Protrusive Dental Podcast

Are you confident in spotting a child at risk of neglect? Do you know what to do if you witness abuse in your practice? How can you raise concerns safely while protecting both the child and your team? This episode with Dr. Christine Park provides tangible actions, practical scripts, and clear guidance for managing challenging scenarios—like seeing an adult hit a child in the waiting room or recognizing neglect in the dental chair. These are situations dental school rarely prepares us for. Every practice needs clear protocols for safeguarding. This episode acts as a North Star, helping you stay compliant while ethically doing the right thing. If you treat children, you must listen to this episode and share it with every colleague who treats children. https://youtu.be/-kYs23Xa4Ls Watch PDP251 on YouTube Protrusive Dental Pearl: Find the phone number of your local child safeguarding board / social services. Verify it, then display it where you and your team can quickly access it. Key Takeaways Dentists are trained observers of family dynamics. Recognizing normal behavior is key in dental care. Unconscious observations can guide professionals. Feeling uncomfortable about a situation is a valid signal. Empowerment comes from trusting your instincts. Dental care professionals see many aspects of families. It’s important to act on uncomfortable feelings. Observation skills are crucial for effective care. Children’s interactions reveal much about family health. Awareness of discomfort can lead to better outcomes. Highlights of this episode: 00:00 Teaser 00:59 Intro 02:40 Pearl – Child Protection Hotline 05:23 Dr. Christine Park’s Background and Expertise 08:37 The Role of Dentists in Safeguarding Children 11:19 Practical Scenarios and Guidelines for Safeguarding 15:35 Recognizing Silent Cases of Neglect 17:29 Team Collaboration and Support in Safeguarding 21:58 Guidelines and Policies for Effective Safeguarding 22:03 Midroll 25:24 Guidelines and Policies for Effective Safeguarding 28:32 Handling a Tough Safeguarding Scenario 32:18 Dealing with Poor Oral Hygiene and Neglect 39:12 Managing Parental Reactions and Consent 43:08 The Importance of Safeguarding in Dentistry 45:34 Further Guidance and Resources 46:10 Outro 📢 Safeguard your young patients with confidence! Catch Dr. Christine Park at the Scottish Dental Show in June or via her NES webinars. Check out the BSPD guidelines on dental neglect —an essential resource for any dentist treating children ✉️ Get in Touch with Dr. Christine: General: Christine.park@glasgow.ac.uk Patient-info: Christine.park7@nhs.scot If you loved this episode, don’t miss How to Manage Children in Dental Pain – Paediatric Emergencies – PDP159 #PDPMainEpisodes #Communication #CareerDevelopment This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A and D. AGD Subject Code: 430 PEDIATRIC DENTISTRY (Identification and reporting of child abuse) Aim: To equip dental professionals with practical knowledge and skills to recognize, respond to, and appropriately escalate safeguarding concerns involving children in dental practice. Dentists will be able to – Identify key signs and red flags of child neglect, abuse, or welfare concerns in dental patients. Apply clear communication strategies to discuss concerns with parents/caregivers and involve relevant authorities. Follow practice-based and multi-agency procedures for safeguarding, including documenting observations and escalation.

Let’s be honest – the occlusion after Aligner cases can be a little ‘off’ (even after fixed appliances!) How do you know if your patient’s occlusion after aligner treatment is acceptable or risky? What practical guidelines can general dentists follow to manage occlusion when orthodontic results aren’t textbook-perfect? Jaz and Dr. Jesper Hatt explore the most common challenges dentists face, from ClinCheck errors and digital setup pitfalls to balancing aesthetics with functional occlusion. They also discuss key strategies to help you evaluate, guide, and optimize occlusion in your patients, because understanding what is acceptable and what needs intervention can make all the difference in long-term treatment stability and patient satisfaction. https://youtu.be/e74lUbyTCaA Watch PDP250 on YouTube Protrusive Dental Pearl: Harmony and Occlusal Compatibility Always ensure restorative anatomy suits the patient’s natural occlusal scheme and age-related wear. If opposing teeth are flat and amalgam-filled, polished cuspal anatomy will be incompatible — flatten as needed to conform. Key Takeaways Common mistakes in ClinCheck planning often stem from occlusion issues. Effective communication and documentation are crucial in clinical support. Occlusion must be set correctly to ensure successful treatment outcomes. Understanding the patient’s profile is essential for effective orthodontics. Collaboration between GPs and orthodontists can enhance patient care. Retention of orthodontic results is a lifelong commitment. Aesthetic goals must align with functional occlusion in treatment planning. Informed consent is critical when discussing potential surgical interventions. The tongue plays a crucial role in orthodontic outcomes. Spacing cases should often be approached as restorative cases. Aligners can achieve precise spacing more effectively than fixed appliances. Enamel adjustments may be necessary for optimal occlusion post-treatment. Retention strategies must be tailored to individual patient needs. Case assessment is vital for determining treatment complexity. Highlights of this episode: 00:00 Teaser 00:59 Intro 02:53  Pearl – Harmony and Occlusal Compatibility 05:57 Dr. Jesper Hatt Introduction 07:34 Clinical Support Systems 10:18 Occlusion and Aligner Therapy 20:41 Bite Recording Considerations 25:32 Collaborative Approach in Orthodontics 30:31 Occlusal Goals vs. Aesthetic Goals 31:42 Midroll 35:03 Occlusal Goals vs. Aesthetic Goals 35:25 Challenges with Spacing Cases 42:19 Occlusion Checkpoints After Aligners 50:17 Considerations for Retention 54:55 Case Assessment and Treatment Planning 58:14 Key Lessons and Final Thoughts 01:00:19 Interconnectedness of Body and Teeth 01:02:48 Resources for Dentists and Case Support 01:04:40 Outro Free Aligner Case Support!Send your patient’s case number and get a full assessment in 24 hours—easy, moderate, complex, or referral. Plus, access our 52-point planning protocol and 2-min photo course. No uploads, no cost. [Get Free Access Now] Learn more at alignerservice.com If you enjoyed this episode, don’t miss: Do’s and Don’ts of Aligners [STRAIGHTPRIL] – PDP071 #PDPMainEpisodes #OcclusionTMDandSplints #OrthoRestorative This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A and C. AGD Subject Code: 370 ORTHODONTICS (Functional orthodontic therapy) Aim: To provide general dentists with practical guidance for managing occlusion in aligner therapy, from bite capture to retention, including common pitfalls, functional considerations, and case selection. Dentists will be able to – Identify common errors in digital bite capture and occlusion setup. Understand the impact of anterior inclination and mandibular movement patterns on occlusal stability. Plan retention strategies appropriate for aligner and restorative cases.

Do you have a “hopeless” retained root you’re ready to extract? Think implants, dentures, or bridges are the only way forward? What if there’s a way to save that tooth — predictably and biologically? In this episode, Dr. Vala Seif shares his experience with the Surgical Extrusion Technique — a game-changing approach that lets you reposition the root coronally to regain ferrule and restore teeth once thought impossible to save. Jaz and Dr. Seif dive into case selection, atraumatic technique, stabilization, and timing, all guided by Dr. Seif’s own SAFE/SEIF Protocol, developed from over 200 successful cases. https://youtu.be/2TyodqgAP9w Watch PDP249 on YouTube Protrusive Dental Pearl: When checking a ferrule, consider height, thickness, and location of functional load. Upper teeth: prioritize palatal ferrule. Lower teeth: prioritize buccal. Tip: do a partial surgical extrusion, rotate the tooth 180°, then stabilize. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Surgical extrusion is a technique-sensitive procedure that requires careful planning. Case selection is crucial for the success of surgical extrusion. A crown-root ratio of 1:1 is ideal for surgical extrusion. Patients are often more cooperative when they see surgical extrusion as their last chance to save a tooth. Surgical extrusion can be more efficient than orthodontic extrusion in certain cases. The importance of ferrule in dental restorations cannot be overstated. Proper case selection is crucial for successful outcomes. Atraumatic techniques are essential for preserving tooth structure. The ‘Safe Protocol’ offers a structured approach to surgical extrusion. Patient communication is key to managing expectations. Flowable composite is preferred for tooth fixation post-extraction. Understanding root morphology is important for successful extractions. Highlights of this episode: 00:00 Surgical Extrusion Podcast Teaser 01:07 Introduction 02:38 Protrusive Dental Pearl 05:53 Interview with Dr. Vala Seif 08:57 Definition and Philosophy of Surgical Extrusion 15:30 Indications, Case Selection, and Root Morphology 21:37 Comparing Surgical and Orthodontic Extrusion 25:54 Crown Lengthening Drawbacks 28:39 Occlusal Considerations 33:53 Midroll 37:16 Definition and Importance of the Ferrule 43:07 Clinical Protocols and Fixation Methods 01:00:01 Post-Extrusion Care and Final Restoration 01:05:04 Learning More and Final Thoughts 01:09:29 Outro Further Learning: Instagram: @extrusionmaster — case examples, papers, and protocol updates. Online and in-person courses in development (Europe + global access). Loved this episode? Don’t miss “How to Save ‘Hopeless’ Teeth with the Surgical Extrusion Technique” – PDP061 #PDPMainEpisodes #OralSurgeryandOralMedicine #OrthoRestorative This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes C. AGD Subject Code: 310 ORAL AND MAXILLOFACIAL SURGERY Aim: To understand the biological and clinical principles of surgical extrusion as a conservative alternative to orthodontic extrusion or crown lengthening for managing structurally compromised teeth. Dentists will be able to – Identify suitable clinical cases for surgical extrusion, including correct root morphology and crown–root ratios. Describe the step-by-step SAFE Protocol for atraumatic surgical extrusion, fixation, and timing of endodontic treatment. Evaluate the advantages, limitations, and biomechanical considerations of surgical extrusion compared with orthodontic extrusion and crown lengthening. Click below for full episode transcript: Teaser: I always had a problem with extracting teeth. Not a problem technically, ethically. If highly damaged teeth get properly treated and correctly maintained, they are always going to outlive implants. [Teaser]So what I’m referring to here is that the most sophisticated and complicated solutions are not always the smartest one. It’s not about most expensive. It’s not about most advanced. It’s not about most complicated. It’s about the best possible for the patient. We must keep that in mind that there is no such thing as a master key that opens up all of the doors for us. Surgical extrusion, over the years… it actually was presented to dentistry in the early eighties. They were really trying to work on surgical extrusion. And guess who comes out? I have done over 200 cases with a follow-up of up to six, seven years. That is something that you can rely on. In such cases, I take out the tooth and rotate it and put it back in. No way. Jaz’s Introduction: Yeah, so you have a retained root and you think this is hopeless and you’re headed towards an implant, denture, a bridge or whatever. But then this episode comes along and reminds you about the power of the surgical extrusion technique. In plain terms, you are partially extracting the root, and now you have the most important thing in restorative dentistry. You have ferrule, you have tooth structure, you can now crown. Whereas before everything was subgingival and it was impossible to restore. Hello, Protruserati, I’m Jaz Gulati and welcome back to your Favorite Dental Podcast. This is the podcast where you make dentistry tangible and make you fall in love with dentistry again. Four years ago, with Dr. Peter Raftery, the endodontist, we spoke about this very topic, the surgical extrusion technique. I’ll put that episode in the show notes ’cause that was really valuable as well. But in this episode it is special because it’s an update from someone who’s done more than 200 cases. So what he believes, and what I also believe, is he is the most experienced clinician in the world when it comes to the surgical extrusion technique. I haven’t seen anywhere in the literature the kind of numbers that he’s done—so, so much. We can learn from Dr. Vala Seif from Iran, and Protruserati, you’re gonna absolutely love him, right? His storytelling, his analogies. I actually really geeked out and had a great time, and I know you’re gonna love him. Even all the way to the end, the last few seconds, he still gave another tip of how to stop bleeding when you do this technique so you can then add your composite splint to secure the root. He’ll give you that right at the very end. So make sure you don’t miss any of this episode. Dental PearlNow, every PDP episode I give you a Protrusive Dental Pearl. This one’s an occlusion conceptual one, a biomechanical one when it comes to restorative dentistry, but it’s also very relevant to this episode ’cause a really cool, fascinating technique was advised by Dr. Seif, which I really am excited to share with you. So firstly, conceptually, the pearl I’m giving is to remember the following: that when you have supragingival structure all the way around 360 degrees, we call that the ferrule. Something a crown can grab onto, and it’s important that this ferrule is as tall as possible vertically—ideally two millimeters plus—but it’s also important that the tooth structure remaining is thick because if it’s very, like, if it’s paper thin, that’s not really a ferrule, that’s not really contributing biomechanically. Now the conceptual pearl I’m giving to you is to think about the position of the ferrule. If you have three millimeters on the palatal side and one millimeter on the buccal side, then this is still pretty good, especially for upper teeth, because the location of the ferrule is actually really important. Think of the way that the upper incisors are loaded in a class one and class two patient. When a patient is chewing, the palatal of the upper incisors is taking load in clenching, is taking load in mastication and chewing as the food is pushed into centrals, and as you are cutting and incising, the crown is kind of going in a buccal direction. The tooth, the crown of an upper incisor, is heading in a buccal direction, and so it is trying to grip onto that palatal tooth structure. And in a lower incisor, the buccal part of tooth structure is gonna be under more strain because the lower incisor is trying to bend inwards. So why is this important? Well, pragmatically speaking, if you have a scenario where you’re trying to restore a canine and you’ve got lots of tooth structure palatally and not very much tooth structure buccally, then probably you’re gonna still be okay because that palatal tooth structure for an upper tooth, that’s usually more valuable and more precious. It just helps us to remember how teeth are loaded in a biomechanical way. Now, the absolutely fascinating thing that Dr. Vala Seif spoke about is: let’s say you have a scenario where we have a retained root, like a crown–root fracture, and let’s say you have loads of tooth structure buccally but you don’t have much palatally for an upper incisor. Remember: upper incisor, we want more palatal tooth structure. Well, the fascinating thing that he spoke about is: let’s say you do the surgical extrusion technique. You partially extract this tooth out, and so now you’ve got more tooth structure to work with. And don’t worry, the entire protocol will be broken down in this episode. But the thing he said which really wowed me was: okay, you have this scenario. But how about now? You partially extract it and then you basically twist it 180 degrees, and that’s the new position of this tooth. Suddenly you’ve gone from a situation where you had a lot of buccal tooth structure and not much palatal, to now rotating the tooth 180 degrees, and so now you’ve actually created ferrule palatally for this upper incisor. I thought, wow, that’s really clever, because guess what? The PDL don’t care if it’s the buccal or the palatal. The PDL don’t know. The healing mechanism will still be the same, but now you’ve gained a biomechanical advantage. So thank you, Dr. Vala Seif, for sharing that, and I wanna just talk about it because it was just so awesome. It blew my mind. So, dear friends, let’s check out this main interview. I know you’re gonna absolutely love it, and I’ll catch you in the outro. Don’t forget to pay close attention so you can get 80% on the quiz to get your CE credits. Main Episode: Dr. Vala Seif, thanks so much for joining us today. Where are you from? Where are you speaking from? [Vala] Thank you very much for having me. I’m very glad to be here today. I’m based in Tehran, Iran, and obviously I’m from Iran. [Jaz] Well, I appreciate you joining me. I try and think, have I had any guests from Iran before? I don’t… yeah. I’ve got lots of Iranian friends. I love Iranian food. I love you guys’ food. You know, my favorite thing ever to see on TikTok—like my TikTok, I rarely go on TikTok, but when I do, I just see that the algorithm knows what I love so much. It’s like that giant, giant rice dish that you turn upside down and you take off. Like is that an Iranian thing? [Vala] We do have something similar, but what you’re referring to more sounds like Arabic food. But you actually can find a lot of similarities between the food that we are making in Iran and Arabic countries, and obviously even Pakistan and India. So the taste is very close. There’s a good chance that you’re referring to. [Jaz] Man, I love it. I mean, Indian food, I love biryani. But when I see the— [Vala] Oh, I love that too. [Jaz] — the Iranian cuisine and the kebab and stuff, man. I’m a big fan of that. But it’s great to be speaking to you from Iran. [Vala] Thank you, sir. [Jaz] We’re talking about surgical extrusion today, so very excited about that. But just give us a bit of a background on yourself. Are you restorative dentist? What is your background? What are your passions within dentistry? [Vala] Sure. [Jaz] How did you fall to get to the stage where you’d like to talk more about surgical extrusion? [Vala] Yeah. Alright. I have been working as a… I got into university in early 2000. So basically I’m a graduate of 2008. So over 25 years—almost 25 years ago—I got into dental school. So after that, I actually completed a course in a master by research in oral surgery. And then I am a former resident of oral and maxillofacial surgery. For some reasons I had to stop the training for family matters, and I have been in private practice for the past 15 years, almost. [Jaz] And what do you love? What aspect of oral surgery do you enjoy the most? Is it wisdom teeth? Is it implants? [Vala] Area of interest is cosmetic dentistry and implants. So basically in my clinic I’m working on ceramic and porcelain veneers and also implant dentistry. But my passion for surgical extrusion started about seven years ago because I always had the problem with extracting teeth. Not a problem technically—ethically, basically. So that was when I was exposed to surgical extrusion because it’s actually a very forgotten type of treatment in dentistry. And I was very glad when I realized that you also shared the same passion as I have for surgical extrusion because it’s going to save millions of teeth probably if it becomes— [Jaz] It was approximately seven years ago when I came across it as well. I think that’s when some of the research, some of the Italian people were talking about it a lot more. And now recently I’ve been on orthodontic extrusion course actually, so that was wonderful. By Dr. Guido—Guido Fichera—I’m probably saying his name wrong. I mean, what a genius guy. And so that was really cool to learn how to use brackets to rapid orthodontic extrusion. But you know what, in real terms, to have the materials, to have the patience, to have the technique to be able to do orthodontic extrusion… whilst when you compare to surgical, I do think it does have a lot of benefits doing the orthodontic, but it’s not accessible to every single dentist, right? [Vala] Correct. [Jaz] It’s more difficult to get by, and a lot of patients will not accept having brackets of any form, so I do like the more instant, if you like, potential of surgical extrusion. So I guess the best place to start is: define. Let’s define. What is surgical extrusion? And then when we go from there, we’ll talk about, okay, what were the earlier ways—seven years ago, ten years ago—they were doing it, and what changes may have happened? And I’d love to obviously learn about your protocols, but let’s start with that. What is surgical extrusion technique? [Vala] Alright, Dr. Jaz, I’m pretty sure this is going to be a wonderful chat between you and me because I have a lot to share with my colleagues. The first thing is we look at surgical extrusion from two different angles. One is technical, the other one is ethical, or basically the philosophy behind doing surgical extrusion, right? So number one, technical, is that you are going to, through a very delicate surgery, you are going to reposition the tooth more coronally in order to have sound tooth structure with a 360-degree ferrule, as well as doing it in such a way that you are preserving gingiva and PDL and bone altogether. And the reason that I’m a very big fan or defender of this idea is that many, many beautiful, great articles that I can share with you later are referring to this fact: that if highly damaged teeth get properly treated and correctly maintained, they are always going to outlive implants. So body is going to outperform titanium in any given circumstances. [Jaz] I totally agree. And I think implants are not the panacea we once thought they could be. And we are seeing so many more complications—peri-implantitis. Implants are great when you have a gap and there’s no other options. But when there’s one more chance—and then we’ll talk about case selection later—when there’s one more chance to work with nature, in a modified way, I guess, in enhanced way… Then let’s take that, because it’s so much better to have an implant when you’re 50 or 60 than an implant when you’re 30. And I don’t think any—even the most astute implantologist in the world—will disagree that for their own daughter, for their own mouth, they’d like to save their teeth for as long as possible. [Vala] That is very true. And that’s when the philosophy behind a treatment comes up. Let me put it this way. May I give you two simple examples? That is going to help us understand this philosophy better. You know that when NASA engineers were trying to send man to outer space—this is a funny story, it’s an interesting story—they were trying… there was no gravity. They were trying to make sure that they were gonna find a way to… when the astronauts were trying to write down the information necessary, there was no gravity so the ink could not flow to the tip of the pen. So there was a project—thousands of dollars—they were trying to spend to make a pressurized pen. And I’m sure you know how the story ended, right? The Soviets used a pencil. And I’m going to give you another, really, I’m gonna give you another example. It happened in my country many years ago. There was this company; they were making very nice chocolates and exporting it to the European countries. And there was a small problem. This was actually happening around 50 years ago, 40-plus years ago. And the small problem was this: some of the chocolate packagings were actually empty, so the machine was doing the packaging but there was no chocolate inside. So there were some complaints and the board of directors sat together and they were deciding… they were trying to find a way to solve the issue. There were devices to detect the faulty packages, to get them out of the lines and everything. And one day, the board of directors were actually walking through the factory to locate a designated area for the machines, and they realized one of the very old workers of that company who was there for so many years, right in front of the rails that take the packaging to put in the boxes and everything, he actually put up a stool with a fan. So the fan—the air that was flowing toward the empty packages—because they were very light, there was no chocolate inside, the empty packages were flying away. And the board of directors were actually very surprised by the fact that they were ready to spend thousands. So what I’m referring to here is that most sophisticated and complicated solutions are not always the smartest ones, are not always the best ones, are not always the… because as dentists, we are trusted that we are coming up with the best decision for the patient. It’s not about most expensive. It’s not about most advanced. It’s not about most complicated. It’s about the best possible for the patient. So we are working in patients’ best interest. Surgical extrusion… I’m not against implants. Please keep that in mind that I am a big fan of implants. It is one of my passions. I do implants every day in my practice. Sometimes implants are miracles. But we must understand one thing: if we are having weapons in our arsenal, if we are having tools in our toolbox in dentistry—veneers, onlays, inlays, implants, surgical extrusion, bone grafting—we must keep that in mind that there is no such thing as a master key that opens up all of the doors for us. We must keep that in mind that each and every