. They didn’t need any LA for that. That was okay. In that scenario, you are able to then seat it, which is great. Now going back to the stainless steel crown, the conventional technique is there sort of like a hybrid technique whereby you are doing the conventional technique, you are zipping off the contacts.

But you are not adjusting the occlusal for whatever reason. And then essentially what you have is kind of like a modified approach because with the whole crown, they’re gonna have super occlusion, their mouth be propped open. And so is there a place to utilize that approach, either to make your treatment quicker, more efficient?

So given the patient LA, you are zipping the contacts, but you’re not then doing the occlusal reduction because it will dahl in or it will settle occlusally anyway. Is that any need to do the occlusal adjustment? 

[Tim]
No, the short answer is no. I agree with you. There is certain circumstances where I’ve just got a zip between, and I won’t numb them up for that because they really don’t tend to feel it.

I would still, for in my hands, I still sort of call that the hall crown. For me, conventional crown is when I’m picking a needle up and I’m giving LA which is pretty rare on its own. Usually it’s when I’m doing a pulpotomy or I’m doing like back to back things, I’m extracting a tooth and then I’m like, oh, I’ll just put this on at the same time.

But, yeah, vast majority of time. Yeah, absolutely. You can just sort of zip between if you need to. But I’d say to most people, the vast majority of times, 80% of cases, you’re not gonna need to pick a single driller. You’re just gonna need to clean the gunk out. You’ll have seps (separators) in, leave ’em for a couple days, pull ’em out. You’ll have room and on your go. 

[Jaz]
And at the point of placing just a little technique here, but at the point of placing I placed, and then what’s the most efficient and best way to remove that GIC cement without then removing the crown or pausing discomfort to your child? 

[Tim]
Yeah. So my usual discussion with the parent or child before we’ve even got to that point is, I describe how we’re gonna do this technique. And I usually describe it in such a way, like you asking before about what, how does it work? My analogy I give to most parents is, imagine if I had a water tank and I put you in it, Jaz, and then I filled it full of concrete. How would you go? Not very well, you’d be dead. Right? And that’s what’s gonna happen to all the germs in here.

Okay. Now I need to put rubber bands between the teeth. Your child’s gonna be most upset by this bit out of the whole procedure. Why? ‘Cause it hurts. It’s like having a big chunk of corn stuck between your teeth. Usually at this point, I say to the kids, hey, you ever eaten corn before you eat meat? You know, we get stuck between your teeth.

It’s really annoying. So what we’re gonna do, I’m just gonna floss this in. It’s gonna be a little bit annoying. Always do the harder contact first. So usually on a D, do between the D and the E first, and then do the D and the C, right? If you’re doing the six, do the most, whichever one looks, the dodgiest do the hardest one first, and then the kids usually get a bit upset because it’s hurting and they wanna pull ’em out.

I always just reassure the kid and the parent that every minute it sits there, it’s gonna get less uncomfortable ’cause we’re making space and that’s the worst part of this whole procedure. So usually when they come back for the hall crown, they’ve got the space. Now there’s a particular set of pliers called Howe Pliers, H-O-W-E.

So there’s two pieces of equipment you need to place the stainless steel Crown. Well, there’s Crimpers, which sort of tighten the the gingival margin and make it sort of click, click on and retain better. And Howe Pliers, they’ve got like flat ends. They’re like little pliers with just flat ends. And what you do is you actually put them on interproximally on the crown and you can squish it a bit meso distally.

So they’re brilliant for those cases where you’re lacking a bit of space. Okay. And then it makes it a bit wide buccolingually, so you gotta crimp that in. That will help with you get those two things with good set of separates, you’re pretty good. Then I clean out the gunk, I’ve sized it up pretty well.

I’ve eyeballed it. Sometimes I sort of nearly put it on, can be a bit uncomfortable. I don’t tend to put topical anesthetic on the gum anymore. I tend to find the kids just got the taste of it half the time and I hated it. So I just pretty much now just load the crown up. With a, like a runny glass ionomer cement such as, like in Australia we call them Fuji 7, would be the type and then- 

[Jaz]
Or like a Ketac™ Cem or- 

[Tim]
Ketac™ Cem, perfect GI cement. Yep. 

[Jaz]
So you shouldn’t use the Fuji 9, for example. It’s too thick. 