one of these tools are going to be great for us and for the patient if the case selection is correct, picking up the right tool is correct, applying it is done correctly, and at the end of the day, we are having promising long-term results that we can completely rely on. That’s the fact. [Jaz] That was so eloquently put. I absolutely love that—there’s stories that you weaved in there to really drive home the point there that we don’t need complicated solutions. Sometimes we need to look to simplicity. And so you led very nicely to case selection as well. So which teeth, where in the mouth is this technique suitable? And there must be some radiographic markers of predictability. There must be some clinical markers of predictability. Do you mind just going through: which is the ideal case for whether it’s your first case, your 500th case—universal principles to adhere to? [Vala] I have worked on over 200-plus cases. It’s not 500— [Jaz] Two hundred is a significant amount for a very niche technique like this. That is a lot. You’re probably up there in the top five in the world probably who’s done this technique so many times, in my opinion, based on… it’s to actually find the case. That’s like sometimes you’re trying to find the perfect case to do this on, and then you have to wait for that case to walk through. To get 200 is a significant number. [Vala] Dr. Jaz, I’m very honored to say this: based on the searches that I have done through literature, actually this is the biggest data set in the world. I’m really honored to say that no one has done this before, because if you browse through all of the articles that have been published before, many of them are actually just case reports. The biggest ones that I have come across are 50-plus or near 60 teeth. The rest of them were 10, 20, 30 cases. And normally there is no follow-up for the long term, but because I had enough time and I have done it in my practice—and these are the patients who are always showing up to make sure that everything is okay—in a university setup it is different. Sometimes you cannot call the patients back. But I have done over 200 cases with a follow up of up to six, seven years. That is something that you can rely on. Anyhow, back to your question. Case selection is extremely important, because if the case selection is not done properly, you are actually getting ready for big failures. As there’s this idiom: if you fail to plan, you’re planning to fail. So basically number one is: we need to make sure that, number one, the root length should be proper. Meaning after you have done your extrusion, after you have removed the decay or the fractured part, you need to make sure that after everything is done, the crown–root ratio of one-to-one is going to be there. That is number one. [Jaz] So what we’re looking for is that, by the end of it, you’re not having a crown that will be longer than the remaining root. So the first thing that comes to mind is someone who’s already had orthodontic resorption would then be a bit more difficult, and also someone who’s had periodontal disease. So whether they’ve lost the bone or whether they’ve lost the root from the apex—i.e., the resorption—or they’ve lost the bone from perio. But usually these perio cases are not the ones that will come in your clinic with the fracture at that level because usually the mobility cushions it and all that weakest link theory. So yes. Okay, that’s a good point. So one-to-one is obviously… if you’re better than one-to-one, if your root is longer than the crown, that’s better. But bare minimum one-to-one. That’s a very good starting point. [Vala] Alright. If we want to go—let’s put it this way—if we want to look at the indications of doing this treatment: number one, some of the teeth, actually many of the teeth with… they say severely decayed, non-restorable teeth. So that is number one. Number two is crown–root fracture. Number three is even external resorption. Alright. These are the cases that I have done and it worked wonderfully. So when you want to pick the cases: crown–root ratio is important. Number two is: you don’t have to have active perio problem. Number three is: you don’t have to have active infection. We’ll get there. Number four is—this is done especially to the colleagues that are going to start doing this for their patients—it is important to know that this extrusion works best for single-rooted teeth. Alright. And when it comes to morphology of the root, we must understand this: in order to be able to extrude the tooth properly, the shape of the root has to be conical. Otherwise, if you have a curve or you have hypercementosis, it is very difficult to get the root out. So it’s not going to be atraumatic. So if you cannot do it atraumatically, please don’t do it because we are negotiating with the body to talk the body into accepting something again. And these are the important parts when you want to pick the cases. And obviously if we go further, I’m going to explain how we deal with infection and other problems. [Jaz] Okay. It’s the—classically—it’s central incisors, lateral incisors. The only thing I probably mention here that you haven’t mentioned yet, and something that with your experience you’ll know very well, is just a marker of predictability and success for the future could be some occlusal factors. Because if the patient—for a central incisor—if the patient’s very class three or class two div 2, a deep bite, then already… yes, you extrude the tooth, but you’re extruding the tooth in a mouth which is gonna be putting a lot of biomechanical loads as well. And so therefore, pre-restorative orthodontics. But then if you’re doing orthodontics, you may as well extrude orthodontically. So I think maybe just having a good enough occlusion that you do all this effort that is gonna be working. [Vala] Correct. [Jaz] But that’s like a bigger global thing. Same thing like oral hygiene. You want a patient who looks after, like you said, no periodontal disease, and those are some wider factors. But when you are assessing for the case selection, is it just enough to have a periapical? Or do you feel as though the need for a cone beam CT scan—to do a proper assessment of not only the morphology in three dimensions but to be able to do this treatment with success? [Vala] Alright. Number one is yes, CBCT is always helpful, especially when you are coming across a patient who you feel, or you see, that the bone is very thin, the biotype is very thin. So it’s always better to get a CBCT. However, if you allow me, I’m going to have a very small comparison between surgical extrusion and orthodontic extrusion, if I may. Or if you want to postpone it to the other part. [Jaz] No, no. Let’s talk about it because we’re talking about… you gave some case selection. So it’s totally fair to look at the alternatives, ’cause one alternative is: you extract the tooth, you do an implant or denture or a bridge or something. But the other good way to work with biology is orthodontic extrusion. [Vala] Yeah. Even if you allow me, we can also bring in crown lengthening surgery so I can explain better to the fellow colleagues how to do it. So please, you guide me which part of it you want me to explain first. [Jaz] Let’s do ortho extrusion first, and then we’ll talk about crown lengthening as well. I think that’s a very good point. [Vala] Sure. When we are doing orthodontic extrusion—as we have mentioned before—all of these are weapons in our arsenal. It’s not that one is the best and we should throw away everything else. I have done ortho extrusion as well, but for some reasons I find surgical extrusion more efficient and more effective. Number one is: when you do orthodontic extrusion, obviously it takes time. And if you want to come up with best results, sometimes you need to call the patient for a fiberotomy to cut the fibers. And the other thing is: when you put all of those appliances or the— [Jaz] Brackets. [Vala] —brackets and everything in the patient’s mouth, it is more difficult for the patient to keep it clean. And sometimes, because of the appearance, patients are not really eager to go for the treatment. And the other thing is: sometimes when you are moving the tooth, the gum and the gingiva are also moving with it. So at the end— [Jaz] But the reason for the fiberotomy that you mentioned is to minimize that, to reduce that. There are techniques for that. But yes, exactly—quite often a complication if you don’t get the protocol just right, or particular biotype, then you get the migration of the gingiva, which you don’t want because you want the ferrule, you want the tooth. You kind of want a pure extrusion without the dentoalveolar complex to come with it. So you have the pure ferrule. But yeah, sometimes it may not work fully that way. [Vala] Exactly. Especially if the patient is not fully cooperative. You may need to do an additional surgery. And the other reason that we are doing fiberotomy is because there is a chance of relapse to some extent. [Jaz] Relapse—I’m just saying for the listeners—is what we mean by relapse here is: relapse, i.e. intrusion of the tooth. Once you do orthodontic extrusion, the tooth will go back in. But also, sometimes you extrude but then the gingiva will just come down thereafter, which again—you don’t want to lose all that space that you gained. [Vala] That is very correct. So when you are trying to do it with surgical extrusion, it is done in one session. You get the results almost immediately and it’s much faster. You are sure that if you do it in an atraumatic way, nothing else is gonna come down with it—not the gingiva and the bone. In terms of how it looks in the patient’s mouth, the patient is actually—in my experience—they accept it better. And one more thing: as compared to other treatments, like removing the tooth and replacing it with something else… in my experience, it is very interesting, Dr. Jaz. The patients are much more cooperative and thoughtful with keeping it clean because they see it as their last chance. Emotionally, they don’t want to lose a tooth. So when you are giving them the warning, “Hey, this is the last bullet in the magazine, so please help me help you,” they’re very cooperative. So yes, I think for the reasons that I counted, surgical extrusion works—in many cases—works better. [Jaz] I get the patient aspect, especially for those who don’t want to go through a longer, regular recall for fiberotomy and the brackets and stuff. So I think it’s a very viable alternative for sure. And then, with crown lengthening, it’s easy to say that with crown lengthening you are removing bone. Quite very often you are removing gingiva. And then therein lies the issue whereby now if you have the gingival zeniths that are even, now one tooth will migrate up and then you have to do it all together. And so there are some surgical considerations and complications there. Anything else you wanna add to crown lengthening as a disadvantage? [Vala] Yes, sir. Absolutely. Dr. Jaz, when we are doing crown lengthening surgery—especially in cases that are high lip lines or the ones who have a gummy smile—a big issue is this: you are going to have a long, whitish, ugly crown that most of the patients can’t live with. So that is number one. Number two is: you’re gonna have probably dark triangles. Number three is: it is very difficult to keep them clean. So here comes the issue: when you have food getting stuck there, there is a chance that cavities or gum problems start again for the same tooth or the adjacent teeth. So now you are facing a new challenge. There is a risk for perio problem or new cavities in this area. And the things actually don’t stop here. I am trying to bring your attention and all of my colleagues’ attention who are viewing or listening to us to this matter. Let’s say—God forbid—one day you have to take that tooth out. What is going to happen? Obviously you are going to put an implant, right? What was the previous problem? You had a long, ugly, whitish crown and you couldn’t keep the area clean. So it’s either putting an implant there and redoing the whole scenario. So at the end of the day, the same thing is gonna happen. The implant is going to have peri-implantitis, whatever. Or the adjacent teeth are going to face the problem. Or you are going to have to rebuild everything that you had removed before. [Jaz] So it’s removing the precious bone, and now you’ve lost it when you… yeah. You’re lost now in terms of this scarce resource. [Vala] That is very true. So I believe that surgical extrusion—for the very same reasons that I just explained—I believe that surgical extrusion is the treatment to go in cases like this. [Jaz] Right. So I think that’s a very nice overview of the alternative options. And so I think what we’d love to know now is: we’ve talked about case selection. We talked about ideally to have a CBCT—would be great—but I appreciate that, from what I’ve seen in the literature, sometimes periapicals are just fine. Especially if things are looking quite straightforward, and not everyone around the world has access to cone beam CT scan. And so let’s talk about a classical case, and for those who are watching—obviously we’re being very good for the listeners on Spotify, Apple and whatnot. But those who are watching, I don’t know if you wanna maybe share a case and just be descriptive for the audio listeners for when we talk about the protocol. Step one, the patient comes in, presentation, this is what you say to them, and then that’s what you do. And then how many weeks—all the nitty-gritty details. [Vala] Sure. But before we go to that, part of your question was left unanswered, if you allow me to answer to that part. You were mentioning occlusion. Alright. [Jaz] Oh yeah. You’re such a great guest. You know that? You are an amazingly clear guest. Thank you so much. [Vala] I appreciate. Thank you. Thank you, sir. So what I want to point at is this: obviously you do implant in your practice. So when you want to do implants—especially in practices that the same doctor does the surgery and does the crown—the best way of doing it, we all know, is that it’s not surgically driven. It’s prosthetic driven in terms of putting the implant. Am I right? [Jaz] Mm-hmm. Yes, absolutely. Restoratively driven, basically. [Vala] Yes. So basically, Dr. Jaz, it’s kind of a reverse engineering. When I want to put implants, this is what I do: I’m going to try to imagine this: “Okay, this is where my crown needs to be in order to be beautiful, in order to be able to get cleaned very well, and in order to withstand all of the forces of mastication that are going to be applied on this tooth.” Am I right? So the same thing happens with surgical extrusion. Please note this: surgical extrusion is not extracting a tooth. Surgical extrusion is not a simple extraction. Surgical extrusion is a very technique-sensitive surgical treatment. You are not just going to take the tooth out and put it back in and then, okay, boom, the crown comes on and everything is solved. No. Same reverse engineering is going to happen. You have to keep that in mind, especially when it comes to front teeth, Dr. Jaz, because when you look at, for example, if you look at a central incisor—the upper one—or the upper canine, the tooth comes out of the gum and then there’s a divergence, and then it comes back, and the tip of the tooth becomes smaller and smaller. And the root is actually very thick. So if you do not consider the occlusion or the bite—let’s say I’m having a canine extruded—if I do not adjust the angle correctly, there’s a good chance that a problem in occlusion is going to happen. Maybe sometimes when we are splinting the tooth, we are going to remove the excess and everything… okay. The healing is uneventful. But when it comes to the prosthetic part, then you don’t have enough space to put the crown. [Jaz] For someone here like—I don’t do implants, right—but I know this much: that if I’m doing an implant for the, let’s say, lower molar, right? Lower first molar. I want to make sure that the implant, when it’s pointing, that it’s gonna be going towards the fossa of the upper molar. You don’t want it pointing too much buccal so it’s in crossbite, or lingual so it’s in crossbite. So what’s fascinating here is: you raise a good point that yes, when you extrude the canine or extrude the central, the sort of projection that’s gonna take is important to make sure you have enough overjet, enough clearance. It makes sense. But here’s something I didn’t appreciate: how much wiggle room do you have? How much freedom do you have? So when you do a surgical extrusion, let’s say you surgically extruded three millimeters, right? Or four millimeters—and we’ll talk about exactly roughly how much it ends up being—but when you have it, obviously now the root is gonna be a little bit loose inside the socket, right? So how predictably can you change the angulation a bit more buccal to maybe not be so involved in the envelope of function? [Vala] Alright. Here’s the key. As I mentioned before, this technique is done on all of the single-rooted teeth. So we’re starting from the upper central incisors, laterals, canine, first premolars provided that they are single-rooted, or the furcation is very low—very apical—and then obviously second premolar. Same goes for the lower teeth. So when you are talking about premolars, it’s okay to have the tooth extruded more than 2, 3, 4 millimeters if the root is really long and strong. But when it comes to front teeth, because we have overbite and overjet, you are not allowed to pull it out as much as you think it is okay. If you have two millimeters of ferrule, it should be enough for you. That is number one. [Jaz] And I think it’s important to talk about ferrule because we have so many episodes—we have done episodes about post crowns and ferrule and importance. But someone who may be listening to the podcast for the first time: a student, a young dentist… I think it’s really important to spend a couple of minutes to pay respect to the importance of ferrule and how it is one of the most important prognostic factors of our dentistry. So, can you just tell us about: define ferrule? Which part is the ferrule? And if it’s subgingival and you can grab onto it—does that still… is that still good enough to call a ferrule because biomechanically it’s giving you something? Because some clinicians I see, they’re very strict, that they only see the bit that is supragingival—the clinical crown. They say, “That’s the ferrule. Anything subgingival, consider it not a ferrule.” It’s an interesting distinction. Whereas I always say that, look, if I can do a vertical crown and go half a mil to a mil subgingival and I’m actually grabbing onto that tooth, that will biomechanically assist me. And I’m counting that as a ferrule very often. But where do you see that? [Vala] Dr. Jaz, I am very, very, very careful when it comes to going subgingival. I respect the gingiva and the periodontium a lot, so I really do not appreciate going subgingival too much. Maybe half a millimeter. But basically yes, when I am doing surgical extrusion, to me ferrule is what is above our sulcus. What is above our gingival level. So yes, to me that is ferrule. And for the listeners who are probably younger dentists or our future colleagues or the dental students: ferrule is defined as this—the supragingival structure of at least a minimum of two millimeters of the tooth with the thickness of at least one millimeter around the— [Jaz] That’s the bit we often forget, right? The thickness. We are all talking about, okay, the vertical ferrule, but we don’t appreciate the horizontal ferrule, right? Because there’s no point in you having a tooth—and we’ve all done this, right—and you think you’ve got two millimeters of ferrule, but actually the endodontic access is so huge, or the caries destruction was so huge, that actually it’s very thin and it’s just… it’s going to snap. That is not serving you in a biomechanical way. [Vala] That is correct. And when you forget that, what happens is your post and core is going to have a wedging effect. And then you’re gonna have a root fracture. So all of the effort that you have put in treating something that you were not diagnosing correctly in the beginning is going to end up terribly, and you’re going to—at least—lose your patient’s trust. [Jaz] And in your case studies so far of 200-plus cases… [Vala] Yes. [Jaz] The ideal gold standard will be that you do achieve 360-degree ferrule of two millimeters. [Vala] Correct. [Jaz] But there are some pragmatic concerns, that sometimes that may not be easy or not possible. And so in some schools of thought—depending on the occlusion—if you have someone who’s class two, a bit more class two, a bit more overjet, then maybe if you are getting a bit of palatal ferrule, maybe you get two, three millimeters palatal ferrule in the way that the tooth broke, but you only have one millimeter ferrule buccally, then maybe this could suffice. Or do you think that you get such good results because you’re very strict? Like, how strict should we be with this 360 degrees, two millimeters? Because sometimes the way the teeth fracture, the crown–root fractures, you’ll end up with four millimeters ferrule buccally and two millimeters palatally—and that’s great. But sometimes you get three on one and one on the other side. How strict are you, Vala? [Vala] Okay, Dr. Jaz, that is an excellent question. I’m going to give you two answers. The second one is going to surprise you. I’ve already surprised you. Alright. Number one is: you are absolutely correct, sir. In so many cases, for example, you are having a very deep cavity on the surface of the root and you remove everything and then you extrude, and then you realize that, okay, you cannot extrude more than this and you cannot achieve 360 degrees. But you realize that three-quarters of the tooth is going to give you good ferrule. In that case, I have done so many and, so far—touch wood—they are in the patient’s mouth. Functional, clean, healthy. So yes, there are some flexibilities. But please, I’m asking our listeners to bear in mind that if you want to start, please start with simpler cases. Just like when we are learning to put filling in patient’s mouth—we are starting with class one, and then class two, and then we go to cosmetic and all that. For implant, same thing applies. So yes, there is a chance that you don’t achieve 360 degrees—you get three-quarters of a tooth. That is going to be enough. And sometimes—this is gonna surprise you—sometimes you realize that, okay, if I had ferrule on this side, it was better. Or if I had ferrule on that side and the other side was a part of our casting post, it was much better. In such cases, I take out the tooth and rotate it and put it back in. [Jaz] No way. [Vala] Yeah. [Jaz] That’s so cool. Okay, cool. That’s like reimplantation. That’s pretty cool. I didn’t even consider that. That surprised me. But I love that because my mind always said that, okay, when you do this technique, you take it out a bit and then, you obviously do the suturing—we’ll come onto that—and then fixation. But I didn’t actually think that, okay, let’s say you have a lot of… for an upper incisor, that you have a lot of buccal ferrule and no palatal ferrule. But actually you want to have that palatal ferrule to resist, and then to do a 180-degree… that’s really clever. I like that. [Vala] Yeah. And sometimes—this is one more thing I need to talk about because there’s a chance that I forget—it’s not… sometimes when you are trying to extrude the tooth, you don’t need to do a full extraction. Especially if the tooth has not undergone endo treatment. So you just try to take it out, and once you reach that ferrule, just leave it. [Jaz] Yeah. That’s what’s going to be your air-time, right? Your air-time is zero. Right? So every time you take it out, now it’s exposed to the environment that is coming against you. But I know that, like you said, if you’re going to do the 180, then you can take it out, inspect it, make sure there’s no cracks, that kind of stuff, and then put it back in. But I think you’re going to give us some nuances now. [Vala] Yeah. That is very true. What I wanted to refer—I wanted to point out—is normally, if you have a tooth that is having a severe decay but has not undergone endo treatment, you just need to pull it out a little bit, get the ferrule, and that’s it. But if that tooth has undergone endo treatment, you need to do a full extraction. Take it out, do a complete careful visual inspection to make sure that there is no perforation, there is no crack whatsoever, and then you can put it back in. This is something I didn’t want to forget. [Jaz] Okay. Yeah, excellent point. Okay, lovely. I’m enjoying this so far. Okay, so now let’s talk about the clinical protocol, because the question that will come is: okay, let’s say in the non-endodontically treated tooth, obviously it’s more than likely gonna be necrotic—it’ll need the root canal. But when you do extrude it, and you don’t need to take it all out all the way because there is no existing root canal, what are the different methods of fixation and stabilization? How long should you wait? And ideally, before in your protocols—before you do the root canal—any considerations that you need to do? Like, sometimes you may even think that if you have pulled the tooth out and maybe it’s come out fully by accident in that moment in time, maybe you should get the ruler and get your perfect working length at that moment in time and put it back in. I don’t know if you’ve ever done that, but I’ve heard that one before. But we’d just love to know the waiting times, the loading protocols, the temporization. Are antibiotics necessary? Last time I asked this question to a lecturer, he said, “No, we don’t think antibiotics are necessary.” However, someone else once I asked said, “Yeah, I just give antibiotics,” and I don’t know where you lie in your protocols. And I think we can learn a lot, because something that one of our mentors, Lane Ochi, taught me is: you can have all the in-vitro studies in the world, you can have 500 simulations of this technique, but the one case study that you do—just the one clinical case study—is worth a thousand times more than all those in-vitro studies. So your experiences are extremely valid because clinical experience is one-third of evidence-based dentistry, and your evidence is very, very important. So if you say that in those 200 cases you did it with or without antibiotics, or you have some clinical guidelines that you’ve made, that is very valid. [Vala] Sure. First of all, one thing that I would love to say here is that surgical extrusion over the years—it actually was presented to dentistry in early eighties—and the problem that it was not very popular, it did not become very popular, was that… try to imagine this: there is a singer, young, very talented, with great future in the music industry, who is going to be presented to the world of music and fans and everything. But—I don’t know if I call it bad luck or whatever—the same time that this guy is going to be presented to the world is going to be exactly the same time that the fame and popularity, or the explosion of fame, of Michael Jackson happens. So this guy is always overshadowed by MJ. I’m a big fan of MJ, by the way. So during those days, they were really trying to work on surgical extrusion. Guess who comes out? [Jaz] I’ve got his name now, the Godfather of Implants, who passed away a few years ago. I forget his name now. [Vala] Per-Ingvar Brånemark. [Jaz] Brånemark. That’s the one. Yeah, yeah, yeah. Rest in peace. [Vala] The implant. Yeah. Peace be upon him. The implant comes out, and the implant steals the show. Becomes the rockstar. Becomes the new technology and everything. Everyone is screaming and shouting. So this little guy was pushed away. So here’s the thing— [Jaz] But also, you know what? It’s important to mention, Dr. Seif, that a lot of things that become mainstream in dentistry are not necessarily what’s the best for the patient or what’s best for clinical dentistry. It’s also dictated by the market, manufacturers, the industry, because you can’t—industries cannot monetize… they can a bit here and there—techniques to do atraumatic extraction. We talk the Benex, etc.