[Tim]
Too thick. Can you get a struggle to seat it down very well. So you wanna runny. Not an RMGIC. Absolutely not. You wanna run GIC bit more like a looting cement? Okay. Yeah, yeah. And then load the crown up and definitely load it up. Good halfway. Keep in mind ’cause you haven’t taken a whole heap off, you don’t need a huge amount. And then just push it on. Okay. And then to clean it up, I usually just get some gauze and just wipe around all the excess initially.

Then the strongest way to get that crown to sit down is 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. Okay. And then I get my triplex and I just wash all the cement off and off you go. Then you get a floss with a knot in it, and then you put it on and then you get your DA to put dental assistant 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. 

[Jaz]
That can be tricky, right? That can be a little bit tight and annoying. In my experience it has been. Have you found the same as well? 

[Tim]
Absolutely. But you gotta do it. Yeah. Otherwise you’ll glue the contact.

[Jaz]
It’s a stressful part of the procedure where you’re like, okay, quick, quick, quick. 

[Tim]
Yeah, spot on. But keep in mind, if you get a slower setting one, you’ve got about two to three minutes. And that’s where if you put it on and you look at it, you’re like, it looks like the one surface is sitting in the air.

That’s when you’re thinking that’s not on, like it should be like a mill and a half high. Right? If you’re looking and it’s like, it’s low on the mesial, really high on the distal and that’s where my cavity is. And that’s your time to get it off. 

[Jaz]
Can be quite fiddly to begin with. But like you said, it’s such an incredible success rate you get, and it’s great to be able to intervene in this way just so I can make sure that for the show notes, everything is correct and my understanding has been correct as well. So I’ll summarize.

You’ve done a wonderful summary here of the hall crown technique, why we do it, why it’s beneficial compared to the conventional technique, but just there are still some scenarios whereby you may use the conventional technique with LA, occlusal reduction, zipping the contacts, and that is. A, when you’re doing pulpotomy B, when the caries is very subgingival, is there any other times where you would veer away from the hall crown technique? 

[Tim]
When you’ve got that significant space loss? Okay. And then potentially, like if I’m doing a quadrant of dentistry, like the second primary molar is gonna hole in it. The first primary mole’s got a big hole in it and the canines got a hole in it. You can’t hall crown a canine, so I’ve gotta numb ’em up. And then I might just say, I’m just gonna knock out all three in one go. I’m not gonna get ’em, do all these hall crowns come in and numb ’em up. So I might do, potentially a composite on the second primary mole.

If it’s small, if it’s big, I might do back to back crowns, for one needs an extraction, whatever. I’ll probably just move ahead and just, ’cause I can get a, it doesn’t take me long. I just get a quite nicer fit. Yeah. But you nailed it mate. That’s pretty much it. Brilliant. 

[Jaz]
Thank you so much. And that was all down to your wonderful summaries. So let’s now the last bit. Okay. Zirconia is a newer product in the market for children. It has been around for a little while now, but I haven’t seen it in the UK, been used very widely, but perhaps because the bias of me not looking at what the children’s clinics are doing in the UK at the moment. So tell me, my friend, how far are we in the zirconia being potentially replacing metal? And what have been your experiences with it? 

[Tim]
So we place quite a lot of them. They probably make up about 40% of the crowns that we place in comparison to hall crowns and conventional crowns. The main reason is obviously aesthetics.

Okay. Success rates are pretty similar between a stainless steel crown and a zirconia crown. If placed well, okay, so why would we put ’em on? It’s just purely aesthetics. That’s it on posterior teeth. So I would usually discuss with the parents and say, hey, look, your kid’s got, let’s just say they got all back eight molars in decay.

I’ll say, hey, look, all back eight molars with decay, whenever I’ve got a cavity in the first primary molar, the success rate of fillings is pretty low. So I usually will say, you got your choice is, are stainless steel crown or zirconia crown for a first primary molar. For a second primary molar, i’m a little bit more comfortable doing restorations on them, intracoronal restorations.

Okay, so let’s say they’ve got that, I’ll be discussing with them and say, hypothetically, let’s say they need eight crowns based on what I’m seeing. They’re all really big holes. I will say to them, oh, we can do eight stainless steel crowns. Your success rate sits in eight, that 95 to 97, your main drawback is you’re not gonna love the way it looks.

They’re gonna look a bit like jaws. So you’re gonna have all these visible eight teeth. So the other option you got is that we can do zirconia crowns. Now the more visible teeth are the first primary moles. So you can do them all in white. All in silver. Or you can do a mix. You can do maybe the front baby teeth in white and the back baby teeth in silver.

And so then when the kids smile for school photos, you’re not really seeing all that metal work. You’re predominantly just seeing a nice aesthetic looking tooth and Jaz that would be our most dominant use. We don’t commonly get that many parents who wanna do like all eight teeth in white because it costs more to do, they do take more time as well.

That can take fair whack a bit more time if you’re doing eight of them. And the reason is it’s a non flexible material. So if we talk about zirconia for a minute, most general practitioners are familiar with zirconia crowns or zirconia is a product for adult. We know it’s not flexible. We know it’s very strong and durable and compressive strengths, excellent once it’s cemented, but it’s not flexible.

So if you sat there with your fingers or got a little interest. Banged on it, it’ll fracture which means that you can’t squish it on like a stainless steel crown for kids where you’re like, oh, my prep’s not perfect, but I’ll just push it and the crown will bend on. And that’s why hall crowns work.

‘Cause it’s a flexible material. So for zirconia, you have to prep the tooth and it’s a bit like an adult crown prep with like no edge, no, no ledge, no feather edge, no shoulder, nothing. So what you do is you take about a mill and a half to two mil off the top, and then you take roughly about a mill everywhere else.

And then, so pretty much you create like a ledge all the way. So usually the way on which I would do it is I’ll take it off the top first ’cause it makes you crown shorter. So you then having to remove less. Then I stay on the same bur, which is usually like a football bur. Then I take some off the buccal and the palatal.

‘Cause you try to remove bur changes. That’s what makes things quick. Then I get a stiletto bur, or flame bur you gotta go below the gum. You’re about a mill below the gum, and then you buzz all the way around, get all your edges away, clear in proximals. And then for the new smile, you get a try in crown, which is excellent compared to that other brand called Sprig.

The reason is you use the try in Crown, which will get contaminated by blood products and things, and you try to fit it on, and there’s a classic size and there’s a narrow, the narrow is obviously designed for where you got space loss and you try it on so it passively fits, so you’re not forcing it. If you force it, you break it so you don’t want it rocking.

You want it passively fitting on with still contact points established. Once you go onto that, you then go and get your white crown, the one you’re gonna cement. You get good hemostasis of the gingiva. So sometimes they’re, I’ll use local ’cause it’s got adrenaline, so I’ve already had the patient numb, so whenever I numb a patient up for any procedure, I always numb through the interproximal gingival to the palatal lingual.

Every case I do more so for zirconia. And then otherwise you can use like hemostatic pace like 3M makes a hemostatic pace. ‘Cause you would need much better hemostasis than you do for stainless steel crowns. And then fill it full of the same you want. Now you want a runny R-M-G-I-C potentially. Okay, so you take too long for you if you just go use just a thin, like Ketac™ Cem, you want something you can cure with a light.

Okay? But you still want it thin. You don’t want like a food. You can cement with Fuji too. But for posterior teeth it’s a bit thin. Thick and sometimes you can’t get the crown out ’cause the cement can’t escape. So we use a 3M based product, which comes into syringe called RelyX. It’s really nice material and then you load your crown up, you put it on, and then I don’t touch anything.

I just set it. And so there’s excess cement everywhere, but it’s sets really quite tacky. So it’s a bit like a tack cure, but you’ll set for 40 or 60 seconds and then I just clean all the extra cement up. If you use Fujii2, it sets like bloody, like sets like rock, and it’s really difficult to get out in approximately, and then you’re done.

That’s it. Nice and easy. How long would it take? Look, I can probably do a stainless steel crown, conventional stainless crowned tooth in about three to four minutes. Okay. While zirconia might take me closer to 10- 

[Jaz]
This is because the zirconia involves that buccal and lingual additional prep, and essentially you are removing the belly of the tooth, right? You’re just removing the undercuts. 

[Tim]
Spot on. You just sort of, I mean the listeners, they can’t see. But for those who are watching on YouTube, I am going to describe something. So Jaz, I’m sorry for your listeners, they won’t be able to see this, but I’m going to describe it. For those watching on YouTube, you’d be able to see this.

So this is an anterior case, but I’ll show you posterior. So with it, you’ve gotta make them quite sort of peg, like see, there’s nice hemostasis there. I’ve got stainless steel crowns on the first primary molars, and on the anteriors I’ve reduced the anterior is down to look a bit like a conventional crown preparation, and then I’ve cemented four zirconia crowns there. The gums look a bit like minced meat. They get a bit traumatized here, but they always heal up really quite nicely. Now I’m gonna show a photo of a posterior. 