—that kind of stuff, right? They exist. You can’t sell lots of units of anything or market lots of units. 3M can’t produce anything for… so innovative and different types. So for the industry and the business of dentistry, implants are obviously where the money of research and all the attention and the conferences and education would go to as well. There’s something just worth considering. [Vala] Very true. So for the past few decades that here and there they were doing surgical extrusion, everyone was trying to do it in such a way that made sense to them. But after doing 200 cases and having a follow-up of seven years, I have come up with a final protocol. It is called the SEIF Protocol for Surgical Extrusion. [Jaz] I love that because guys—because his name is Vala, Dr. Vala Seif, right? Seif is spelled S-E-I-F. So do you call it “SEIF” or do you call it “SAFE”? [Vala] Alright. In this case it’s obviously my name, SEIF. But it’s still… it is actually— [Jaz] It’s pronounced “safe.” That’s awesome. [Vala] Yeah, correct. [Jaz] It’s the SAFE protocol. I love it. [Vala] Thank you very much. I appreciate it. So finally we have a protocol, and in this protocol these are the 1-2-3 that we should go through. Number one is obviously case selection. For case selection we are working on single-rooted teeth. I have done it on lower molars—I’ll send you the pictures. It works really well. It is actually similar to bicuspidization; however, you bicuspidize and you extrude it. [Jaz] Okay, so bicuspidization is like a hemisection, right? [Vala] That is true. [Jaz] And then maybe you remove one of the roots, or do you keep both as two separate units? [Vala] Alright. It really depends. For example, one of the cases that I did for one of my friends—it’s been in his mouth for two years now—the mesial root was fine; the distal one was not. So I extruded the distal one and splinted it to the mesial. Once everything was settled, then I did the prostho part. And sometimes you have to take out both, and then the rest is obviously known to the listeners. So number one, case selection: it is going to be single-rooted teeth, with conical shape, long enough, because after extrusion you’re gonna have to have a crown–root ratio of at least one-to-one in the absence of active infection. And number two is atraumatic extrusion. Please understand this. [Jaz] Now, before we get to number two, I just wanna cross off a thought on number one. Sure. So let’s go stage by stage. Okay. The only question mark I have now about stage one—case selection—is: you said no active infection. Okay, but what if you do have infection, but you’re gonna be root-canal treating it anyway, and therefore if it has an active infection but has got potential and structure is looking good, what’s the protocol like? Would you root-fill it? But then the problem with actually root-filling it is you don’t have enough ferrule to put the rubber dam on. So how do we talk about that scenario? [Vala] Alright. This is the way I’m going to do it. Normally, postpone endo treatment to the time that I’m sure that everything is healed and reattached. However, if you have an abscess, if you have any kind of infection, this is what I do: we do the first stage of endo treatment. We put calcium hydroxide, and then we wait for the symptoms to subside, and then we do the surgical extrusion. Once everything is done and the tooth is reattached to the PDL and the bone and then gingiva and it is stable, we go for the endo treatment and post, core, and the final or temporary restoration. [Jaz] That makes sense. Okay, great. I’m now fully happy with stage one, case selection—including the bonus tip of, okay, if you do have an active infection, this is what the SAFE protocol advises. Lovely. Stage two, sir. The actual—the make or break—the bit where you’re doing it for the first time, you’re a little bit nervous. You’re sweating because everything now hinges on you taking this root out without it fracturing to pieces. Because then, okay, then you have to say, “Okay, yeah, we’re gonna do an implant.” [Vala] Yes, that is true. That is very true and that is the very important and the very difficult part because you have to be able—first, you need to be good at doing extractions. You have to have a very expert hand when it comes to extractions, because it is not a normal extraction. When you want to take the tooth out, it has to be done in a very atraumatic way, number one. So we are talking periotomes. We are talking very delicate forceps. And you mentioned Benex. I also use that, but not in all cases, because if you want to extract a tooth that is hopeless, when you are trying Benex, even if the tooth breaks, it’s okay. But when you promised your patient that “I’m saving it for you anyway,” that one is a bit risky—unless the root is very thick and everything. So, we’ll get there. [Jaz] So this is because when you use the Benex, I think something screws inside the tooth, right? [Vala] That is true. [Jaz] That’s the point where it could induce some weaknesses and propagate a fracture. Is that what you mean—when the force applies? [Vala] Exactly. [Jaz] Okay. [Vala] Not the force applied by itself; when you are screwing the… engaging that screw inside the root—that is going to have a wedging effect sometimes, and then it gives you a vertical fracture. So the important part when you are taking the tooth out is: you need to make sure that you are not doing it buccolingually. You have to be able to rotate it and take it out. So if you… that’s why we are emphasizing the shape of the root, that it has to be conical. Otherwise you cannot rotate it and take it out. [Jaz] So if a tooth… some centrals, they’re in a bit like—not rectangular—but you know what I mean. They’re very wide-ish; they’re not like a pure circle. They’re more like an oval. And that oval one… I didn’t know it makes hearts on the screen if I do that. There we are. That’s the first time I’ve seen that. I’m loving this so much. You see? So Vala, you’re saying that the oval-shaped one may be… because you can’t rotate that so well, that’s maybe something to consider as not an ideal root morphology. [Vala] No, no, no. It’s not that, Dr. Jaz. If you remember, I emphasized on doing it atraumatically. So atraumatically means minimal manipulation. When I’m asking everyone to do a rotation, it does not mean that you have to—it’s not a watch winding, alright? [Jaz] It’s very minuscule. It’s a micro-movement. [Vala] That’s meticulously—exactly what you referred to. The word that you picked was perfect. It’s a micro-movement. So please make sure that you’re spending enough time on it. There shouldn’t be any rush. [Jaz] How long does it take you—a central incisor—typically from your cases? Obviously every tooth is different, everyone’s different. But someone might think, okay, I’m gonna spend five minutes. Someone else might say, you know what, actually you might say that typically I spend half an hour and I spend my time. How many minutes? Obviously for the novice it will take longer, but as a guideline, how long is a reasonable amount of time spent on this very crucial part? [Vala] Correct. When I started for the first time—obviously I didn’t take any courses whatsoever; I was just trying to self-educate myself on this. However, we are having courses now and I’m trying to teach other dentists. For the first time when I did this—just like the first implant I placed 16, 17 years ago—it took me one hour and 55 minutes. After 16, 17 years, I do the same thing within 14 to 15 minutes. But I’m not proud of that because we are not setting a record here. We are doing the correct, perfect job for the patient. Normally for a routine extrusion for me—after doing 200-plus cases over seven years—it takes around 10 to 15 minutes from the start to the end. But two weeks ago I was doing a lateral incisor for a young patient; it took me around 45 minutes to take the tooth out because the fracture line was palatally and very deep. So I needed to spend as much time as necessary to make sure that I’m keeping this tooth for the young patient who came to my clinic with tears in her eyes saying, “I’m too young to lose a tooth.” So that comes first. Take as much time as necessary to do the perfect job for the patient. Normally within a half hour you should be done, but for the first cases it goes up to one hour, which is okay. Practice makes perfect. So no rush. [Jaz] No rush. That’s the main lesson here. You gotta be so delicate—and no rush. But again, consent the patient that, look, we’re trying our best here, but sometimes the tooth can crack and whatnot, and therefore we always have our plan B but we will try our best. Nothing is promised. [Vala] Yes. Yes, correct. [Jaz] Has it happened to you before—when you tried to do it and then actually, no, it’s fragmented, it’s broken, and then you’ve had to no longer proceed? [Vala] Yes, there was. But one thing is very important, and that is: you must—if you feel that this case is going to be too risky—you must explain to the patient before you touch anything. Because if you are explaining to your patient before you start, it’s an explanation. But if you don’t, and you do the job and something happens that you predicted but you did not inform the patient—if you have all of the explanations, the correct ones in the world, to the patient—it is an excuse. It’s not explanation. [Jaz] Absolutely. [Vala] So I tell my patient: “Okay, I have done this for so many years; I know what I’m doing. But this specific tooth is too risky. So please understand that I am doing whatever in my power to save the tooth for you. There still is a chance that it fractures, it doesn’t work. So be prepared, because if you go to 99 out of 100 clinics, they would take the tooth out and place an implant for you. I’m trying to save it for you. “So if something happens, please be aware or understand this.” [Jaz] That’s a good way to frame it, for them to understand that if you walk into any other clinic, there’s always still a plan B, and to be a bit more forgiving. So it’s all about adequate conversations before you do the treatment. Okay. So atraumatic extraction: stage two. Obviously you teach this on your courses and stuff and there’s only so much we can talk about it now. But let’s just, for the sake of completing the SAFE Protocol: Case selection, number one. SAFE atraumatic extraction, number two. What’s number three, sir? How do you fixate the tooth? [Vala] Alright. There are different ways of doing it. Number one is: they used to suture the tooth. I am not a big fan because to me it is not reliable. Others—they actually use wire and composite, which is fine. I have done this. But after a while, I started only using flowable composite, which works for me. But the key here is: do not use too much composite. Because number one is: when you have a bulk of composite there, it is difficult to keep it clean. And the other thing is: we are talking about semi-rigid fixation. Semi-rigid fixation allows you to… it actually prevents ankylosis and root resorption, which are two risk factors here. [Jaz] Okay. But I’m just trying to visualize this now. The patient’s gonna walk around with flowable just like tags… like, let’s say it’s an upper left central incisor, some flowable is attached to the fragment and the adjacent teeth next door. So like the central and the lateral. But then that’s not a very aesthetic solution. How are you managing the patient expectations in terms of temporization during this time? [Vala] Alright. How are you going to deal with a patient who has lost enough bone to have an immediate insertion and needs bone grafting and soft tissue grafting, and you cannot give the patient an immediate prosthesis? [Jaz] Essix retainer with a composite inside or something is a popular choice? [Vala] Is that… is a choice, but not all the time you give it to the patient. Because sometimes you have to give the tissue enough time and space to heal. Obviously aesthetic is a big part of the patient’s expectations, but we must understand that—and we must try to make the patient understand that—it is a part of the solution that we are having. The patient is going to walk around with that tooth for about probably four weeks. So it is much faster than implants in many cases. So basically, no. My answer is always no to a temporary—unless you give the patient an Essix and the patient’s occlusion and bite allow you to place it inside the mouth and you can relieve around the, for example, palatal part of the root that you have extruded. Not in every case. Initially I used to give the patient an acrylic temporary crown immediately after I did the extrusion, but I realized that gum healing is not best when we do it. So we really need to talk to the patient before the treatment and discuss everything and say that, okay, this is the healthiest type of treatment that we can do for you, and these are the facts you must understand, and try to help us help you to get the best results. [Jaz] Okay, so the no-temporary—while aesthetically is a downer—allows for the best healing and cleansability. [Vala] That is true. [Jaz] Okay, great. So now we’ve talked about flowable as a fixation. Obviously I’m sure there’s more nuances, other ways to do it. But in the interest of time, what’s the next step? [Vala] The next step is removing the splints. So after two to three weeks, the patient comes back in and then we remove the splints. I’m asking my colleagues to not be terrified when they remove the composite and they realize the tooth is still moving—is mobile. It is going to be okay after a while, because very mild stimulation on PDL is actually good for reattachment and everything. So after two to three weeks, we remove the splint. And normally after four weeks, I send the patient to our endodontist for endo. And then post and core comes, and then we are going to either give the patient a temporary crown or the final restoration, depending on the soft tissue, because at that time soft tissue may not be perfect. So we’re giving the patient the temporary, waiting for a while, and then we will go for the final restoration. [Jaz] Okay, great. And so that’s the full protocol explained, right? That’s all of it. [Vala] Obviously, as far as… I don’t remember. [Jaz] There’s so much deeper—obviously you go deeper in your education stuff. But as an overview, it’s okay. Fine. So what questions do I have at this point? Let’s see. So just to summarize: the splint stays on for two to three weeks, the composite splint. Is that fair? [Vala] Yes, correct. [Jaz] Yep. And then, when you remove the splint, that’s the same time that you have the endo, or you give it a bit more time after you remove the splint but before the endo? [Vala] Dr. Jaz, when you remove the splint, the tooth is still mobile. And if you are going to do a perfect endo, we know that we have to put clamps and rubber dam is necessary. Sometimes you can put the clamp on the adjacent teeth, but usually I do not risk applying any force on that tooth. So I always ask the patient to wait for a while, and after probably four weeks the tooth is strong enough. So then we go for endo. [Jaz] Perfect. Okay, so now that’s making sense to me. And then, the last consideration actually is about post crowns. There are some philosophies that if you have enough ferrule, then you don’t need a post, because now our core is being retained by our adhesive system. And therefore we can use the sort of canal space and stuff—or the access cavity area, if you like—to get it. So how important do you think it is to have a post? Is this like, yeah, in your protocol it always gets a post? And then if so, does it matter for you if it’s a fiber or a metal cast—that kind of stuff. Tell us a bit more about your philosophies on posts, because it’s a very popular question we get from listeners, as you can imagine. [Vala] Alright, sure, sure. Absolutely. Number one is: we must understand one thing—that every case might be different from others. So yes, sometimes for some of my cases, there is no need for a post. So a very good restoration—a buildup—is going to do the job. Sometimes, because the more and more I go into this technique, the cases that I am treating become more complicated. So yes, most of the times I prefer to go for a post and core. And in many of the cases, I prefer casting posts and cores. [Jaz] Okay. It adds a bit more time and extra step, but I appreciate that philosophy, because the more tooth destruction you have, the more rigidity can help you. And basically, people always say about, oh, the fiber post is more retrievable—when it fails, the adhesive will fail. But the way I always view it is: when that fiber post fails, this is a complete disaster. Who’s going to retrieve that? It’s the end of the line. So why don’t you give something that’s more rigid, and then it’s probably gonna last longer overall? Is that your thinking? [Vala] I have retrieved many, many, many posts before. [Jaz] Okay. Nice. [Vala] Fiber posts, those casting posts, and prefabricated posts—which I call the prefabricated ones the lazy posts. Because in my opinion, when there are better ways of doing something for the patient, you always should do that. I understand that sometimes time matters. Sometimes it’s the cost of treatment and everything. But most of the posts—with proper technique and spending enough time—they are retrievable, unless they have broken very deep inside the root, and then no, we’re done. But you are absolutely correct. When the post fails, it’s a disaster. [Jaz] Fine. So your preference is cast post. I get it. You’ve answered all my key questions. I’m so happy. I’ve really, really enjoyed it. Dr. Seif, tell us, how can we learn more from you? Tell us about your Instagram page, about your courses. Are they all in Iran? Or are they around the world? Are they online? Tell us more about that. Because this hour is a really great introduction to the surgical extrusion technique. You’ve told me you’ll send some papers—please send them to us so we can make them available. But to have absolutely spoken for eight hours on every little point and shown cases and stuff… I think that’s only fair from your education. So tell us more about that. [Vala] Sure. Basically, we are trying to connect with other colleagues around the world, especially in Europe, to organize courses which will be announced later. But in order to have better access to colleagues all around the world—and for them to have access to me—I set up an Instagram page. The name is Extrusion Masters. Yes, in a very humble way, by the way. In a very humble way I chose the name. So they can follow us on Instagram. I’m going to gradually put up a lot of my cases on that page, along with some good papers. I’m going to have a review on them. I’m going to write my opinion of the way they have done the work—again, in a very humble way. And also we are having online courses. So for the people who are… for the colleagues that are not able to travel to different countries, or they are too busy, or they want to spend a weekend learning such techniques—it is available very soon again. [Jaz] So follow the Instagram Extrusion Masters to find more information about that, right? [Vala] Yes. Correct. Correct. [Jaz] Amazing. Dr. Seif, I really enjoyed the SAFE protocol and your humility, your storytelling. It was a perfect episode, right? A great introduction to surgical extrusion. [Vala] Thank you. [Jaz] A great revisit. I know I visited it once before, but it’s really nice to connect again—new colleagues, new ideas around the world. And you answered my questions so nicely. I wish you all the best. I’m gonna put all your links and everything in the show notes, and I really value your time. Thank you so much. [Vala] Thank you so much. Really enjoyed it. And I’m really glad that… obviously I texted you many times. I know you are a busy man. But let me—seriously—let me tell you this: the last message I sent to you, I was this close to actually deleting and unsending it because I waited for so long for an answer from your side. But I said, okay, it is worth it to send another text to you because many of my colleagues—and their patients, obviously, eventually all around the world—can benefit from this. And I would like to add one more thing when it comes to technique, because a few years ago you talked to a colleague who was an endodontist from the UK, and he mentioned something that I… I came up with a very simple solution. It helps all of my colleagues. Do you remember, when you were chatting with that endodontist, this esteemed colleague mentioned something. He said: “When I want to do the bonding to do the splinting, I’m having a very hard time to do the bonding because the saliva and the blood and everything comes out.” You remember that? [Jaz] Yes. Yes, yes. [Vala] Alright. The answer to that is very simple, my friend. You just take the tooth out, put it back in, blood is coming out—give it five minutes. Don’t do anything. Just give it five minutes. The bleeding stops. And then you irrigate, and then you can do the bonding without any hassles. [Jaz] There we are. Yeah. So actually, how important is the taking out and putting it back in? So let’s say it’s a non-endodontically treated tooth—for the sake—are you saying that for the sake of bleeding, to take it out and put it back in actually is… [Vala] No, no, no. [Jaz] Is it a secret? Okay. [Vala] No, no. The secret is: once you are done with repositioning—whether you are taking it out fully or you are partially taking the tooth out—obviously you’re gonna have bleeding. [Jaz] Yep, yep. [Vala] Don’t do anything. Leave it there for five, six, seven minutes. Try not to splint and bond and etch and everything. Just give it time. After five, six minutes, once you irrigate and you wash everything, there’s no blood coming up. [Jaz] Amazing. You’re the man that keeps giving, man. I appreciate that very much. I’ll have to put that episode in the show notes, let people revisit that as well. But yeah, I appreciate you tuning into that. And thanks for the messages. At the moment sometimes life gets very crazy with the DMs, and I appreciate sometimes that’s the best way people reach out. But I’m so glad we did get this arranged. I wanna thank manager Alex who helped arrange this and the team. So this was an absolute goldmine of information. And hopefully if you’re in the UK one day, we’ll go out for some food and catch up again. [Vala] Absolutely. [Jaz] It was very, very lovely to talk to you, my friend. [Vala] Same here. I really appreciate it. And thanks for having me. And I hope that we have a chat in the future sometime soon. [Jaz] Absolutely, my friend. Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end. And even right at the end, he gave us that little tip. The previous episode we did—which was episode 61, four years ago with Dr. Peter Raftery—I’ll put that in the show notes. I’ll put any papers that Dr. Seif sends me. I’ll put the link to his Instagram, Extrusion Masters, so you can see his cases and papers and join his courses and that kind of good stuff. And I just want to thank him again for being such a wonderful guest. I want to thank you for liking this video, subscribing, or if you’re on Protrusive Guidance—the nicest and geekiest community of dentists in the world—please do drop a comment as well. And if you’re not on our community, what are you waiting for? We have so many premium clinical videos, webinars, Verti Preps for Plonkers, the whole shebang. It’s there. Head over to protrusive.app to discover more. We are a PACE-approved education provider, so if you are on Protrusive Guidance, scroll down, answer the quiz, and claim your CPD. You’ve done the hard work—you’ve listened, you’ve learned. Now it’s time to validate with reflection that forms part of your PDP and a certificate that’s valid everywhere in the world. Thank you again, dear friends, and I want to thank Team Protrusive as ever. I’ll catch you same time, same place next week. Bye for now.