[Jaz]
Yeah. I’m gonna say it looks a bit like a vertiprep in a way that you just went round. You got rid of all the undercuts and it is not much of a margin.

[Tim]
No. No, you don’t want a margin. You don’t want a ledge. So on the posterior tooth, I’m now showing, you can see that I’ve actually created a ledge. That’s what I was talking about before. So you create a ledge, it just gives you an indication of where to reduce. Then you cut that entire ledge away, which you can see there goes under the gum. Then you try the crown. 

[Jaz]
This is the shoulder that Verti prep. Lovely. 

[Tim]
And then that’s your crown cemented. So the crown’s cemented on sits quite nicely. You want it roughly the same occlusal height as everything else, and you want it sitting under that gum quite nicely. As I said, the gum will be a bit traumatized, but it will be okay. 

[Jaz]
Now here’s an interesting question then, because you’ve just raised a really good point that you want it the same occlusal level in this scenario whereby you are off a bit, then you’re kind of like in the whole crown scenario, you are leaving it in supraocclusion. Are you okay with that because you’re used to doing it anyway in children and they adapt really well? Or are you a little bit more fastidious that you’re gonna start adjusting to equilibrate the bite? 

[Tim]
No, I’m okay with it. I do try to get it a bit more even, but just for comfort and particularly, let’s say if I’m under anesthetic and I’m doing a whole quadrant. I don’t want, just like I’m only chewing on a couple of teeth, it’s just a bit uncomfortable.

So if I can, I’ll try to get it as close as I can. It won’t be perfect. But we do know for the whole crown, it can sit proud and it’ll settle in quite well. So they’re really good. The other place where they are so much better, which I actually personally feel they should replace entirely, is strip crowns so anteriorly, right?

So for a strip crown, it’s the same sort of principle you gotta do like that vertiprep, get rid of the decay. The issue is strip crowns. Success rate’s not great ’cause it’s resonant just chips. Kids go put bloody carrots in there and they bite grizzly bars and all sorts of things. And you just, in any pediatric dental program, when you’re a a first year, you spend all your time dealing with fractured strip crowns from the third years of the guys who graduated.

And so you benefit of your zirconia crowns is they very rarely fracture. You need a really solid trauma to break it, which would’ve broken the tooth anyway. So your main drawback is they might to bond. There’s not much retention on ’em. So that’s where we do cement them with Fuji 2. So we are at thicker R-M-G-I-C in the anteriors, but they are such a better aesthetic result.

You don’t get discoloration . They work very well for pulpotomies. You can successfully pulpotomy and anterior tooth, they can mask. If you’ve put silver diamine fluoride on and it’s black, they so they look a lot better. They last a lot better, so they’re much more superior material. Your main drawback is if you’ve got a kid with heaps of crowding, it can be a bit difficult to try to get ’em to fit all together.

So just tip for young players on that one. That’s where strip counts can help. But mate, well 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.

[Jaz]
And for those you know who are listening, I would encourage you just reference back to this video, make a little handout ’cause this is Tim, this has been absolutely amazing. We make a little handout. Do you have permission to use those images in that handout for our Protruserati? 

[Tim]
Yep. 

[Jaz]
Okay, amazing. So I’ll put those images so you can easily download because they were wonderful. It really shines. The benefits of this approach. And it’s nice to know that, a very significant percentage of time actually you are using this. And also to learn about how you’ve no longer pretty much using strip counts anymore. That was amazing. You’ve answered pretty much all my questions in terms of the technique itself. Now I know you do some teaching in Australia and maybe more as well.

Before we get to that, I wanna say, give you, pay you a compliment, Tim, if I had your accent right, which I love, by the way, if I had your accent, I would do the dental version of Aussie Man reviews. Right. I would just think it’d be so funny and good to see these dental procedures happening, and then you just like, honestly, I really enjoyed listening to you today.

The hour went by really quickly. The audience would’ve loved you as well, the Protruserati. Please tell us how can we learn more from you? I know you are active in the education circuit, and I think for everyone. Like it’s nice for them to be inspired by what we discussed today, but I think it’s very fiddly and to just secure the protocols and so much more to it to get hands on experience. How can they learn that from you? 

[Tim]
Yeah, absolutely. So we have a like free dental website could kidsdentaltips.com and you can describe, there’s a whole heap of articles on there. How to manage permanent traumas, do pulpotomies, how to extract primary teeth prevention techniques, fluoride, toothpaste, or anything you can think of for peds.