Are you confident in replacing a single missing central incisor? When is a denture the right option — and when should you consider a bridge or implant instead? Why is the single central incisor one of the hardest teeth to replace to a patient’s satisfaction? In this Back to Basics episode, Jaz and Protrusive Student Emma Hutchison explore the unique challenges of replacing a single central incisor. They break down when each option — denture, resin-bonded bridge, conventional bridge, or implant — is appropriate, and the biological and aesthetic factors that influence that decision. They also share key communication strategies to help you manage expectations, guide patients through realistic treatment choices, and avoid disappointment when dealing with this most visible and demanding tooth. https://youtu.be/czjPQxKpwPw Watch PS018 on YouTube Need to Read it? Check out the Full Episode Transcript below! Key Takeaways:  Replacing a single central incisor isn’t just about technical skill — it’s about communication and case selection.  Success comes from helping patients understand that a restoration replaces a tooth’s function and appearance, not nature itself.  Clear conversations about expectations, limitations, and maintenance are what turn a difficult aesthetic case into a satisfying long-term result. Highlights of this episode: 00:00 Teaser 00:28 Intro 01:56 From Dental Nurse to Final-Year Student 07:38 Challenges and Considerations in Replacing Central Incisors 12:51 Patient Communication and Treatment Planning 18:33 Discussing Treatment Options and Enamel Considerations 21:16 Communicating Options and Guiding Patient Decisions 25:51 Choosing Between Fixed and Removable Options 27:10 Midroll 30:31 Choosing Between Fixed and Removable Options 31:05 Handling Old Crowns and Patient Communication 34:17 Conventional vs. Resin-Bonded Bridges 37:57 Occlusal Load, Function, and Implant Considerations 43:40 Digital Workflow in Dentistry 45:54 Managing Aesthetic Expectations 48:34 Final Thoughts and Recommendations 52:59 Outro 🎧 Want to feel confident with prosthodontics? Explore these essential follow-ups to this episode: Dentures vs Bridges with Michael Frazis Crowns vs Onlays with Alan Burgin Dentures with Finlay Sutton RBB Masterclass on the Protrusive Guidance App Quick, practical lessons to sharpen your planning, communication, and anterior aesthetics — all in your pocket. #ProsthoPerio #OcclusionTMDandSplints #Communication #BreadandButterDentistry This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes C. AGD Subject Code: 610 – Fixed Prosthodontics Aim: To provide a clear, clinical overview of replacing a single missing incisor — focusing on when to choose a denture, bridge, or implant, and how to communicate realistic expectations. Dentists will be able to – Identify the key biological, functional, and aesthetic challenges in replacing a central incisor. Compare the indications, advantages, and limitations of dentures, resin-bonded bridges, conventional bridges, and implants. Communicate realistic outcomes, limitations, and maintenance expectations effectively to patients. Click below for full episode transcript: Teaser: Have you heard of something called central dominance? Teaser:No. So in the face, the central incisors should be the star of the show, should be in the middle, and the centrals should be like twins. When we lose a central incisor, we have to discuss how was that central incisor lost, and most common cause is trauma. The most important predictor success of a resin bonded bridge is the same as it is for veneers. If you’re not sure what the treatment plan should be, you probably haven’t asked a patient enough questions. Jaz’s Introduction:Welcome to this Back to Basics episode on replacing the single central incisor, why the single central incisor is the most important tooth, obviously, but so that we can just go a little bit deeper into this topic rather than talking about replacement options in general, which you’ve already done on the podcast. There are certain features which are very special when you’re replacing the central incisor and why it is regarded as the most difficult treatment to deliver in terms of patient satisfaction expectations. We’re joined by the Protrusive student, Emma Hutchison, where we’re gonna go into the basic overview of decision making. When is a denture appropriate? Is it ever appropriate for an incisor? How about bridges and what type, and what are the implant considerations, and actually choosing between these options? I think one of the biggest takeaways you might get from this is communication. There’s a specific way I communicate to patients about this, and that’s what I think you’ll probably take away the most from this episode. Hello Protruserati. I’m Jaz Gulati and welcome back to the student edition of your favorite dental podcast. I know we call it Protrusive Students, but young practitioners or those returning back to work often find these episodes very valuable. Of course, we’ve got so much more where this came from. We’ve got all sorts of genres and topics covered in Protrusive Podcast and recently on YouTube. We’ve done the playlist so you can actually pinpoint the different themes of the podcast. On our app, Protrusive Guidance, head over to protrusive.app if you’re interested in that. It’s the community of the nicest and geekiest dentists in the world. We put some extra videos, not on YouTube, on there as well. Let’s now join Emma, and I’ll catch you in the outro. Main Episode:Emma Hutchison, the Protrusive Student, welcome back. How are you doing? How is clinics going? Final year, you’ve done your exams, but it’s the actual more clinical exposure. How’s everything going? [Emma] Mm-hmm. Yeah, it’s going good. So as I was saying last time, it’s just more, lots more experience this year, which is good. So I’m up in Falkirk in Scotland every second week, just Monday till Friday, nine till five, seeing about four or five patients a day. And then the other second week I’m in Glasgow doing more specialized stuff, watching some consultants in restorative and things. So it’s good. It’s good. Just plodding along quite nicely, which is good. [Jaz] Good. And you obviously have been a dental nurse. So once you’re seeing four to five patients a day, you have this extra level of insight that maybe your colleagues don’t have. Like, in the real world it’s 30, 40 patients sometimes, sometimes 12, sometimes one. Like, it’s such a variation. ‘Cause obviously you’ve been an implant nurse as well. So what advice do you want to give to your colleagues who are maybe listening to this and they’re seeing these four to five patients, and you want to prepare them for the real world? What would you say with your very unique perspective? [Emma] Yeah, I think when I was working as an implant nurse, I remember speaking to the dentist I was working with and he was saying why he moved to private dentistry initially is just because the real life just isn’t like the gold standards that you’re taught at dental school. In the NHS especially, you’re time restricted. So I think I do have that in the back of my head. I know that I won’t have the luxury of such long appointments when I graduate. So yeah, I’m just getting myself prepared for the real world. ‘Cause I am gonna do VT or DFT so that I can work in the NHS to start off with and then see where I go from there. But I do know that in the back of my mind it’s gonna get a lot busier as soon as I start VT practice. So yeah, just that you’re not gonna have the best materials that you do in dental school. I know in Glasgow anyway, we tend to have really quite good materials. Good rubber dam. I know I’ve spoke to you about things like that before, and just that it might not be like that in the real world when I graduate and get out there and start working. So just to prepare myself for that. I’m aware of it, it’s fine. And I’m just trying to relish the opportunities that I have at the moment and the staff around me that I have as well. I think that’s one thing. [Jaz] You’ve gotta be like a leech, Emma. You’ve gotta be like a leech, like a sponge. [Emma] And just ask all the questions whilst you have all these specialists and consultants around you and just take note of everything that they’re saying. Especially the way that people communicate with their patients and pick up little things that they’re saying to their patients and make it your own. So I’m trying not to wish away my last year, so that’s good. [Jaz] No, enjoy it. Enjoy the comfort and the bubble and the protection you get in school before you enter the big, bad world. Do you think your experience as a nurse and seeing over the shoulder, you’re suctioning, you’re seeing things close up? Having said that though, I always find that maybe the nurses, we think they’ve got a great view, but they often don’t, especially when you are trying to juggle a million things. ‘Cause recently I’ve been using my clinical loupe camera more and more, and so now the nurses who’ve been working for 20, 25 years, they’re like, “Oh, now I got to see what you are seeing.” So maybe it hasn’t been that much of an advantage that you come from a nursing background. What do you think about that? Just be honest. [Emma] I think initially, when I got into dental school, first and second year, it helped obviously. Premolars, molars, all the very basic stuff. And then maybe second, third year when I started to see patients, I was pretty much at the same level as everyone else. Apart from communication. I’ve found the big thing is that patient communication has came quite naturally to me, and I think that’s because of my dental nursing background. [Jaz] Because you heard those conversations, right? [Emma] Yeah. [Jaz] You were present, and you’d seen the dentist explain the risks and guide patients to certain treatment philosophies and whatnot. That’s a really good point. [Emma] Yeah, so I think communication. Doing it yourself is a whole different ball game. Getting that manual dexterity is something that you need to work on. But even just communicating with patients, I’ve taken so many tidbits from other dentists and how to explain things to patients. I’ve worked with a paeds dentist, John McCall. I worked with him for a year, so I say a lot of similar things that he did to children, and I get on really, really well with children. And then when I worked in implantology, that’s maybe transferred over into oral surgery when I’m talking about those sort of things. So definitely in the communication side of things. [Jaz] Super. Well, we’re talking about more than just communication. We’re talking about replacement of an incisor tooth, right? Because I thought, okay, we could talk about replacement of missing teeth full stop, but I just feel that’s so broad, right? Like when you talk about a molar to a premolar to an incisor. So I thought, why don’t we go a little bit deeper and just talk about incisors. Let’s talk about central incisors, maybe some laterals, that kind of stuff. But just generally somewhere at the front of the mouth, you’re missing a tooth, be it trauma or long-term missing, and we’ll get into it. But we want to discuss the considerations and treatment planning options and the delivery techniques, little details and nuances when it comes to this type of dentistry. So Emma, take it away. What would you like to know in your student lens when it comes to replacing incisors? [Emma] Replacing incisors. So I actually had a patient in my outreach center. He had a missing central incisor and had done for quite some time. He had a single tooth denture in there, wasn’t getting on with it at all. And in student clinic we have the luxury that our patients don’t have to pay anything, and we’ve got quite good labs on our hands and things. So we thought, let’s try an adhesive bridge for this patient. And my clinician at the time said that replacing a single missing central incisor is often considered one of the most difficult things to do in restorative dentistry. So why is it so difficult in your opinion? [Jaz] Okay. I’m gonna turn the question back on you. What is your perception? Why do you think it’s actually more difficult? What did you think? [Emma] So I think from my perspective, seeing that patient, he had no other missing teeth. All his other teeth were natural, a few composites here and there. So I think just in terms of restoring that central incisor… I’m not too sure how to answer this actually. [Jaz] It’s okay, if you’re not sure, I’ll help you out. But I’m just trying to understand from a student’s perspective. Because I remember being a student learning this as well and I was like, wait, why is it so tricky? What are the special considerations for a central incisor? They say the single central veneer or the single central incisor, full stop. You’re quite right to say it’s difficult, and I only really appreciated it more and more when I actually started to replace central incisors, how difficult it actually is. Do you want me to go for it or have you got more ideas? [Emma] Yeah, go for it. Go for it. Go for it. [Jaz] Okay. So have you heard of something called central dominance? [Emma] No. [Jaz] So in the face, the central incisors should be the star of the show, should be in the middle, and the centrals should be like twins, right? Centrals should be like twins. And so when you’re trying to copy the adjacent central, therein lies the problem, right? Because yes, you may be able to copy the shape, but there might be some compromises. But getting the shade right, getting something to look good, okay. And then also a really important thing is smile line. When I talk about smile line, what is a smile line? What does that mean? [Emma] Like how much tooth is at show when your patient’s smiling or where your lip sits? [Jaz] That’s important, but yeah, where your lip sits. Because more important than tooth is how much gum actually. Because if you have a very gummy smile, so very high lip line, when you smile like curtains, your lip raises really high and everything’s on display. Those are by default considered very challenging cases because now not only are you worrying about white aesthetics, the aesthetics of your restoration and the ceramic and whatnot, but now you’re also worrying about pink aesthetics, which is the gums, right? How it’s so critical not only for the shape of the restoration to be matching so closely to the adjacent tooth, the shade characterizations, but now with someone with a high smile line, when they smile, that gum contour is so critical. And you would’ve seen this in implant dentistry. How much grafting and attention. It absolutely blew me away when I spoke to some of my patients who’ve had… I’m very lucky. There’s a really great dentist that works nearby me called Rob. Okay, I dunno if you’ve heard him. He’s brilliant. Okay. A lot of dentists will refer to him for the single central incisor. And he’s not cheap. And you know what? He fully justifies his fees. Like you could buy a small car. We’re talking about near five figures for a single central incisor. And when I first heard that, I was like, wow, what’s going on here? And as I gained more experience and I restored more centrals, I was like, wow, you know what? That fee is totally justified. Because when I see his cases, not only is he paying for the top-end lab work to try and really match the ceramic, really trying to match that tooth, but more often than not, when we lose a central incisor, we have to discuss how was that central incisor lost? And the most common cause is trauma. And when there’s trauma, there’s often soft tissue loss and hard tissue loss, because the bone, the buccal plate, it’s paper thin. And so what you have with implant is you’re dealing with the scenario where we have less bone in such a critical area. And so there’s soft tissue grafting, bone grafting, and it’s all to do with getting really high-end symmetry and aesthetics. That’s why it costs so much. So ultimately, central incisors are very tricky because we’re always trying to match to nature usually, or the adjacent tooth in general. And there are soft tissue and hard tissue considerations, and that’s why it’s difficult. And so the number one thing is, if ever you’re replacing a central incisor, even if it’s a resin bonded bridge, like your patient you described, you have to explain that, hey, what we’re giving you is gonna be a replacement, but you have to really tell me how perfect you want it to be. Because there’s different levels. Because the way that a restoration reflects light is very different to a tooth. And they need to understand. I used to work with a consultant called Raj Patel, and he would basically wave a tissue in the air to a patient and say, “What color is this tissue?” And they’re like, well, it’s white. And Raj was known for this kind of communication, right? He’d be slightly, okay, I hope he doesn’t mind me saying this, but slightly sometimes, in terms, patronizing. Like he’d ask a patient, “Do you like flowers?” And the patient goes, “They’re okay.” “I guess, okay, I like flowers.” And then like, “What do flowers need?” And the patient’s like, feeling patronized. “Well, sunlight, growth, water,” that kind of stuff. It’s like, whoa. Your teeth and gums are like flowers, and so his hygiene discussion would come like that. And I saw him do this with like a builder man. I was like, what the hell? Like, what’s going on here? Yeah. So anyway, back to the tissue. He’s waving this tissue and he’s like, “What color is this tissue?” It’s like, well, it’s a white tissue. Okay. And then he’d put it on his trousers over his lap, right? And so now that tissue was still white, but it looked like, because you see his dark trousers through it, so it’s kind of like grayish now. Do you see what I mean? And the patient’s like, okay, well yeah, I see that it’s still white, but it’s not the same white. And then he’d try to get the patient to understand that look, we can’t match the adjacent tooth perfectly. He’s very good at that, and I always took that example. So I very carefully choose the patient through that tooth. Does that make sense now? [Emma] Yeah. Yeah, that does make sense. And it’s the first thing that people see, and the ones that people are more aesthetically worried about are their central incisors naturally. And I don’t know if this is maybe good for my first case replacing that central incisor. My patient wasn’t— [Jaz] Have you done it already? That patient, the denture replacement? How did it go? [Emma] It was good. Yeah, so we did a resin bonded bridge, like a Maryland from the other central incisor. But he wasn’t too aesthetically demanding, and for this patient going private wasn’t really an option, just financial wise. And he was just happy to have any sort of replacement other than a denture. And so to me, like it was nowhere near perfect match, you know? But we’d done the best that we could. His contralateral central was three different shades in one tooth. You’re never gonna get it matched perfectly. And with what we’ve got on the NHS, you pick one shade, and that’s sort of what you’ve got to stick with. And he was happy. And I saw him for a review last week and it’s still in there, which is good. And he’s happy with it. But yeah, it was— [Jaz] What did you think? When you look at that central, does the shape match well to the adjacent tooth? [Emma] Yeah, I’d say he was happy with the original denture that he had and the shape of that tooth. And he wasn’t wearing that denture because it was actually broken, and I sent that denture away to the lab as well. [Jaz] Oh, nice. [Emma] I know that they’ve got impressions of the uppers anyway to match to the other, but they might as well just have it to see what this patient’s already happy with, mould-wise. So he was happy with that. I don’t think it’s too bad a result, but yeah, you can definitely tell that it’s not a natural tooth that’s there. But he was happy with it, and I’m happy with it for my first go. But it was tricky. It was tricky. [Jaz] It’s always tricky. Now we’ll talk a little bit more about that, but when it comes to replacing that incisor, you did a resin bonded bridge and therefore, a metal wing or— [Emma] Yeah, yeah, a metal wing, yeah. [Jaz] Okay. Did you find that the central incisor that you were sticking to, the abutment tooth, did it go a bit gray or not? [Emma] Not that I noticed, no, but I know that can happen. [Jaz] Do you know when that would happen? Which kind of patient is particularly susceptible to that? [Emma] Would that be if the tooth has been retreated? [Jaz] Not necessarily. It’s more to do with if someone’s got minimal wear and therefore that incisal, translucent zone. Probably this patient. How old is this patient? [Emma] He’s in his 60s. [Jaz] Okay, so fine. But did he have a bit of wear on the edge? Was it a bit worn? [Emma] Yeah, a bit. He’s got a bit of wear, yeah. [Jaz] Okay. So sometimes when you don’t have much wear, or generally some people have more translucent teeth, right? As a feature of their teeth. And therefore in that scenario, you have to warn the patient about graying. And so one thing you could do is you can get a cotton roll and take a photo of the tooth as it is, get the retractors in, and then you put a cotton roll behind it and you take a photo. And then you see how much impact did that cotton roll have on the tooth. Like if the tooth looks different just by putting a cotton roll behind it, then you know that when you put something black there that is going to look… metal there… it’s gonna look a lot different as well, basically. And so you’ve gotta warn the patient of that. I’ve seen some cases I’ve done before earlier in my career which really grayed up. And then one way to mitigate that is to use opaque cement. Now, before we go deeper into that, just remember the main lesson, the really important lesson: shape with a P is more important than shade with a D. i.e., shape is more important than shade. So if you absolutely nail the shape, that’s actually more important. It’s going to have a more pleasing outcome than if you get the shape wrong but the shade right. Okay? So shape is super, super important. Always remember that. And everything you do when it comes to anterior aesthetics, shape is always more important when you’re trying to match. Did you discuss with that patient any other treatment options, or how did he come to you and your sort of mentor or supervisor come to the decision that resin bonded bridges would be the most appropriate? And did you consider any other options? [Emma] Yeah, so I think just from hearing other dentists talk about replacing gaps in practice and things, I always go and tell my patients that there’s four options usually. Does that sort of ring true with you? So the first option is to do nothing, because we always have that option for our patients. The second option was to try a replacement denture for that patient, and he wasn’t really keen to give that a go. He’s had one… I don’t think he even had it for very long, and it had already broken and wasn’t very retentive, X, Y, Z. And then I say the third option is to do something more fixed, so like bridge work. And then the last option would be to go privately and do something like implants. And it just wasn’t in the patient’s financial budget at the moment. So he was interested more in going for something more fixed. So I discussed with him that we could maybe do a bridge on that tooth, a Maryland bridge with the metal wing. And then I had a chat with him about that, although I didn’t actually mention to him about the metal wing and that possibly shining through. And I did have a chat with him. He had quite heavily restored teeth. He had composite on the other central incisor and on the lateral. It was— [Jaz] Was it a big composite? Was it a large composite? [Emma] It wasn’t… I’d say on the lateral there was quite a large composite. [Jaz] Okay, but what about the central, your abutment tooth? Did it have a big composite? [Emma] It had a distal composite, but it wasn’t massive or anything like that. [Jaz] Okay, good. Good. Because having a large restoration in your abutment tooth for a resin bonded bridge usually has more negative outcomes because there’s less surface area of enamel. Did you know that the most important predictor success of a resin bonded bridge is the same as it is for veneers? So how well your ceramic veneers will bond and resin bonded bridges is the same. Availability of enamel and surface area of enamel. And that is really, really key. That’s the number one factor when seeing if there’s going to be success. So it’s good that fine, it’s a small one. Ideally, unrestored. Okay. So you talk about all those options, and here’s a communication tip for you and your colleagues and anyone listening. I used to do the same thing. I used to say, okay, there are four things you can do and blah, blah, blah. And sometimes for a lower incisor, right, if you’re missing a lower incisor and there’s crowding, you could say, well actually, how about we relieve the crowding and then have three lower incisors. Look, I got three lower incisors here, not four. Okay. So you can do something like me and then we can relieve the crowding at the same time. And so sometimes ortho is an option, but obviously wouldn’t be for an upper incisor, right? ‘Cause that would look weird. So when we give those options, I think it’s much nicer to do it the following way. So Emma, is it important for you to have a front tooth? [Emma] Yes. [Jaz] How important is it? You’re missing a front tooth and you have a denture and you hate it. How important is it to have a front tooth? [Emma] For me, very important, yes. [Jaz] Extremely, right? So really doing nothing is not an option. [Emma] No. [Jaz] Not gonna give you that option because that’ll be inappropriate for what you’re saying here. Okay. Is it important for you that it’s fixed, or do you mind having something removable? [Emma] For me, I would ideally like something fixed. [Jaz] Okay, that’s fine. Would you like to be able to eat corn on the cob with it, or are you not so fussed and you’re happy to be a little bit careful with what you eat? What do you think? [Emma] Yeah, I’d be happy to maybe be a bit more cautious about what I’m eating, yeah. [Jaz] Okay. Do you see, just from those questions, I now know that doing nothing is not an option anymore. A denture is really not an option because you said you want something fixed. So that only really leaves a bridge. And then what type of bridge? We know the adjacent tooth is minimally restored, so maybe not a good candidate for a conventional bridge where you have to prep the tooth. Okay, so fine. We know it’ll be a resin bonded bridge or an implant. And they both are still on the table here. Both are still on the table. Now, if you said to me that, look, it’s really important for you to be able to eat corn on the cob, and really use your incisor a lot, and you like to bite into apples, and that’s really important for you, then I’d say that look, you’re probably best going for an implant. Okay. And then in terms of budget, like is money no question? You want the best there is? Or are we on budgetary constraints? And we talk about that, and then we’re like, okay, well actually based on what you said, that you wanna be able to eat corn on the cob, in a hypothetical scenario, then really you’ve gotta go for an implant. But because of your financial constraints, then a good compromise will be a resin bonded bridge. This is blah, blah. You explain what it is. But remember that this is essentially an aesthetic appendage, something glued. It’s for smiling. It’s not for chewing. You cannot bite your nails with it. You cannot bite tools with it. You cannot cut into… you can’t bite a baguette and tear it. It’ll come away. The worst thing that can happen is it comes away, but you know what? It can be glued back. But you just have to be extra cautious. And when you have that kind of conversation with patients, they get it. And if you choose well, resin bonded bridges enjoy a very, very high success rate. The King et al. study, very famously quoted in Bristol, they had like 700-something RBBs. At four years, 80% were totally fine with no issues. And if they do last four years without debonding, they’ll probably go on to last 10 years and then beyond. And one thing I can tell you is I used to work with… well my predecessor, who I used to work with now, he has been doing resin bonded bridges for years. So I’ve got patients on my books that have had RBBs for 25, 28, 32 years, never debonded. The odd one debonded 16 years ago once, and then it’s been okay. Do you see what I mean? And so my predecessor, using the cements back in those days, did a fantastic job. Case selection was really good. And all the Americans out there: resin bonded bridges indeed can be very successful, but the patient must play a role. I know that my lower zirconia resin bonded bridge I have, I cannot have corn on the cob. It would be a stupid thing to do. You are overloading it and you’ll break the bond. And so those are some important considerations. Now if the patient would like to be able to chew with their front teeth and they’re like, look, I want something fixed. I don’t want to have to worry about it ever coming away. I want something that’ll last the longest term possible. Then you really… you’ve now selected an implant. You’ve self-selected implant. So an analogy I use, in the podcast episode I did with Michael Frazis—have you listened to that one, Emma?—is it’s like you’re playing Guess Who. If you ask enough questions, right, you only have a few people left. And so really, you’ve only got a few options left. So if you’re not sure what the treatment plan should be, you probably haven’t asked the patient enough questions. [Emma] Yeah, yeah. I think that’s interesting how you were talking about almost getting the patient to self-select and guiding them into their own treatment option, which is interesting actually. Because I’m usually just listing off the four options. “Oh, we’ve got four options, do nothing,” and you’re never really gonna do nothing if that patient’s main complaint anyway was that missing central incisor. So that’s interesting. And I know you were talking about, so if you’re going down replacement options and would you like a fixed versus a removable, what other sort of factors do you consider from a dentist perspective when you’re deciding whether a fixed option is appropriate at all, or whether a removable option is one that you would more recommend? [Jaz] Removable has its place. Like, if it’s for a single central, then more often than not removable is not gonna be… it is very much a budget thing, right? Like it is major budget concerns. And look, I can’t afford even the resin bonded bridge, and you gotta go for an acrylic denture flipper. But there’s also things like poor oral hygiene. They’ve got poor oral hygiene. It’s a double-edged sword actually, because if you’ve got poor oral hygiene, then you don’t wanna give ’em a denture. But equally, if you know they’re gonna be losing other teeth of poor prognosis, then you can actually be adding to the denture as you go along. And if they’re missing a central, but they’re also missing a premolar on one side and another premolar on the other side, and then you can actually replace all those teeth in one go, then that is a consideration. Sometimes when you get a little bit fancy chrome denture and you have palatal backings and you kind of make like a splint type framework at the same time, as part of a bigger case for tooth wear. So there’s a lot that can be done, but it’s about understanding the patient’s history, the number of teeth involved. But if we’re talking purely the missing a single tooth only, mm-hmm, which is a front tooth, removable is something that I would struggle to recommend unless it was a budgetary thing. There’d have to be some really good reasons not to. Now, for example, let’s talk about age, right? So we talk about smile line, but we’ve gotta talk about age because if it’s a growing patient right up till the age of 25, you don’t want to do implants. Okay. So therefore, it is a resin bonded bridge, for example, or it’s a denture until you are old enough to have an implant. ‘Cause it’s still growing. And so that’s a very, very common thing. And what happens is they have these resin bonded bridges, and they’re successful for many years, and then maybe in their forties they end up having an implant. It’s much better to have an implant in your forties than it is in your thirties. And some patients, all they need is just a new resin bonded bridge, and that’s all they need. So age is really important, and their growth status. [Emma] Yeah. Yeah. Okay. [Jaz] And then one more thing, when you are deciding, not so much fixed–removal, when you’re deciding the type of bridge… if that other central in your patient’s case was already a crown, then you just take off that crown, polish up the prep, and now you have a conventional bridge. [Emma] Yeah. And that’s what I was actually gonna ask you next. Because one of my friends had a similar case. There was an adjacent crown, and then there were chats about what would your approach to that conversation be about taking that crown off? Because I know that there’s a lot of dentists who would have hesitation around that, to take that old crown off if there’s nothing wrong with that crown to then put a bridge on it. Does that make sense? Does my question make sense? [Jaz] Yeah, totally makes sense. But the question would be, how old is that crown? And if it’s more than about 15 years old, eventually the replacement event’s gonna come anyway, whether you like it or not. [Emma] Okay. Yeah. [Jaz] And I used to worry about this as well, but having done several cases now… you get your pulpal diagnosis, you get your apical diagnosis. If everything’s sound, you just remove the crown as atraumatically as possible. You just give it a nice prep, give it some love, and you put a bridge on. And I haven’t had any issues doing this. And I think everyone’s right to be concerned about it because, fair enough, you don’t know what’s inside that crown, underneath that crown. That core could have been really weak. So yes, you’d be silly not to warn your patient of like, okay, we’re kind of going into the unknown. Okay. But I wouldn’t want to do this if the crown’s been a recent crown, last five, ten years. But if it’s an older crown, it makes sense. But of course you have to warn the patient. You also have to find out, okay, how did this tooth fail? Check the periodontal probing deficit. If it’s like a single isolated pocket and you’re worried, could this tooth already be quite compromised and cracked? Then maybe not. If the tooth already has a big post in it, and maybe mechanically you’re a little bit worried about it, then maybe the implant is the best way to go. And maybe you should be having a denture until you can save up enough money to have an implant, or if the patient can afford it, go for an implant. [Emma] Okay. Okay, that makes sense. So if you know there’s a crown on it about 15 years old, but otherwise looks sound, you’re looking to replace the adjacent gap, as long as you’ve communicated that with your patient and all the risks, you would be happy to go ahead, remove that crown and replace. [Jaz] Yes, I would, and I have done it on many occasions. And it’s a good option, because you already have a… it’s like the worst thing you could do is crown a virgin tooth to do a conventional bridge. But you’re literally replacing for like… it’s just carrying a pontic next to it. And again, the same thing goes with it, that you gotta warn the patient that, hey, you gotta be careful. This one tooth is now carrying another one. Let’s not stretch it by chewing or incising on your front teeth in a harmful way and overloading that unit. [Emma] Okay. And just when you’re talking about overloading of units there, that sort of takes me onto my next question about, especially in the anterior region, is there any situation where you would prefer or recommend a conventional bridge over a resin bonded bridge, or vice versa? Like especially in terms of occlusion and things like that as well. [Jaz] Yeah. So really what you’re asking here is, when you are doing resin bonded bridge, you’re relying on the adhesion, and therefore the point of failure is a debond. Whereas you wouldn’t typically get that with a… you feel more secure, you can sleep well at night. Like, you made that comment a little while ago where you said you saw the patient review and it’s still there. You probably wouldn’t have said that if it was a conventional bridge, right? ‘Cause you know you’ve got the whole 360 degrees, you’re cementing it on. It’d be a much bigger surprise if that came away than a resin bonded bridge. So I see where you’re going with that. And yeah, if you have a deep overbite, then that is a little bit worrisome because when they’re chewing, right, the time in contact, the time that the lower incisors are thrusting up against that pontic… because the rule of bridges in general is that the pontic is allowed to be lightly in contact in MIP or ICP. But in any excursion, any chewing movements, you want to minimize rubbing. But with a deep overbite, as soon as you put some food in between, you’re kind of milling. Like even though it might not be touching, there’s still food trying to push that pontic away. And therefore a deep overbite may be a reason. But then again, would I still prep? Would I still prep a virgin tooth to make it into a cantilever conventional bridge? Probably not. I’m probably gonna say, look, your functional demands are quite high. Would you like ortho? Or would you like to maybe go down implant, which still will have its own issues because we don’t want to overload an implant, but probably it’s less risk. It also matters about the patient’s occupation because if the patient’s a high-level barrister and is doing lots of public speaking and that kind of stuff, you may say, look, with your bite in consideration, then I may suggest, let’s do an implant here because resin bonded bridge is just glued onto the tooth next door. And with your bite, it’s a lot of demand. It could still work, but there’s a little bit of element of risk in there. And you try and assess the appetite for risk for that patient and your patient’s occupation as well. The lip line, all those things. Basically because if the lip line’s really low and you don’t see much, then actually you can get away with a lot more. But if it’s really high, not only are you thinking, okay fine, if you’re gonna do something it’s gotta look good everywhere, and therefore not only is it just an implant, it’s a complex implant where you’re doing soft tissue grafting and really trying to get the best out of the aesthetics. [Emma] Yeah. Okay. Okay. That makes sense. And I think that relates to my patient because the reason he was struggling with the denture… a bit had chipped off, but he wasn’t wearing it anyway. He’s a musician, he was a singer, and he was actually at a gig and his denture came out. And so that obviously is not good for him. And he has quite a deep overbite. And I had like a lengthy chat about him and chatted to the clinician, my supervising clinician, about conventional bridge or a resin bonded bridge. But we were like, let’s try it, let’s try it first and see how we go. And it did need a little bit of adjusting, but that’s why I was quite pleased when he came back two weeks later and it’s still there. We adjusted it a little bit further. Happy with where it’s at at the moment. But yeah, there’s just so much to consider, and so much to consider, and yeah, definitely. [Jaz] I want to remind you and all the listeners that when you do resin bonded bridge… which you guys know I’m a huge fan of. We have the RBB Masterclass on the Protrusive Guidance app as well. Have you done that yet? [Emma] No. I’ve not done the RBB Masterclass yet. No. [Jaz] Okay, fine. [Emma] I was waiting until I was at a point where I understood everything, ’cause I started working with you when I was in second year. So maybe now’s a good time. [Jaz] Now’s a great time to do RBB Masterclass. Yeah, yeah, do it. So I’ve got some clinical videos on there of actually putting bridges on, which you’d like to see. But as part of delivering a resin bonded bridge, it’s totally fine to adjust the pontic palatally to make sure it’s out the occlusion in that scenario. You want to check excursions and protrusive movement to make sure it’s not there. But again, equally it’s really important the patient understands that it’s glued onto the tooth next door. You must not put anything between the teeth, or you must not chew that baguette. I always use a baguette example, or corn on the cob. And once they understand that, then you’ll get success. I had a patient who I did a resin bonded bridge for. I get a very good success rate with resin bonded bridge. I believe in them very much. I do think for a lower incisor, for a single missing lower incisor, the standard of care is the lower resin bonded bridge central. I think if you’re trying to force an implant in that delicate and small area… yeah, why? Why is anyone doing that? I honestly… please, my listeners, if you are routinely advocating an implant for a lower incisor, email me. Give me a justification. I just… honestly, I can’t see. I’m a very open-minded clinician, but in that one scenario, maybe it’s ’cause I’ve been affected by this and I’m missing a lower incisor and therefore I have it. I just cannot fathom how you can try and force and try and get a small implant, all the complexities of that, when you can just have a resin bonded bridge and just be careful with it. Mine’s been going for about seven years now. So just remember that you have to look at the patient as a whole and their chewing habits. Just going back to that again, basically. [Emma] Yeah. That was actually also one of my questions. You sort of just answered. You speak about implants, not a tooth replacement, but… I’m missing… I don’t know if it’s you or if it’s one of the clinicians at uni, it might be yourself, Jaz, that always says an implant is a good substitute for no tooth, but it’s not a substitute for a tooth. Is that you or a clinician? Anyway, I’ve heard that somewhere. [Jaz] I’ve said it before, but it’s not mine. Like, it’s from very clever people. I can’t say who. It’s one of those things, definitely said by a lot of people, speakers and writers, and it’s a great thing, right? An implant is not a replacement for a tooth. It’s a replacement for a gap. And that’s… yeah. Or any restoration you do. And just going back to be it implant, where you’ve gotta manage the occlusion carefully as well, or any form of bridge, especially resin bonded bridge… like, for example, if you’re doing a premolar. I know we’re talking about centrals, but I think the premolar example really drives it home. If you’re replacing a premolar, maybe you’re using the second premolar as an abutment, right? So palatal and occlusal wrapper of the wing. And then you’re placing a premolar. Why does that pontic of the premolar need to have a palatal cusp? There’s no need. You can literally put a canine to replace a premolar. Because ultimately it’s aesthetics. When the patient smiles, it should look like they have a tooth there. It’s not for chewing. And so the same kind of goes to some degree with implant, where we try to make the occlusal table, right… the occlusal table narrower, smaller, so it’s taking less load. Now implants are… you can chew on implants, they can go for it. Okay. Whereas you wouldn’t want to do that on a bridge, so they’re different in that regard. But to make the occlusion really focus on the aesthetics and explain to the patient that this is smaller, that you’re missing half the tooth around the back, because that’s not important. It’s not to chew. And if the patient doesn’t understand that, if they’re not willing to buy into that, then you shouldn’t be doing a resin bonded bridge. [Emma] Okay. And so an implant-supported crown, you talk about that being the gold standard in terms of replacing teeth, but it’s not always in certain situations, especially like— [Jaz] Yeah, lower incisors it’s definitely not. In my opinion, yeah. But an upper incisor… you’re a good surgeon, then you know, if you wanted to get something that’s gonna really be the most secure, longest lasting, then an implant. It just makes sense. Would I be happy to have a resin bonded bridge on my central? I probably would. Okay. I probably would. Honestly, I believe in the treatment protocol. But it depends on the occlusion once again. Like, if you were to do veneers on someone, or if you were to do a central incisor resin bonded bridge, what’s the ideal occlusion to pick? Like, if you wanted to give a lifetime guarantee to a patient, who would you pick? What kind of malocclusion or occlusion would you pick? I’ll give you a clue here. [Emma] A class one. Wait, sorry, say that again. For— [Jaz] On anterior upper anterior veneers or lower anterior veneers, in fact any aesthetic work anteriorly, who is the best occlusion to work on, which is almost gonna give you a lifetime guarantee? Almost. [Emma] A class one. [Jaz] Okay. If it’s a severe class two, then the lowers for sure are gonna last forever. The uppers… there’s always a trauma risk. [Emma] Okay. Yeah, that’s true. [Jaz] An anterior open bite. No contact. Like, you know anterior open bite, right? This is why if you look at your anterior open bite patients, their posteriors are worn. The anteriors, they often have mamelons still. The functional load, the wear on those teeth, are minimal. So if you wanted to give a lifetime guarantee, the only patient I would ever even dream of doing that for is an AOB, right? Obviously you wouldn’t, but you get the point, right? So that is a really good example. We teach this in our occlusion courses that we do, where we think about, okay, think of the patient, think of their functional demands as well. Are they what we call a high occlusal risk patient, low occlusal risk patient? And that always plays a part, by understanding that an anterior open bite actually extends your longevity and prognosis for replacing an upper incisor. It’s a level of occlusion that just is more practical and makes sense. [Emma] Yeah. That makes sense. That makes sense. And then my last question for you, Jaz, was actually just about a digital workflow and CAD/CAM milling. Is that something that you utilize in your day-to-day? [Jaz] I don’t do chairside making. So like, whether you think you’re digital or you’re not, you’re digital. Even if you’re sending impressions, when the lab gets the impression now, they’ll pour it up and then they’ll scan the model, and now it’s all become digital. So everyone’s digital, right? And so, yes. I like my technician to, because the shape is so important, they’ll send me an Exocad file, show me the digital design of the bridge, for example, or the crown or veneer, whatever we’re doing. And so I get to see that on the web browser. I get to move it around, make it translucent, opaque. I get to suggest some amendments, and then it goes for the milling, and then it gets sent back to me. So it’s not I’m scanning, obviously. So scanning. But what I’m not doing is milling in-house, in the practice. But your lab is doing all those things, so whether you like it or not, you are digital. [Emma] Yeah. Is that a thing, like milling in-house? Is that… [Jaz] Yeah. I mean, look at CEREC. People are doing zirconias and Emax and they’ve got a little oven in the practice as well for Emax. I dunno if you’ve ever worked in a practice like that, or have you nursed for a practice like that? [Emma] No. No. Never. No. [Jaz] I mean, it’s amazing. I’d love to be in a practice like that one day. It’s like a whole… I like the idea of same-day dentistry. Like you come in and then they do it all, which is cool. I’m pretty sure you can do good bridges with it, but I see lots of veneers and anterior crowns that are done with it. And it’s great. There’s whole Facebook groups, “Keep CEREC Kicking” is one. I see their work. I’m like, wow, that’s amazing that you didn’t need a technician for that and you did it yourself. That’s so cool. [Emma] Cool. Yeah, I think that’s all the questions that I had today, Jaz. [Jaz] Okay. So the only thing I wanna add to that then, I think for completeness, is when you’re doing the shade, give as many photos as possible to a technician. When you’re doing the shade tab photo, put the incisal edge to the incisal edge. Put the cervical of the shade tab to the cervical of the tooth. Don’t be afraid to tell your technician, look, I think the cervical is A3, the middle is A2, and then there’s white effects here. The more detail you give, the more closely they’ll look. Lots of good photos. You need to make sure that you undersell and over-deliver. So whether you want to use Raj Patel’s tissue technique or whatever, you gotta tell the patient that, look, it’s very difficult to match a central incisor. We’ll never match, will never be perfect. And if the patient’s got a problem with that, they can go somewhere else. Because you run into trouble if the patient’s expecting perfect. Because sometimes we think… oh my God, this is from my first year in practice. I had this patient who didn’t pay any money towards the bridge ’cause she was exempt. And so I did a bridge for her, and she was happy overall, except she had a high smile line and this resin bonded bridge, the way the pontic sat on the gums, right? It kind of made a dark line. So replacing a lateral incisor from the canine, and where the pontic touches the gum. At that time I didn’t have the skill or the knowledge to do an ovate pontic. It was good, but you could just about see a dark line where she could get some floss under the bridge. But you could see a bit of a dark line if you really zoom in. And she said, look, she doesn’t like that dark line. And then I go to my principal trainer, I said, oh, listen, what do I do? Like, the bridge is looking good, we’re happy with it, but that dark line. And the first question he asked me is like, well, okay, how much did she pay for the bridge? I’m like, she didn’t. And he looked at the before, and he’s like, wait a minute, she didn’t pay for the bridge and she has a problem with it? And actually I think he was wrong. I actually think he was wrong, because it doesn’t matter whether… so first, it doesn’t matter if they’re paying or not. You need to warn about everything. It doesn’t matter if they’re fee-paying or not. I should have explained that, look, the way this pontic is gonna sit against it, you’ll feel it, you’ll see it. Why? Because you have a high smile and you show everything. So if you want the highest level, you see a periodontist, do some soft tissue work and get that kind of stuff done. But when a patient is paying a fee, whether they’re paying one onion or five onions… okay, onion can be any currency that you want… basically, if they’re paying, just assume that their aesthetic expectations are sky-high. And so your job always is to bring that down to an appropriate level. I’m not saying always say that it’ll look really bad, honestly, like you’re just gonna look so, so bad. And then when it looks half-decent, be like, hey, what can I say? Don’t tell them a lie, but you need to give them an appropriate… because obviously you wanna do a good job for them, but you can show them and share with them the intricacies and difficulties of doing that. And then when it comes to decision-making tree and planning for an incisor, just make sure that you ask enough questions so you know exactly what direction you feel confident in recommending that option to a patient. And be it a denture, be it an implant, be it a bridge, we’ve kind of done a little bit of a very brief overview. It’s up to our Protruserati to delve deeper into that, and there’s a really good episode that I would recommend. We do “Dentures versus Bridges.” I did that with Michael Frazis. That’s a good one. We also do one called “Crowns versus Onlays” with Alan Burgin. That’s a really good one. Mm-hmm. We also talk about dentures with Finlay Sutton. There’s so many other episodes out there. So for students out there, go back in time and listen out there. And speaking of students, we have some student notes. What are the notes that you are adding to the student section of the app? [Emma] I think I might even… I’ve not put it together yet, but I think I might even just take some bits here and there for just replacement options. Not even just for a central incisor, but just for gaps in general. Even just like a communication guide for talking to your patients as well. Making sure you’re not missing any risks and benefits and alternatives. And yeah, just for replacement options, I think that would be good to put together. [Jaz] Okay. That’ll be available in the Crush Your Exam section of the Protrusive Guidance app. There’s one thing that we didn’t touch on, I just remembered, is when we are replacing with a denture or a bridge… we’re talking central incisors predominantly, but you can actually have weird and wonderful incisors. Like if you’ve got small teeth, you can have small pontics, small dentures. But with implants, we’ve gotta reconsider the dimensions, the CT scan, how much bone is available. There’s a whole biological element, which you kind of, to a large degree, can skip with dentures and bridges. However, the biological for a high smile line is still important because the way the pontic, the fake tooth, sits against the gum… that’s soft tissue. Aesthetics then come in for someone with a high smile line. But you need a minimum distance between one tooth and the next tooth, a minimum distance between the roots. So sometimes you look at the gap, the central incisor, and you think, yeah, this is great, I can put an implant here. But when you take a PA, you see that the lateral incisor and central incisor roots converge. And therefore actually you don’t have the space. You need to have some very complex ortho to torque and fix the roots here. And so there’s so many more nuances. This is why the top dentists that are doing single central incisor implants, they demand a top fee because they deserve it. It’s very, very complex. And, you know, hats off to those clinicians. [Emma] Yeah, absolutely. I think if you’re putting all that work in, then yeah. Charge for it. Absolutely. Absolutely. [Jaz] Good, good. Amazing. Emma, thanks so much for being the Protrusive Student. Thank you very much. Next time… I don’t know if you’ve thought about next time. We were gonna consider doing medical histories, guys, but honestly it didn’t excite me enough because I’m like, okay, am I the expert on medical histories? I can kind of advise, okay, let’s open the BNF kind of thing. But it’s something that I think is important though. So please do some self-reading on medical histories. But are there the more clinical topics that you’d like to— [Emma] What have we not really covered? Bear with me two seconds, Jaz, ’cause I actually have a list of— [Jaz] Okay, cool. [Emma] Let’s see. We’ve not really done any basic oral medicine, have we? Or oral surgery. I know that we did an extraction topic, but maybe we could do something similar… oral medicine— [Jaz] Oral medicine. I defer to this really lovely Australian dentist, Dr. Phoon. We’ve done some red patches, white patches, done oral cancer with her. And so it would be a blasphemy if I was to start answering questions on his pathology of oral cancer and stuff. But we can talk about some other clinical themes. But there has to be a… I love it when you have a patient problem. Like when you have… it is so great that you had a recent patient with that bridge. So I want you to start looking out for real-world clinical dilemmas. ‘Cause that’s what the podcast is about: real-world clinical problem-solving. So over the next few weeks, have a look at what clinical dilemmas you’re facing and then let’s decide the topics from there. Okay. I think we’ll make it more tangible for everyone that way. [Emma] Okay. We’ll do that then. Perfect. Thank you very much. [Jaz] Amazing. And guys, if you’ve got a recommendation to students for what you’d like, or young practitioners… I’m really proud of the series, the previous 17 episodes we have so far. So, so great. It’s really, really good. But if anything else needs a back-to-basics, something for young practitioners that’s not gonna bore me to death, then please do comment and let us know what you’d like. All right. Thanks, Emma. [Emma] Perfect. Thank you. Jaz’s Outro: Well, there we have it guys. Thank you so much for listening all the way to the end. If you are a qualified dentist and you’d like to claim CE credits for this episode or enhanced CPD, you can do it. Head over to Protrusive Guidance or scroll below. If you’re already logged in, answer the quiz and claim your CPD. You deserve it. You listened to the whole thing, and now you get to test your knowledge and your understanding, and we will reward you with a certificate. We are a PACE-approved education provider. We’ve got over 400 hours of CE on Protrusive Guidance. All the masterclasses, episodes, and the accompanying premium notes that we provide. Transcripts and infographics are second to none. Now, specifically for students, we have the Crush Your Exam section where Emma uploads her notes, which helped her smash her exams last year. So the one to accompany this episode will be all the replacement options for teeth. Particularly useful for OSCEs and great revision material. Some of the earlier ones that she uploaded were dental materials, for example, which a lot of you found very helpful. If you wanna fast-track access into that, email student@protrusive.co.uk. Send us your proof that you are indeed a student, and you’ll be allowed into that part of the app. Otherwise, thank you all for listening and watching so much. If you are on YouTube, make sure you hit the subscribe and like button, and if you’re on Protrusive Guidance, please do comment. I love reading comments and replying to them. Thanks again and catch you same time, same place next week. Bye for now.