That’s pretty much on there. It’s free access. There’s not a great deal of videos yet. Jaz, I haven’t quite got to that point yet. There’s some free lectures on there as well that you can view. Otherwise, we do do hands-on programs in Australia with which I’m actually doing one, I’m doing a four day one coming up on Thursday, the next few days, we haven’t done any internationally, but Jaz if you think there’s a place for it in the UK, I’d be very happy to come across for a nice trip to the sunny UK. Do some courses there, but, otherwise, if you are interested in doing something like a zirconia crown. You can find in videos of like how to on the Nu Smile.

So N-U-S-M-I-L-E, the Nu Smile website will have like how to videos and they do tend to run international events as well. I just dunno if they’ve gone into the UK ’cause I know that you market is quite different in regards to nHS and private. So for example, in Australia, there’s really no very limited public funding dentistry where it’s all private, which has got its own problems.

If you don’t have money, you can’t pay for it. It’s bit like America. Conversely, in the NHS, I know you’ve got a lot of restrictions on time and how much you really encouraged to get through things quickly. So, and perhaps that’s why that they haven’t targeted that market previously.

Look, if you listen this, there’s good demand out there. So I’m very happy to come across and run a course on hall crowns, zirconia crowns, restorative materials, local anesthetics and stuff. 

[Jaz]
Yeah, I think that’d be wonderful. So I think if there’s enough comments below, we’ll reach out and see. But I think what you’ve talked about today was absolutely fantastic. In one hour we actually managed to to cover a lot. So I would encourage you, I’m gonna put the website, just say the URL again for my benefit. 

[Tim]
It’s kidsdentaltips.com. 

[Jaz]
Lovely. I’ve seen the website, that’s how I managed to reach out to you guys. If you wanna learn more about Pediatric Dentistry, check out Tim’s website and check the articles out there as well. And if you are in Australia, there’s a good whack of Protruserati in Australia. Please check out Tim’s courses and maybe coming soon to a nation near you. And Tim, I wish you all the best.

‘Cause I really love your education style. I just love people that you are so direct and honest and just full of little nuggets and tips. And I know for a fact that Protruserati would’ve loved today’s episode, so we’re gonna make a little handout for them as well. So, Tim, thank you so much my friend. I put all the links in the show notes. Are you active on social media? 

[Tim]
Not too much. I am in Facebook and I do a few posts and things like that as well. But not, I just time poor Jaz, with three young kids. 

[Jaz]
Oh, I can relate. I can totally relate my friend, but no, it was so nice to connect you on Facebook and thanks for applying to me and being so wonderful on here. I really appreciate it, Tim. Thank you. 

[Tim]
My pleasure. Thanks for having me. I think you do a great job as an interviewer mate. You’re very engaging as well, so thanks very much for having me. 

[Jaz]
Amazing. Thank you.

Jaz’s Outro:
Well, there we have it, guys. Thanks you so much for listening all the way to the end. If you’d like CPD or CE credit, scroll down, answer the quiz and get your CPD. You’ve done the hard work, like how many times do you have to sit through boring webinars to get your CPD?

Well, you’ve just enjoyed Tim’s fantastic commentary and explanation of this awesome technique. And now to validate your learning to be able to reflect and get a certificate, you can just answer the quiz on Protrusive Guidance if you are on one of our paid plans, which I think is the best value educational resource on the planet, but of course I’m biased.

It’s fully tax deductible as you know, and it helps team Protrusive to grow and to make better content. So if you’re not already on there, head over to protrusive.co.uk/ultimate and that unlocks Verti Preps for Plonkers or Sectioning School, all the various other master classes we have on there.

Especially, and of course, the community of the nicest and geekiest dentists in the world. The infographic is also there. We also have a secret space called Protrusive Vault, which has got all the downloads from over the years. And lastly, like Tim is such a cool guy to learn from. I know he does his courses on Australia, so next one is in November.

So if you scroll down, I’ll put a link to his course in Australia in November. Predominantly for the Aussie and Kiwi audience. But you know, if you’re in Asia or sometimes you wanna make a tax deductible trip to Australia, then this is a great reason to go. Tim is absolutely brilliant, and of course I’ll put a link to his website.

And with that, I will say thank you so much guys, honestly, for listening to the end. If you enjoy this episode, please send it to a colleague. This is how we grow. All the best. I’ll catch you same time, same place next week. Bye for now.