What if one bad decision completely changed the course of your career? In this exclusive, members-only episode, Jaz sits down with a fellow dentist from our community who shares his raw, honest story about a moment of misjudgment — committing fraud — and the painful lessons that followed. This isn’t about blame. It’s about insight, accountability, and redemption. From the shock of investigation and court hearings, to the struggle of rebuilding trust and identity, this conversation shines a light on what really happens behind closed doors when things go wrong. The aim of this podcast was to hopefully deter colleagues from temptation which can affect anyone at any time. https://youtu.be/QF-UNrlYjcw Watch PDP248 on YouTube How to Watch the Full Episode This is a members-only podcast episode due to its sensitive nature. You can access it by creating a free Community account at: https://www.protrusive.app Highlights of this episode: 00:00 Teaser 00:49 Introduction 05:49 End Screen Love this episode? Don’t miss Divorce, Alcohol and Rough Patches – Overcoming Adversities (IC040) #PDPMainEpisodes #BeyondDentistry This episode is eligible for 0.5 CE credits via the Quiz on Protrusive Guidance.  This episode meets GDC Outcomes A and D AGD Subject Code: 555 Ethics in Dentistry Aim: To reflect on the ethical, professional, and emotional lessons learned from a real-life case of dental fraud, highlighting accountability, insight, and rehabilitation while identifying practical steps to prevent similar incidents. Dentists will be able to – Recognise how workplace pressures, lack of mentorship, and poor oversight can lead to ethical lapses. Understand the legal, professional, and emotional consequences of dishonesty and poor record keeping. Identify support systems, coping strategies, and self-reflective tools to prevent burnout and maintain integrity.

Ever had a patient swear their bite feels “off” – even though the articulating paper marks look perfect and you’ve adjusted everything twice over? Or maybe you’ve placed a beautiful quadrant of onlays, only to have them return saying, “these three teeth still feel proud.” If that sounds familiar, you’re not alone. In this episode, I’m joined (in my car, no less!) by Dr. Robert Kerstein, who was back in the UK to teach about digital occlusion and the power of the T-Scan and ‘disclusion time reduction therapy’. We dig into why a patient’s bite can still feel “off” even when everything looks right, how timing is just as important as force, and why splints and Botox don’t always solve TMD. Robert explains why micro-occlusion is the real game-changer, how scanners could mislead you, and why dentistry still clings to articulating paper. So if you’ve ever wondered why “perfect” cases still come back with bite complaints, or whether timing data can actually prevent fractures and headaches, this episode will give you plenty to chew on – pun intended. https://youtu.be/0lCAsjFhsXI Watch PDP247 on YouTube Need to Read it? Check out the Full Episode Transcript below! Key Takeaways: Micro-occlusion, not just “dots and lines,” is the real driver of patient comfort and long-term tooth health. T-Scan measures both force and timing, which scanners and articulating paper cannot capture. Many patients show signs of occlusal damage without symptoms. Disclusion Time Reduction (DTR) treats TMD neurologically without splints, Botox, or TENS. Relying on occlusograms alone for guiding reduction is risky. Dentists can reduce post-treatment complaints by balancing micro-occlusion with T-Scan. Adopting T-Scan requires proper training. CR can be a convenient reference point, but MIP works well in most cases if micro-occlusion is managed. Objective, repeatable data builds patient trust and provides medico-legal reassurance. Highlights of this episode: 00:00 Teaser 01:13 Intro 4:41 Protrusive Dental Pearl –  Removing a Temporarily Cemented Crown 06:39 Introduction 08:48 Global Training Footprint 09:32 What Robert Teaches (DTR & T-Scan) 09:55 Occlusion as Neurologic 10:33 Macro vs Micro-Occlusion 11:33 Neural Pathway 15:00 MIP vs CR Framing 16:48 Signs Without Symptoms 19:16 Silent Majority 20:08 Why Treat Asymptomatic Signs 20:50 Disclusion and MIP 22:28 Occlusogram Caveats 24:53 Midroll 28:14 Occlusogram Caveats 28:29 Why Occlusograms Mislead 29:21 Don’t Adjust From Color Alone 31:47 What Pressure/Timing Enable Clinically 33:02 Prosthetic Reality Check 34:46 Patient-Perceived Comfort 35:29 Why Isn’t T-Scan Everywhere? 36:29 Political Resistance 37:42 CR as Utility 38:18 MIP and Vertical Dimension. 39:48 Macro ≠ Micro 41:00 Material Longevity Benefits 41:57 T-Scan Training 42:58 Three Competencies to Master 44:20 Micro-Occlusion Rules 44:46 Outro If you want to get more clued up on TMD, tune into this episode for the latest insights and guidelines! PDP213 – TMD New Guidelines –  however be warned that the guidelines are contradictory to what Dr. Kerstein advises….ah the wonderful world of TMD!  #OcclusionTMDandSplints #OrthoRestorative This episode is eligible for 0.5 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes A, C. AGD Subject Code: 250 – Clinical Dentistry (Occlusion/Restorative) Aim: to explore the role of micro-occlusion and timing in TMD and restorative success, highlighting how tools like T-Scan provide data that other tools cannot. This episode seeks to give dentists practical insights into diagnosing, preventing, and treating occlusal problems with greater accuracy. Dentists will be able to: Describe the role of micro-occlusion and disclusion time in TMD symptoms and tooth wear. Recognising the limitations of traditional methods of occlusion adjustment. Understand how objective occlusion data supports comfort, longevity of restorations, and preventive care. Click below for full episode transcript: Teaser: Pressure is a force over surface area. And when it gives us the red, the blue, yellow, it's not measuring the force, so it cannot tell us the pressure. So tell us about what the nuances of being careful with the occlusogram and where it fails in the face of something more sophisticated, like the T-scan. The essence of a scanning technology is that all the teeth are scanned with the patient’s teeth apart. No one’s biting. There’s no forces captured. There’s no contacts. There’s no gathering of teeth banging together or rubbing around. So it completely is falsely representing. These colour coded occlusograms have no force information in them at all. Anyone who’s used articulating paper, which most of us do, and the T-scan, you still mark the teeth with paper, but you choose the contacts to treat based on the data, not based on where the paper marks look. And very often, the most pressure points of contacts are small, scratchy little marks that dentistry says are light force, which you’re completely wrong because again, the load is applied over area. So if you have a very small area, you have the potential for very high pressure. Jaz’s Introduction:Protruserati, the occlusogram is lying to us. Does that sound familiar? Well, we welcome back again, Dr. Robert Kerstein. If you remember way back in episode 109, we made an episode called, “Articulating Paper Is Lying to Us,” and you guys absolutely loved it because Arctic paper is lying to us. You should totally listen to that episode if you haven’t already. And if you haven’t, essentially the arctic paper marks you see on teeth are flawed in the sense that you can’t look at a mark and accurately say that, oh yeah, that’s more force, or that’s less force, or that’s hitting first. You don’t get that data. And not only that, but you also get false positives when it comes to articulating paper. Now, similarly, I’ve got Robert Kerstein back again talking about the occlusogram. Now the occlusogram is that heat map you see when you do a scan, when you do an intraoral scan of a patient, upper arch, lower arch, and then you do the occlusion. Most modern scanners will give you some sort of a heat map of the occlusion and we call that an occlusogram. And we may all at the beginning make this mistake, this very simple error, that when you see red on the occlusogram that means high force. Well, we will absolutely and emphatically bust that myth today. You see the heat map or the occlusogram is just a measure of proximity. How close in space is that cusp to that fossa? And if it’s very close, it’s gonna be red. And if it’s maybe a few microns away, it’ll be a colder colour. Absolutely does not tell you how much force or timing or pressure, none of that stuff. Just contact proximity. So we must be careful in how we interpret that data. It would be misinformation to tell a patient that a certain tooth is having more load because of the colour. Hello Protruserati. I’m Jaz Gulati and welcome back to your favourite dental podcast. Today’s guest is none other than Dr. Robert Kerstein. Rob Kerstein is like the godfather of digital occlusion. When I was in New Mexico a few months ago with Dr. Bobby Supple, he described Dr. Kerstein as the Einstein of occlusion, and it’s an absolute pleasure to chat with him again. It’s a different format of the podcast. We’re driving, well, I’m driving, he’s my passenger. And so one of the team members, when they were listening to this, they said, it’s like carpool karaoke vibes. And don’t worry, we will not start doing a little singing and dance in the middle of this episode, but something a bit different, a bit fresh. Me and Dr. Kerstein were on the way to some DTR training in the UK. DTR is Disclusion Time Reduction, essentially, if you listen to that episode that we did with Nick Yiannios. We talked about frictional dental hypersensitivity, and essentially lots of friction between the back teeth could cause your teeth to become sensitive. So this posterior dental friction is also implicated in TMD, thus resurfacing that old debate: is occlusion a causative factor of TMD? Now, we all know some CAMs and some reviews that suggest that occlusion has no relationship to TMD. Whereas my guest, Dr. Robert Kerstein, says that TMD is a neurological condition and has everything to do with occlusion, and particularly that muscular TMD group would greatly benefit from an occlusal adjustment or something to change about their occlusion, to reduce that sensory input and their noxious muscular spasms. And I saw all this freehand. I can’t wait to share my experience of what I witnessed when Dr. Robert Kerstein came to my practice and I treated three patients. So I’ll leave you on that teaser if you like, ’cause we have another episode coming with Dr. Jeremy Bliss talking all about occlusion, TMD and Disclusion Time Reduction, aka DTR. Dental PearlBut for now, let’s enjoy this episode of occlusogram. And just before we join the main interview, I need to give you your Protrusive Dental Pearl. Every PDP episode, I’ll give you a top tip that you can use right away. And today’s one, like many pearls are, are from Dr. Mohammed Mozafari. Mohammed’s one of the most selfless and caring and giving people on our Protrusive app community, always helping our colleagues. And today it was our good colleague Yazan. And just yesterday on the group, Yazan had a query. He’s got these crowns, definitive crowns, temporarily cemented with TempBond. Now we all know of that scenario that it could have happened to you or a colleague, whereby you put these crowns in temporarily. Even some colleagues, they try in a crown, let’s say a PFM crown without any cement, and they put the crown on and they just cannot take it off, and it’s like impossible to get off. It’s not happened to me yet, but I’ve heard of this happening many times. So quite appropriately, Yazan was right to ask on the group, what’s the best way to remove a definitive crown that’s been temporarily cemented? Because you want to remove it in a way that you don’t damage the porcelain or the material itself, and you want it to be nice and easy and not very uncomfortable for the patient whatsoever. Now, what I was going to say before I read all the comments was there are these like special pliers you can get with these, like these plastic ends, but they can be a bit hit and miss. Sometimes they do slip off, like they have got this like textured surface to prevent the slippage, but it can slip off. So I really like what Mohammed suggested. So Mohammed suggested you get some bite registration paste, you put some buccal and lingual of the crown, then you put some gauze over it. You obviously let that bite registration paste set a little bit, and then you can get your hemostat or your mosquitoes and squeeze and try and wiggle the crown off. The benefit is that the gauze and the bite registration paste are kind to the crown, but at the same time giving you enough of a grip. Haven’t tried this exact way before, but it just sounds amazing to me, and Yazan was able to report back that he was able to get the crown off. So thank you again, Dr. Mozafari. Really appreciate all the help and support you give to all the community members on Protrusive Guidance. Let’s now join the main episode and I’ll catch you in the outro. Main Episode:Dr. Robert Kerstein has entered the UK once again and we’re doing an extremely rare driving podcast. So, Robert Kerstein, welcome back to the UK. How are you today? [Robert] I’m good. Thank you for having me. [Jaz] Absolute pleasure. You know so many dentists around the world, around the world. [Robert] Yes. [Jaz] And you’ve done these trainings where I’m sure you’ve sat in lots of dentists’ cars. [Robert] Yes. [Jaz] And so therefore, I want to start by apologizing for probably the worst car of a dentist you’ve ever sat. [Robert] Oh, it’s very nice. [Jaz] No, no, no. Listen guys, as you guys know, I’m not into my cars at all. I literally googled what’s the cheapest electric car I can go buy for tax efficiency, and I landed on this Chinese car, the MG ZS EV. So I was trying to start by apology, but one of my, like a slight detail for you, talk about the good stuff, is one of my philosophies in life when it comes to spending money is things that I don’t value and I don’t love, I always skimp on. But things that I value, I will spend mercilessly. I will save mercilessly where I can, but I will spend lavishly on the things that I value. And so one of the things I value so much is education. Education and investing in myself, which goes back full circle to why you are here in the UK right now. Myself, Riaz Yar, Shreyas Mhatre, Haider Raza, and then of course the previous group that you trained are also part of this, and you’re gonna do this one week intense tour around the UK with a didactic day on Thursday. And we’re talking about Disclusion Time Reduction and the use of T-scan and all the benefits. And so previously we’ve done the episode on “Articulating Paper Is Lying to Us” that had about thousands of hits. You also very kindly shared lots of papers and that link is still active. If someone wants to download the papers that you kindly shared, that link is active. So I’ll link that episode there. But now that I’ve done like a little introduction, I want people to really understand the scale of your education, the mentoring that you’ve delivered over the years around the world, ’cause it truly is an international operation. So tell me, how far and wide does it take you? How many dentists have you trained and what are you actually training on to help the younger docs understand? What are you actually showing chairside to dentists? [Robert] Well, I’ve trained dentists in many countries, so I’ve been very lucky to travel the world, see dentistry in Korea and Thailand and Japan and Russia and Europe. Many dentists in the UK and the United States, South America, it’s really Canada. It’s hard to– [Jaz] India being a hotspot. [Robert] India, many dentists in India. And so, it’s been a unique experience for me, for sure. But what we teach, what I’m teaching, is how to use the T-scan technology chairside effectively, and Disclusion Time Reduction is specifically to treat TMD muscular patients and how effective it is at resolving it. No appliances, no Botox, no TENS, no jaw repositioning, no appliances, no smaller guards, no acupuncture, no massage, no chiropractic care, no hypnotherapy. It’s the only treatment that’s neurologic, treats the central nervous system. That’s just why it resolves TMD, which is really the occlusal neurophysiology is at the core of TMD, even though there’s unfortunately many incorrect advocates around the world who keep teaching that occlusion has no role. Occlusion is the number one cause of TMD, muscular TMD, and even some breakdown of the joints because of how the occlusion impacts disc position, lateral pterygoid strain, and therefore affecting the internal joint space. [Jaz] So what you’ll be teaching me today is we’ve got three patients booked in and some of these patients I’ve done orthodontic correction on because their occlusion was not conducive to any sort of immediate anterior canine guidance. It was a mess. So I’ve got a good foundation and that’s what you taught me is the macro occlusion. What we’re dealing with today is the micro occlusion, not looking at just the dots and lines, but really the force and the timing being the most important thing, the timing. So as you said, and also something Nick Yiannios has also said recently to me is, as our jaw moves aside and there’s teeth contacts happening, they’re like little speed bumps. And so we want to eliminate these speed bumps. Is that a good way to explain to a young doc who’s trying to understand what DTR is? ‘Cause trying to spread the message and patients will be tied up with this EMG, so muscle data coming from temporalis, masseter, anywhere else you can let us know now ’cause I’ve literally just got the kit in my car, haven’t opened it. So how’s a good analogy, a good way to explain to doctors what you’re training me on today? [Robert] Well, the speed bump analogy really discusses like the tooth contacts that rub together frictionally when people use their teeth. But it’s really the transfer of the neural information from the rubbing of the teeth through the pulp and the PDL that is what causes many occlusal problems. And so the timing of that, the duration of these frictional speed bumps, if you will, sets off long periods of muscle firing. And the muscle firing is directly influenced by the teeth directly from the brain. There’s a single no-synapse pathway from the molars and the premolars, pulps and PDLs. It goes directly to the centre of the brain and it enters a structure known as the reticular formation, which controls five or six different major body systems, mostly as it applies to this, your training today, is swallowing and masticating and pushing food down into your throat rather than into your lungs, because the teeth modulate all of those movements so that you don’t asphyxiate by putting food into your lungs. So all these muscles that are involved in chewing, swallowing, and moving food into the digestive tract are controlled by the teeth. And this is why it goes on without us thinking about it. Nobody sits around and says, I’m gonna chew for a while and I think now I’ll swallow and maybe I’ll chew longer and no, I wanna swallow. None of that happens. You’re just rubbing your teeth together and then all of this physiology takes place with neural control from the brain. And the tooth contacts can hyperfunction those muscles. So you can still use them to do all the things you’re supposed to do, but they get tired, they get sore. They get tight because the tooth contacts create too much contraction information, and the Disclusion Time Reduction minimises the amount of contraction information that the teeth are passing on to the brain to control swallowing and moving food into the digestive tract with the least amount of muscle activity. So when you disclude someone in a rapid timeframe, the least amount of muscle activity is used to perform these actions, and that allows the muscles involved to operate without pooling lactic acid, without becoming hyper-contracted. And then the symptoms that are associated with that: tight throat, facial pain, headaches, clenching and grinding, difficulty chewing, tired chewing, soreness after chewing, those things go away. Because it’s neurologically resolved, not externally resolved with like splints and Botox and TENS and appliances. Those things don’t really work. They try to work, but they never stop the problem because the occlusion is still perpetuating all of this electrical activity that the brain is putting out into those muscles. So it’s a very powerful treatment. It controls how the central nervous system works, and that’s why it’s so effective. [Jaz] We were talking last night over dinner about centric relation, MIP now, but I would suggest that anyone interested in why the treatment we’re gonna be doing today is not an equilibration in the more traditional sense of seating the joints into centric relation and working from that position. The DTR is very much done, carried out, using MIP as a base. And you covered that really well in the previous episode, but one thing I said to you last night is that, if only such a tiny percentage of the population are, have their centric relation coincident with their MIP, for example, as we know, then surely, why is that our goal? So we’re chasing the 1%, where actually we see physiologically that actually 99% plus are in MIP, which is further ahead, forward to their centric relation, right? And so, but in the similar way, a lot of dentists may say to you, Robert, in terms of why maybe the number of T-scan users isn’t as great as other technology adoption, such as the intraoral scanner, for example. They’d be saying that, ah, I don’t need that level of precision because some dentists say that, accept what you say about MIP because of that. Yeah, you’re right, because such few people are in centric relation and they’re doing just fine. We can and should work at MIP, it makes sense for the patient. But then a similar group of dentists might say that, do we really need that microsecond data because yes, there’s a frictional rubbing of the posterior teeth. It is happening. But if you were to T-scan and analyse most people, most population, you would find that the majority, especially after a certain age, are in group function. You’d find that there would be these posterior contacts. So really what we need to fall back on is, okay, there is the kind of patients that come to us as TMD patients, they’ve kind of self-selected themselves as they’re beyond their adaptive capacity. And then that’s the ones that this treatment modality is for. It’s not for the asymptomatic cohort. Am I right in saying these ramblings? [Robert] Well, it’s a very interesting point because a lot of occlusal problems are not chronic TMD. They’re wear, recession, abfraction, mobility, cracking of teeth, chipping of incisal edges, isolated areas of wear or periodontal problems that arise around certain teeth because of occlusal factors, and those people are not complaining about anything really. They’re just slowly destroying their teeth. [Jaz] Which is the majority actually. The silent majority. [Robert] Well, exactly, because they’re not in pain, but they’re still losing tooth structure or root structure. [Jaz] They have signs but no symptoms. [Robert] Yes. And those signs are damage and the same and over. Well, it’s perceived as overload by like vertically. They’re making too much force, but it’s actually not vertical. It’s lateral movements that destroy their teeth. Friction, rubbing of teeth, milling of teeth for fractions of seconds. That then overload the teeth because muscle activity is raised. And so there’s a lot of advantage to treating the asymptomatic patient who has signs of occlusal wear or damage or roots, abfractions. And those things only progress. They don’t go away. They just get worse day to day. And people who don’t address it early on, 10 years later, have a lot worse of a problem and may need reconstructive dentistry. So there is an advantage to treating people that demonstrate occlusal problems in the same way. Because by treating the disclusion time in those patients, then they use their teeth with a lot less muscle-applied force, because the muscle activity is cut way down. That’s what Disclusion Time Reduction does, is it relaxes muscles, it stops hyper-contracting muscles, so the load to the teeth is then greatly minimised while someone uses their teeth, and then the processes of damage are arrested and, or let’s say tremendously minimised, as opposed to continuing to wear their teeth, sand their teeth away, chip their teeth, cause root damage. And those things are often patients don’t treat them or bring them up because they’re not in pain, they just are destroying their teeth. So enzyme reduction. [Jaz] So that’s a proactive, preventive treatment. But I imagine most of the DTR that’s carried around the world is delivered to the symptomatic cohort. Because to the nature of them being self-selecting and actually coming and having the sort of mindset that, okay, I need treatment and I’m willing to invest in this treatment for the result. Whereas trying to have that conversation, like trying to sell aesthetics to someone like, hey, let’s do veneers and stuff, and that kind of stuff might be actually easier to give ’em what they want rather than what they need is just so a psychology. So that’s why whilst, yeah, DTR would help asymptomatic cohorts, because when we look at occlusion and the chewing system long term over time, that this sets ’em up in a better way. And that makes sense to me. But yeah, I think majority of DTR is probably delivered for the symptomatic individual because of the fact that they are the ones who selected themselves. [Robert] It’s treatment for the symptomatic patient, but the application is far-reaching. But most of the dental injuries sustained that are not traumatic, like getting hit in the face with an accident, the dental damage, I should say, you know, again, the same things: wear, recession– [Jaz] Microtrauma. [Robert] Is microtrauma and it comes from the overload that the lack of disclusion creates. And the disclusion, people often think they have disclusion. Dentists will say, yeah, this person has good anterior guidance, but it’s the first millimetre of movement on either side of the central fossa that matters. It’s not that they disclude at the end of their excursion. No one is chewing food with canine-to-canine tip-to-tip. Nope. So the person has to disclude within a very short distance from leaving MIP in all directions, and that’s what controls the muscle activity. And that control can only come from computer analysis. It isn’t possible for us to measure the kinds of pressures that go on in a very short distance. We can’t pick it up in any other way than using the T-scan sensor, which is a highly sophisticated electronic device that is used all over the world in many, many industries. Dentistry doesn’t understand that. Dentistry doesn’t seem to really want the T-scan to succeed. And many people talk it down, but it’s the most sophisticated engineering tool available to dentistry to manage occlusal problems. [Jaz] Well, talking of sophisticated tools, a lot of dentists, and then I love how you just came to the topic of this very short snippet today, is ’cause we’ll do some more content on Thursday and whatnot. And today, hopefully I’ll get to record some of the DTR that we’re doing through my loupes actually, which will be pretty cool. But sophisticated technology, a lot of dentists, they feel that the data they see from an occlusogram– So for the younger docs, occlusogram is when you take a scan, let’s say PrimeScan, iTero, 3Shape, whatever you use, and then you record the occlusion, and then you get this like heat map of occlusion, and some dentists may be fooled into thinking, why do I need the T-scan? Because this is telling me where the forces are highest. This is telling me already. And then what we need to talk about is why, whilst that has some very basic data, we have to be careful how we interpret that data. And the example I want to start off with before I hear your sort of way you expect the dentist that, okay, just be careful with this occlusogram data. But one of the cases that I teach in our foundational occlusion courses is a case where this lady, late fifties, early sixties, she had a history of having Invisalign, had a fixed retainer, and on the upper and behind the upper anteriors, and this fixed retainer snapped in half along the centrals. And every time she bites together there is very clear fremitus, i.e. when she bites together, the front teeth literally move out the way, mobility, then the back teeth are able to come together, which makes sense as to why the wire fracture is, okay. So when you take the scan of that static position, when the teeth come together, you would see that, oh, everything looks okay. Because what you’re seeing is the end product. Once the teeth are fully come together, once the front teeth have overloaded and moved out the way and the occlusogram would fool you into thinking that there is good distribution of load around the arch. But I think even the younger colleagues can understand that, in this example where we have fremitus, that actually that, how can that be true? Because the front teeth were early contact, they had to move out of the way. And that’s not gonna be good for the PDL, ligament, long term. And then the back teeth were able to come together. But that story, that timing is not captured in occlusogram. It’s not telling us that kind of stuff. And when I showed that case and how I treated it was we did some Invisalign, we gave the correct overjet to allow the jaw closure to happen. And then now, three years on, I checked the teeth now and they are solid, okay, because now, and then you look at the occlusogram, it doesn’t look much different. But the first occlusogram and the second, they might look the same, but it’s the timing data you miss out on. And the force data is actually coming from how close the teeth are together, which is not telling you about the actual force itself because, as you said yesterday over dinner, pressure is a force over surface area. And when it gives us the red, the blue, yellow, it’s not measuring the force. So it cannot tell us the pressure. So tell us about the nuances of being careful with the occlusogram and where it fails in the face of something more sophisticated, like the T-scan. [Robert] Well, the essence of a scanning technology is that all the teeth are scanned with the patient’s teeth apart, right? No one’s biting. And so there’s no forces captured. What happens is the software algorithmically puts the scans together spatially– [Jaz] Stitches them, yeah. [Robert] Right, spatially. But there’s no impact pressures. There’s no contacts. There’s no gathering of teeth banging together or rubbing around. So it completely is falsely representing. These colour coded occlusograms have no force information in them at all. And a recent study showed that clearly they don’t measure pressure. There’s a comparison of the T-scan, force mapping to PrimeScan. And there was way too much overestimation of what appears to be high force in the PrimeScan. But it’s not force at all. It’s distance and tooth proximity, contact intimacy, which is not pressure. And just because you have a good contact, low intimacy, meaning very small distance between opposing teeth, doesn’t mean that tooth generates extreme pressure. That’s a completely false representation that the scanning companies are proliferating and misleading dentists in a very unfortunate way because there’s no impact pressures captured when you scan someone because the teeth are all apart. So that’s a very big difference between– [Jaz] But what do you actually scan? The bite, the teeth have come together, and then held there, and then stitching that. But you’re right, because the actual arch itself is taking the arch in isolation, the lower arch in isolation, that’s scanned when the teeth are apart. And therefore you don’t have the stressors into the teeth. And when the teeth do come together and you scan the left and right bite, and obviously teeth will intrude a bit, hence why you have like minus figures in terms of, someone has intrusion and whatnot, but that’s not giving you force and timing data. So I think that a key lesson for dentists is don’t look at the occlusogram and start doing adjustments on teeth by occlusogram, thinking, oh, the first molars are looking red on the PrimeScan. That means they must be proud. I need to adjust. That would be a very false way to view it. Would you agree? [Robert] Yes, correct. Very, very true. Meaning it’s false. It’s the distance scale does not predict the pressure mapping. And that’s what scanning technology offers is distance between opposing teeth and you know how close or how far apart various surfaces are, and this is not gonna give you pressure mapping because no impact pressures are actually measured in any way at all. So it’s completely false when it comes to force, timing and pressure. [Jaz] So what are the benefits to actually measuring the pressure? So what decisions is a dentist able to make once they know about the timing and pressure data that they weren’t able to do before? Because before, without it, we’re relying on the occlusogram and relying on articulating paper. Now, we talked extensively about why the articulating paper is lying to us. But feel free to revise those concepts for someone who may need to listen to it another time. But what’s the, I guess what I’m trying to say, what’s the advantage of, fair enough, we have data, but it’s the application and the use and how you choose to use the data to help benefit your patient. What is the benefit of the pressure data? [Robert] Well, it allows you to make intelligent decisions about what to adjust and what not to adjust, instead of looking at ink marks that don’t measure pressure at all, or scanning technology which doesn’t measure pressure at all, so that you treat very minimally and definitively without misrepresenting where you should be treating. And of course, anyone who’s used articulating paper, which most of us do, and the T-scan, you still mark the teeth with paper, but you choose the contacts to treat based on the data, not based on the way the paper marks look. And very often the most pressure-responsive contacts are small, scratchy little marks that dentistry says are light force, which you’re completely wrong because again, the load is applied over area. So if you have a very small area, you have the potential for very high pressure. It’s very much like the high heel, the lady’s stiletto heel, right? She steps on that, on your foot with that, it’s gonna hurt you. But if she was wearing a flat sandal and would leave a big imprint, it wouldn’t hurt you as much. So the T-scan data allows you to choose wisely what to adjust. [Jaz] And so, I mean, I think to make it really tangible for dentists is like prosthetics, right? When we are working prosthetics to help our materials, that if you’ve done like multiple crowns, or even nowadays very on vogue is treating wear cases interceptively with composite, and you do a full-arch or majority-arch composite restorations and you check with arctic paper and you see ink everywhere and you think, okay, I have good distribution. But without the pressure data, you know, when you start using, you might see that, oh, 38% of the force is going down one molar. And then the other molars are hardly doing any work. So without that data, you don’t know to lighten it. And the other scenario we talked about last night was the patient that says, you know, I had this work done or whatever, and then these three teeth on the left side, they just feel really proud. And every dentist who has kind of attempted to lighten the occlusion on it, and then still the patient says it’s proud. And then you told me that, okay, when you checked, and this was in front of everyone, you checked it whilst the forces were low on those teeth, it was the timing. They were the first teeth to touch. And it was very subtle. They rise first and then everything comes. And when you adjusted those exact points, led by this data, so not just pressures, timing here obviously we’re talking about, then the patient was able to say, oh wow, now I feel comfortable. And that was a real amazing moment, which I’ve experienced myself. I’ve been using it for a few years, including on some dentists. So shout out to Nikhil Kanani who came to my practice and he wanted me to take it. He was interested in T-scan, so I had a look and I made some minor adjustments and he bit together. Not only did it sound better, which I liked, to listen to the bites as well, but then he actually felt like, whoa, wow, that feels so much more comfortable. [Robert] Yes. Yes, no question about that. [Jaz] There’s no occlusogram that will give you that. Well, as we sort of, we’re about to get to the practice now and start a day of training with you, my last request is any sort of nuances that you want dentists to consider when they’re planning their next case or checking the occlusion and considering about, thinking about technology, digital occlusion, and actually implementing kind of this T-scan technology. Like we discussed yesterday, the adoption of T-scan, whilst it has gone worldwide, to the level that dentists invest in loupes, the level that they invest in intraoral scanners, the level that they invest in so many more bits of equipment, yes, there is a cost to it, but when you look at some of the costs of the other things that we widely purchase, so I don’t accept that it’s the cost barrier because we’re also buying, you know, $80,000 CBCT machines. We’re buying $50,000 intraoral scanners. Why is it that this, 10, $12,000, whatever it is, a T-scan. So I’m not, I don’t think it’s just financial. What do you think’s going on in terms of why are dentists not understanding the benefits of seeing objective data? Like I told you something yesterday, which I say all the time to colleagues who ask me about T-scan, is I felt uncomfortable adjusting teeth without having data, just medico-legally. If I can see that the bite is way off, even in a prosthetic case, or any type of case, and I can do some adjustments to really measurably timing and pressure improve the occlusion, I feel so much safer. But I dunno why that doesn’t translate to worldwide. But obviously you might have a perception or an insight into this. [Robert] Well, the biggest resistance to the T-scan is political. It’s that the T-scan has disproved every occlusal theory. You don’t need to TENS anyone, you don’t need to neuromuscular treat them. You don’t need to put people in CR. CR is a very compromised position that constricts the airway and definitely is not a physiologic position. Putting people there is unnecessary for most dental treatments. And so just by disproving all of these basic principles that people really believe in, no one wants to face that. And the most important one is the carbon paper paradigm, right? T-scan has absolutely disproved the carbon paper paradigm. The big marks aren’t always big force. The little marks always aren’t light force. And making the marks look a certain way doesn’t give you a balanced bite. So there’s a lot of things that dentists have been holding onto politically because they’re teaching these things in continuums and– [Jaz] Can I talk about that? Because it’s something that in my teaching, so I’m involved in teaching occlusion, and so feel free to disagree with me, Rob, I take it, I’m happy to talk about these things, right, is what I teach is centric relation is a position of restorative convenience. It is a utility position. So whilst my patients whose occlusion is generally working for them, I don’t, I work within the MIP. But when we have the opportunity or need to open the vertical dimension, it may be a position of reproducibility and convenience, then I’ll look to use it. ‘Cause when we have lost all references and that’s how me and Mahmoud have been teaching it. What do you think about that? [Robert] Well, the value of finding a reproducible position helps greatly in doing restorative dentistry. I’m a prosthodontist, so I worked a fair amount in centric relation where indicated. But I also found that I could open the bite in MIP and treat the person directly. [Jaz] Didier Dietschi does that. My old principal, Dave Winkler, used to work with, he is now, maybe you know him. Do you know Dave? [Robert] I’ve heard the name. [Jaz] Yeah, so he used to practice here in Windsor. He’s now gone retired in Denmark. Wishing you well, Dave. Hope you’re well, buddy. And so lots of dentists I really respect, you know what, they work in MIP and even when the vertical, like obviously when you open the vertical dimension, MIP is gone. But like what you’re trying to say is like, you’re not really seeking the CR, you just open the bite arbitrarily. And then just trying to create the correct occlusal scheme led by the T-scan in that arbitrary position. And that works well, has worked well for many dentists. [Robert] It works extremely well, actually. And you can mount the casts and then raise the articulating pin and mount them in MIP and raise the articulating pin, and then work in that new vertical dimension, essentially the same way you would in centric relation. So it’s very possible to do. It’s not, let’s say, academically principled that you shouldn’t do it, right, but it’s a reality. [Jaz] A hundred percent. [Robert] And so there is a lack of need for concepts about jaw position being the key to success. You can put someone in CR, but if their micro occlusion isn’t well managed, they’re not gonna be comfortable. It’s not about the position. No jaw position manages the micro occlusion. It’s the micro occlusion that brings about patient health, accurate, not accurate, but physiologic muscle physiology, as opposed to excessive muscle physiology and occlusal comfort for the patient. It’s all about the micro occlusion. That’s why you take a beautiful outcome like Invisalign. The teeth line up beautifully and the patient comes in and says they’re not comfortable. It’s because the micro occlusion isn’t good. The macro occlusion doesn’t make the micro occlusion, and that’s where the T-scan is the huge advantage for finalising cases. That’s the most important thing I would say that the average dentist struggles with is extra visits after delivery. The biggest problem is a patient coming back complaining, saying their bite isn’t right, and then randomly grinding. The T-scan virtually eliminates that. It doesn’t eliminate it in total. Nothing eliminates it in total. But you send the patient out the door with a high quality micro occlusion, there’s a lot less for them to complain about. [Jaz] And also less stress on the materials, ’cause if we’re working with prosthetic materials. Going back to prosthetics now, I’ve had these scenarios whereby, over time in the last few years of using T-scan, patients like, well, some of them, many of them actually, are very accurate. Before the T-scan data comes through, they can tell me that something over here. Now when I check with the arctic paper, everything looks okay. But when I show the T-scan, I can see the early rise or the high point. And they often, for these patients who are very “princess and the pea,” which is amazing. So it’s very validating to them. And the trust aspect is there, but also the flip scenario. Well, the patient says, yes, it feels proud, but I’m going, I’m checking the T-scan and reproducibly, I’m seeing that there’s no timing issue. There’s no pressure issue. Then I feel okay to say, ah, let it settle, kind of thing. You’ll get used to it, or whatever it could be. And then rather than praying and wishing that, oh, hope it’s not proud, and let’s see. So it gives me that again, objectivity, which is why, the reason why I went into– [Robert] Extremely objective and highly repetitive. A user has to learn how to use it. It doesn’t work by itself. You can’t buy it and make it work. You have to take training like you’re about to go through. And didactic training is helpful, but it doesn’t make someone a chairside effective T-scan user. You have to be– [Jaz] It’s a bit like, when you go into implants and you buy implants to use in your patients, there’s a lot of training that comes with implants to be able to do it, right? Same with when you pick an aligner system and you go with them and you go on the two-day course to learn to use the technology. So, fair enough, when I got the T-scan installed, it was like being given an aligner system. But until you learn ortho and diagnosis and actually treatment planning in ortho, and then troubleshooting and retention or everything that goes with the education of orthodontics. So that’s a good analogy to think that, okay, the T-scan is like the aligner system. It’s like the implant, but you need to have the protocols in place to be able to actually get the best results from it. [Robert] And you need to have clinical experience under guidance. It’s not something you can pick up on your own. And this is why people struggle with it. They purchase it. They don’t seek out the training that you’re about to have. That’s what makes someone a chairside effective user. It’s not possible to become chairside effective because you read a book or you read a paper that I wrote about, for example, the disclusion time. Even though it’s well described what to do, it doesn’t make you a clinician. It’s like reading about a crown prep. You can read about a crown prep, but until you’ve cut 50 crown preps, you don’t have the skills to cut predictable crown preps, right? So T-scan is a chairside learning technology that once you understand what to do with it, how to record, how to read the information, how to understand the force versus time graph, which is a critical software feature, and how to apply the information to make intelligent decisions about what to treat, then you can become effective with it. But you have to learn those three things. Recording well, understanding how to read the data, what matters in the movies, what doesn’t matter, what parts of the movies matter, what parts don’t matter, and then how to apply the information by mapping the pressures using carbon paper. But you don’t look at the carbon paper and say, yeah, it’s that one because it’s big, or that one’s too small, we’re not gonna treat that. It’s all data driven. That’s the difference. By doing that you control the micro occlusion and get much more predictable outcomes. [Jaz] Well, excited to walk into the practice now and let’s get into the micro occlusion of it. Well, thank you so much. Alright guys, I hope you’ve got some insight there into the nuances of occlusogram and why that is to be taken with a massive bag of salt, and also a little bit more about the details of micro occlusion, what T-scan does. Uh, and yet wish me luck on my training today. Be kind to me, Robert. [Robert] Yes, of course. Jaz’s Outro: Well, there we have it guys. Thank you so much for listening all the way to the end. A few different themes touched here from joint positions to muscular harmony, and of course the main event, which was all about the occlusogram. And now I hope you’re convinced that it’s lying to us, which doesn’t mean it can’t be useful to us. We can still use that information. Just don’t think it’s giving you something that it isn’t. We are a PACE-approved education provider. You need to be either on the Podcast CE Plan or the Ultimate Plan of Protrusive Guidance. If you’re on the Ultimate Plan, you get access to all the masterclasses, including the recently added Splint Course, everything occlusal appliances, and the 21 Day Photography Challenge. Head over to protrusive.co.uk/ultimate if you’re interested in that. Even just to join the community for free, we need to verify that you’re a dentist first, by the way, and we will do that. It’s very important to us that it’s a safe community, we do not want any members of the public on our special forum, so we do have a verification procedure. But if you head over to Protrusive app and request access to Community Plan, we will get you in. So you can see all the good stuff that we have in the chat and the main feed and all these podcasts are on there. And some bonus ones that are not on YouTube or Spotify. Watch this space for that DTR episode that I promised you. And as ever, I want to thank Team Protrusive who do a wonderful job behind the scenes to get these episodes published and allow me to still practice dentistry, support the community, and serve my family, and essentially be a dad. So thanks again, and thank you, the listener, watcher, once again for watching all the way to the end. I’ll catch you same time, same place next week. Bye for now.

Is social media killing professionalism in dentistry? Are young dentists really “clowns” online—or is lightheartedness perfectly fine? Is social media a disease? Where’s the line between humor, banter, and outright disrespect? In this episode, Jaz is joined by Joseph Lucido from the States to tackle these tough questions head-on. Sparked by a fiery Facebook rant, they dive into whether social media is harming our profession, how dentists should present themselves online, and if there’s still room for fun without crossing the line. Whether you love or hate dental content on social media, this conversation will make you rethink how we represent our profession to the world. Shout-out to two US doctors creating excellent, entertaining content on social media Dr Brady Smith Dr. Nicholas J Ciardiello Check out the 3-Step Modern Dental Marketing Plan from Clear to Launch Dental — designed to help you simplify your marketing and grow your practice without the overwhelm. https://youtu.be/W7Uh-ML9dZg Watch IC063 on YouTube Need to Read it? Check out the Full Episode Transcript below! Takeaways Social media etiquette is crucial for healthcare professionals. Avoid controversial topics to maintain professionalism. A social media presence is essential for modern dental practices. Patients often check social media to verify a practice’s credibility. Content should reflect the personality of the dentist and practice. Highlight satisfied patients to build social proof. Consistency in posting is key to maintaining engagement. Separate personal and professional social media accounts. Batch content creation to save time and effort. Engaging content can lead to more patient inquiries. Highlights of this episode: 00:00 Teaser 00:31 Intro 01:47 Introducing Joseph Lucido: Social Media Expert 03:21 Social Media Etiquette for Dentists 06:14 The Importance of Social Media Presence 12:04 Balancing Professionalism and Humor Online 17:39 Authenticity in Social Media 19:51 Balancing Personal and Professional Content 21:51 Effective Social Media Strategies 25:27 Time Management for Social Media 27:26 Do’s and Don’ts of Social Media 29:43 The Power of Social Proof 30:49 Conclusion and Resources 32:47 Outro Love this episode? Don’t miss Best Practices in Social Media for Dentists – How to Stay Out of Trouble Yet Be Impactful (IC035) #InterferenceCast #Communication #BreadandButterDentistry This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Ultimate Education Plan, including Premium clinical walkthroughs and Masterclasses. Click below for full episode transcript: Teaser: What is the correct etiquette in 2025 and beyond for social media for dentists? Teaser:The biggest shortcut a lot of social media questions get would be, we tell a lot of docs, this is social media, it’s social in nature, so your job is not to directly sell 24/7. The most extreme version of yourself is gonna get the most attention. So you might get, oh, look, I’m getting a lot of views. But going back to what I said earlier, it’s, well, what are people thinking when they see this? Jaz’s Introduction: I saw a rant on Facebook. Obviously it was on Facebook. Where else do rants belong, right? It was saying, what has happened to our profession? What has happened to our beloved dentistry? The kind of crap we’re seeing on social media. This dentist, who’s basically vexing about the way that he thinks young dentists are portraying themselves on social media, this anonymous poster of course, was saying we’re being clowns, we are disrespecting patients, we’re doing all sorts of unsavory things to get views and likes. So Protruserati, is this the death of professionalism in dentistry? Is social media a disease? Is there a proper way to conduct yourself on social media, or is a bit of humor and banter and a bit of lightheartedness acceptable? I’m a bit of an idiot on social media sometimes, but I know someone who does know. Today we’ve got our guest, Joseph Lucido from the States, and I asked him all these tough questions. He knows a thing or two about social media. So in this episode, you’ll find out what is the proper way to conduct yourself and whether Joseph thinks there is a space for idiots like me. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is an interference cast. This is a nonclinical arm of the podcast. Hope you enjoy the main interview and I’ll catch you in the outro. Main Episode:Joseph Lucido, welcome to the Protrusive Dental Podcast. For those who are listening right now, Joseph has sat in this wonderful, you’ve got this wonderful background, that common look of the books behind you, so it makes you look like you’ve got so much authority. And he totally looks badass. But I had to ask him, is this real or is it fake? And actually he reached out, man, this is a very beautiful library behind you. Joseph, welcome to the show, my friend. How are you doing? [Joseph] I’m doing great. Happy to be here. [Jaz] Tell us about yourself. You’re not a dentist, but tell me how you are connected to dentistry. What makes you an authority? Talk about social media for dentists today, which I’m really excited to get into. [Joseph] Sure. Probably starting around eight years old, I wanted to be a dentist. Just being in the dental office, I always loved getting my teeth cleaned. I had a few uncles that were dentists. It was just exciting for me. And then just through my education, formally marketing degree, and then half of the books behind you are on marketing or psychology. And then it comes down to just different reps over and over and over on different platforms with docs, seeing what works, seeing what doesn’t work. I guess that gives me, I don’t know about the authority, but it gives me a pretty sharp edge on what works and what doesn’t. [Jaz] Well, I think that does give you authority. The fact that they have skin in the game, the fact that you work with people on this, so you totally have the authority. Interesting title we’ve opted for, right? Social media clown or healthcare professional. I really like this. When I first read it, I thought, oh crap, he’s onto me. He’s seen my videos. Because sometimes I’m a bit of a clown, and sometimes I’m very professional. I’m really looking for what your thoughts are on this. So I guess the first place to start is, what is the correct etiquette in 2025 and beyond for social media for dentists? It’s a big topic and we can break it down and go anywhere you like. [Joseph] Yeah, there’s gonna be a bunch of nuance to it, but the biggest shortcut a lot of social media questions get would be, what is the potential patient, the person viewing this, the followers, what are they gonna think after seeing whatever I post? That should just be your starting point for everything social media related. Before you post, you want to be intentional in thinking. Now it becomes intuitive after a while to do it the right way, second nature. But from an etiquette standpoint, we wanna be thinking, I don’t wanna post anything that’s too controversial or too polarizing. Now I’m talking specifically through the lens of a healthcare professional. If you’re trying to get attention some other way, that’s fine. But if we’re talking about being a professional in healthcare, we don’t want to talk about politics or religion. Avoiding these topics can alienate 50% or more of your audience, and it also kind of speaks to your self-awareness. You probably shouldn’t be posting this from a business perspective. Arguing online, never a good look. Taking a combative stance, anyone who sees that, even if you’re defending yourself, even if you’re 100% in the right, that’s not what you wanna do from an etiquette standpoint. We tell a lot of docs, this is social media, it’s social in nature, so your job is not to directly sell 24/7. Everyone’s seen the doc that posts and all they’re doing is selling, and you’re not gonna follow them. [Jaz] So what you mean by that is, “Come in for our new patient Invisalign offer,” and just banging on about it every single day, and that’s it, it’s like repeat. [Joseph] Even the other post is too much. And what we’d even argue is, the way that we operate it is we have the docs say, you do nothing from an office level organically. You should be fun, entertaining, posting like that, and then we’ll take care of the direct selling, because that’s what our team has experience in. You don’t have experience in, how do I sell something, specifically the language that needs to be used, the call to actions, where the buttons go. That is so outside of your purview. But what’s inside of you, you’re an expert on you and your office. That’s what you should be posting about. [Jaz] I think one thing that perhaps I should have asked, and I will now, is taking a step back. I think I went too deep too soon. I’m trying to understand what you are trying to say and what we can learn. Like I said, building on that correct etiquette and top mistakes we make. Now we are at a stage where virtually every dental practice has a website, I would imagine. But not all dentists have a social media presence. But those that do, a significant majority of those would probably post on 4th of July and then post on Halloween and then completely abandon it. So let’s tackle that for a second. Do we need a social media presence in this day and age to be a thriving clinic? Because in the past it was, word of mouth is the best and patients refer other patients of the similar kind of caliber and likeness, which works well for clinics. What do you think about that question of the need of social media for every practice? [Joseph] So I think practices still, word of mouth, referrals, those are the best practices. Practices where it’s in the front door, out the back door, they’re always gonna be chasing the new patients. But when it comes to social media, the effort that is required for the return on that investment, if it’s posting once a month, having someone in your office just post strategically once a month. Because what people are really doing nowadays is they’re just checking to see if you have a pulse. Yes, we can get information from your website, but if you have an Instagram account or a Facebook account, you can do the bare minimum. What people are doing is verifying, and it also gives the opportunity to see what it looks like inside of the practice, who works there, what other patients are saying. That’s so important because in a day when people are buying, they’re gonna be looking at multiple different dentists. Even if from a word of mouth standpoint they recommend you and someone searches the internet, social media has an effect where you show up on the internet. Some of your social media accounts will show up. By checking that box at a reasonably high level, with minimal effort, it verifies that, hey, I’m a professional. It gives you an opportunity to make a great first impression outside of your website. [Jaz] I’m aware that, myself included, I had to pick a surgeon for my shoulder. Patients will Google their practitioner, or they’re thinking in their town, they want to get teeth straightening or just find a family dentist. As well as asking friends and colleagues and their new workplace, they will Google, “Who’s best? Name me,” or they might get a hunch about this clinician, “I’ve heard good things about them, let me now Google their name.” Do you think the behavior has now changed so that the “younger folk” are, instead of going to Google, actually searching on Instagram or searching on TikTok? What are your insights showing based on how important presence is, relative to the website presence and what shows on Google? [Joseph] Yeah, we don’t have to guess. The numbers are showing the search volume going up. I think it’s a very well-known fact that YouTube is the second biggest search engine in the world. But then after that, you’re gonna be seeing Instagram, Facebook. People are checking those boxes and looking. Just by having consistency across all of those, you are gonna have the opportunity to put your best foot forward again. So we don’t even have to guess. That is 100% happening. We’ll say younger folk, but younger, I’m starting to date, I’m getting a little old myself. So younger folk being 50 and under is completely applicable in this situation. [Jaz] When it comes to social media, one advice that I took onboard is trying not to be great on all the platforms. Pick one platform at a time and try and make a presence and work on your goal there before you then go elsewhere. Because then what you have is this dead X profile that you never post on, but it just exists and it doesn’t reflect well on you or your clinic. You might as well not have it. Is that what you think as well? [Joseph] I like to have everyone run it through someone else’s perspective. If I see an account, X, Facebook, Instagram, and they haven’t posted in eight months, what are your thoughts? “Oh, they can’t keep up with this. Is this place no longer open?” It puts a seed of doubt that could be completely removed if you didn’t even have it or if you kept up with it. That’s exactly right. I encourage docs, let’s do the main ones. Let’s do Facebook and Instagram. Once we’ve proven that we’ve got a great system in place, and by system I mean someone at the office level putting out great content consistently on those, then you can explore into others. But those are gonna be the main ones that you want to hit. [Jaz] Compared to website, if website has extremely high importance, it’s where you have your testimonials, your contact details, the first place that potential patients see. Is Instagram or a named social media platform the first place that you want to perhaps name drop? How important is it relative to the website presence? [Joseph] People are gonna go different places for different things. Instagram, they’re gonna be looking extremely visual at what they want. On a website, you have the opportunity to highlight exactly what someone is looking for. So if we think of someone who’s doing this great, Dr. Brian Harris out of, I think it’s Phoenix, he is highlighting exactly what the patient experience looks like. Then you also have high profile celebrities who have just gotten their teeth done. He does an unbelievable job of painting a picture for you, and you say, oh, I can go to that office, I know what it’s like, there’s the front desk person. That is more what the website is for, information and guiding people through, “Here’s what it’s gonna be like to be a patient here.” Instagram, TikTok, Facebook, you have an option to entertain and show more of your personality there. Just humanizing yourself is a good way to think about it. They all serve different purposes, but at the end of the day, we wanna paint you as a doc in the best light possible. [Jaz] What if you like to be, I mean, yes, I agree. Religion and politics, that kind of stuff, are perhaps more appropriate on your personal profile, not on your business profile. But I see some hilarious, there’s two really funny US docs. I’ll find their name and I’ll put them in the description. They make really funny content that’s perhaps borderline not appropriate, what dentists talk about, but they do it in a very nice way. They do it not in a disgusting way. It’s good humor and I love it. I love what they do. I don’t know if patients resonate with that, but in terms of, as a dentist looking at it, it’s real talk. It’s hilarious. Is there a place for being funny and being a clown on social media because that could be a true representation of yourself and your values and who you want to attract? Or do you feel that, again, that’s something that belongs on your personal profile? I’m sure you can think of some very successful social media accounts of dentists, doctors who are putting out very funny scenarios. There’s one where the guy’s blind. He’s a dentist, he’s blind, he’s walking in the clinic, and the patient’s like, “Wait, what the hell’s going on?” And it’s like, “Well, you are the one who said you don’t want any X-rays, right?” So you’re doing the whole thing blind, and as a dentist I resonated so much with that. But that’s also being seen by the members of public. [Joseph] Right. I think the idea of entertainment is a loaded word, and there’s a lot of different ways to be entertaining. That’s a very clever way to be like, “Oh, you don’t want X-rays,” but they’re giving the analogy of what it would be like to operate without them. It’s gonna resonate with more docs than it will with patients, but at the same time it’s gonna hit a lot of patients. And I think you hit the nail. [Jaz] It might then get rid of some patients who say, “I don’t believe in X-rays, I’m not gonna go ahead,” and you know what? That’s a win for the dentist and that’s a win for the patient. [Joseph] Yeah, and I think that’s kind of your personality. If you are funny, if you are witty, then yes, being in line doing that. This is where that line, and there’s always gonna be edge cases of someone who does have a big personality and that being entertaining is what they’re gonna do. But entertaining being a loaded word, most people hear entertaining and they think shocking, in-your-face comedy. The reality of the situation is you can be educational, you can be interesting, novel, it can be heartwarming. You could do storytelling, visual. There’s a lot of ways to be entertaining. Planet Earth is a great example of this. It’s not funny at all. It’s very entertaining. It’s very educational. It’s very visual. Completely different than someone who gets a lot of attention. Think of Britney Spears. She got a ton of attention from melting down. Yes, she got a ton of views. That’s not what you’re looking for, so that’s not great. I tell people all the time, the most extreme version of yourself is gonna get the most attention. So you might get, oh look, I’m getting a lot of views. But going back to what I said earlier, what are people thinking when they see this? If you are a clown on social media and you’re dancing and that’s not your personality, or you’re making some jokes that are a little bit too far, then that’s gonna deter people. The problem is, you’re never gonna know that you didn’t get them. Because when you deter people, it’s not like they call and say, “I’m not doing business with you.” They just go somewhere else. So operating on that line of entertainment without being extreme is the fine line that you don’t want to cross. [Jaz] I think it boils down to what kind of frame you wanna put on yourself. I use that word intentionally because of something that one of my mentors, Dr. Michael Melkers, taught me. He was presenting in London. He said something really interesting. He said he doesn’t actually connect with patients in terms of knowing the name of their dog and family and that kind of stuff. The frame he puts on is highly professional. “I’m here to listen to you and diagnose and help in co-diagnosis and helping you.” Whereas I’m very much like, “Hey, how’s your daughter’s football game going?” So I pick my frame. I like to be the friendly neighborhood dentist kind of frame. When he mentioned that, I thought, that’s true. The kind of clientele he attracts and the kind of plans he might be doing will be fitting to that kind of professional frame. Some patients will resonate and enjoy that more. Whereas some patients will be very put off by this friendly dentist and they’re actually looking for someone who’s more of a surgeon than the friendly dentist. So I guess the answer, there’s no right or wrong answer. I think, Joseph, the worst thing you could do is not choose which frame you’re going for. [Joseph] Correct. And I would say there is a right or wrong because you hit the nail on the head. You speak jovially, you’re talking about sports teams and these different things. When people come in there, that’s what they’re gonna expect, and then you don’t have to change personalities in the office. I do like the very professional, very straightforward medical professional who is going to help me with anything that I have going on with my teeth, no nonsense, down to business. So when I’m looking at docs on the internet, I want their content to be about that. You are an expert and you’re no nonsense, and that’s gonna attract patients like me. At the end of the day, you wanna attract patients that you enjoy working with. There’s nothing worse than attracting a bunch of patients that are looking for a different experience, and there’s this subtle disconnect. When that disconnect happens, that’s when you see patients leaving because you don’t have a great relationship with the doc. It’s almost like a mini bait and switch. Docs are like, “Well, I don’t understand, they came in.” It’s like, well, you’re behaving differently online than you are in the practice, and it creates this disconnect that you’re not looking for. [Jaz] Reminds me of something. There was an Australian, I think it was an Australian dentist. His name was Paddi Lund. I think he maybe still operates, but he used to, in the early noughties, teach and do courses about that generation of marketing. I think he wrote this book about dentists, kind of like firing your patients in a way that you eventually kick out the patients that don’t share the same values as you, and eventually you become a liberated and happier professional. One thing he teaches is, if you are passionate about football or soccer, have the jersey of the team hung up there. You’re putting it out there that these are the kind of patients you want. Eventually with time and experience, your list of patients ends up reflecting you. I like to think of it like that. I think what you said there is you just have to decide what kind of person you’re going for and be authentic. It’s all about being authentic and not doing something for the sake of social media, and then patients coming in and saying, “Wait, hang on a minute, this was a different person on social media.” But if you are presenting the same way on social media, you know what you’re gonna get. As long as it aligns with your values, then that will lead to a happier practitioner and actually more fulfillment from their work. [Joseph] Yeah. When you say it like that, it sounds so easy. Just be yourself and you’re gonna attract the people that are coming in there. We call it humanizing yourself. A great way to think about it is, for example, if you’re a dentist and you like to golf, every now and then posting about golf, that’s 100% acceptable, because then other people see, “Oh, my dentist is a golfer. Hey, I’m a golfer, I like this.” You go into his office and maybe he’s got some places he’s been. That’s cool. Now, if you post every week about golfing, then the patient thinks all this guy does is golf. He probably knows more about golfing than dentistry. He doesn’t want to be here, he just wants to be golfing. You do have to think of it through that. But you do want your personality to come out through your social media. Like you mentioned, sports are one of the big ones. If you are a diehard, who’s your soccer team over there? [Jaz] Manchester United. We’ve had very bad, dead seasons unfortunately. I’m gonna have to cut that bit out of the podcast, it’s that bad of a season we had. Anyway, I’m just kidding. [Joseph] Oh no. Historically one of the worst ones we’ve ever seen. Big soccer fan. But if you put that out there, other people are going to resonate with that. Guess what? Eventually you have an office filled with Manchester United fans. Even if you get some Chelsea or Liverpool fans in there, there’s some banter going back and forth. There’s some conversational things. One big thing is we let docs know, on social media you should be shopping or supporting local when you can, letting people know that. Because let’s say you go to a restaurant that’s right down the street from your office and then you post about it. Well, guess what? Everyone that goes there, they tag you. They have a bunch of people that are gonna come there too. Then you’re in the community as well. So there’s a lot of opportunities to be authentic, which is, I think, an overused word in social media. But just be yourself and highlight the things where possible, and you’re gonna get people that really enjoy coming to your practice. [Jaz] You mentioned about not oversharing the whole personal side. I guess it goes without saying that if you want to do the personal stuff on Instagram, have your own personal account and have a separate account for work. Although some people I’ve seen just combine it. They post about their kids and then, “Oh, here’s a smile makeover I did the other day.” What is your stance and advice to dentists who are thinking about, should I have two accounts, or should I just have one and just, that’s the whole package, you get me, you get the whole package? [Joseph] My advice is two separate accounts. One needs to be business related, and you don’t wanna be posting your kids and make it a private account. If someone is a patient and they become, I’ve been in many doctors’ weddings, I’ve become friends with a lot of these docs. There are so many great people in the industry. They follow me on my personal account, and then we also have a business account. What I’m putting out personally shouldn’t be shared with everyone that comes to my practice. So yes, I would say having two different accounts is what I would recommend. [Jaz] Fine. That’s a very clear recommendation. I agree with you. Another thing that’s crossed my mind is with social media, the algorithms and the way it all works so that you have potential to make a good piece of content and it can be seen. One of my reels has over a million views. It’s great, like, wow, this is cool. Now, when clinicians are trying to appeal and raise awareness to patients and attract a certain type of patient, for example, and they do a piece of content that blows up, but actually when you talk about how many inquiries did this lead to, one or zero, because it’s going to the world. If your practice is in Phoenix, Arizona, and someone in Jakarta in Indonesia is seeing this and they’re laughing and they like it and share it to their friends, it’s not really benefited you. So what is the strategy that you advise dentists to do? Because their main goal is not necessarily to entertain, and you can’t deposit likes into the bank. You’ve got to actually be able to be relevant for your local community and solve problems for your local community. How does that change the way that you play the game of social media? [Joseph] I’m gonna steal that, “You can’t deposit likes in your bank account,” because I’ve never heard that and that’s a good one. What I’ll say is there’s nothing wrong with that, but what is your expectation and how did you get it? Did you go viral because you put something so outrageous out there? But let’s say you put out something that was great, clever, whatever it was, and it went viral. There’s gonna be value to that because if a million people are seeing it all over the world, that means the number of people seeing it in your local area is also gonna be high. That’s just how we think about it. Content’s great content. When it comes to the algorithm, highly debated topic. The shortcut for thinking on how the algorithm works: what am I gonna do that is rewarded by the platform? Google’s first algorithm was basically how many websites you were linked to. Now they have hundreds of things that go into that. What is social media rewarding at this time? It’s always gonna be changing, but if you can look around at other people’s content that’s doing well, that’s a clear indication that’s what that particular platform is rewarding at this time. [Jaz] Fine. That helps. As long as there’s good content, it’s good content, and it can only help you. But when you are talking to your clients and dentists about making a difference and actually making, what kind of content do you tell dentists to make? They’re looking to you for advice. Should we just make, “How to brush your teeth better”? “We are doing a fall promotion,” or, “Do you like the fall promotion?” What kind of content is good? We’ll segue from that into the dos and don’ts as a final segment of this podcast. But someone’s listened to this and thought, you know what, Jaz and Joseph are right. I need to have an Instagram presence. Let me reactivate. Let me make one for my clinic. Let me make one for me as an associate or a practice owner and talk about my work. I’m passionate about it, but then they’re like, I don’t know what to talk about. I need some ideas. Nowadays with ChatGPT and stuff, you just need to give the right prompts, you’ll get the ideas. That still needs an expert touch and experienced touch. So with that in mind, what kind of content should colleagues be making? [Joseph] There’s so much nuance to this question. I will try and be brief. Highlighting your strengths. Thinking about the content that you’re putting out. Whatever type of dentist you are, even if you’re a general dentist, why are you good? Highlighting your professionalism. Highlighting patients, because there’s always gonna be this ratio. You don’t want to always highlight patients, you don’t want to always highlight staff. You want to have this blend of it. You want to paint a picture of what it’s like, a day in the life. It’s almost like a mini reality TV show of what your social media looks like. “Oh, I can see these patients. I can see new equipment,” whatever it is. We just want to make sure that it’s your personality being super important and the personality of your office. So you’re saying, “What do I need to post?” I think it’s more, what is the blend that I need to post? Letting people know, these are the type of patients that are here. This is the type of staff that’s here. This is what I’m like personally. This is what I’m like professionally. Then you have just the general throughout the year, like, oh, it is Halloween, it is Christmas, and you can mix those things in. You’ll never be short on content. We have a completely free social media calendar that we put out every single month because it’s just, here’s what you could post every single day of the week, and it’s content ideas. The amount of content that you could post is really unlimited. [Jaz] So we’ve covered there what we could post and there’s so much out there. But the number one thing I hear from colleagues, especially those who are maybe a little bit older, is, how do you find the time? That’s probably the biggest objection: time. So what’s your advice to colleagues who think, where do you find the time? [Joseph] Where do you find the time? This is something that depends on the person. If the person’s on social media and they’re posting on their personal, we can carve out that time pretty easily. But for docs who are not consistently on it or posting, one of the easiest things in the world, because every doc is busy, we know that. They need to be running a business, production, that is the most important. This is something that we typically offload to front desk staff. You can work with them. You do not have to pay them much to do this because it’s so native to someone who is younger. You can also have content days where once a month or once a quarter, you’re gonna get these 20 different pieces of content. That way it’s not an everyday grind. We have some practices that twice a year, two times a year, have a photographer and videographer come in, and you can even do this with just an iPhone. They’ll have a list of, “We are gonna get these 20 photos,” and that is gonna be our posts for the next six months. When it’s, “Can I do content two times a year?” Then the lift seems a lot less heavy versus, “What am I gonna post every three days?” That can be exhausting. So it’s more, we know what to post, now if you’re talking about the tactical, how do we do it, just batch it. If it’s not your thing, outsource it to someone on your team and then batch it a couple of times a year, and you’re still gonna get the outcome. [Jaz] I think a lot of people fall into the trap of they know it’s a good idea, they know they should be doing it, but they don’t have that delegation conversation or some basic training, or imparting the values of what we want to do, and then letting someone on the team and trusting someone on the team to just go for it, then revise it, and have some sort of intention or being proactive about it. So it’s good that we’re talking about this. Let’s then talk about dos and don’ts. Let’s say Joseph’s dos and don’ts when it comes to having a presence as a dentist on social media. [Joseph] I’m such a stickler on, when I see content, it’s impossible for me not to view it from every different angle. So we wanna start with the very basic ones first. Make sure your environment’s clean. Don’t ever show a dirty break room. I can’t tell you how many times I’m like, oh, it’s someone’s birthday, and there’s food wrappers in the background. When I see that, I don’t need to be seeing the back of the house like that, and a patient doesn’t either, because you don’t know how they’re gonna judge you. So just making sure everything’s clean. That’s a big do and don’t, making sure everything is in order and it looks great. [Jaz] It’s like a risk assessment. When you’re in a practice, you have to risk assess every little thing. Before you hit record, it’s kind of like a risk assessment you have to do. What could someone think about this? What could someone think about that? Setting the scene before you press that record button. [Joseph] That’s exactly right. If someone’s new, their only impression of your business, they’re gonna analyze that too. They might not externalize it like we do. It’s like, well, if they can’t even take care of a clean break room, do they have clean ops? Are they good hygiene? Do I really wanna go here? All of that goes through their mind in two seconds and they don’t even realize it. They just know, maybe this isn’t the dentist for me. So step one, make sure everything is clean, organized, highly professional, especially for any photos that you’re gonna be posting. Then dos and don’ts, it’s a lot of the things that we covered. Not selling, not acting crazy, versus running it through the filter of, how are people going to view me in this situation? Once they see this post, are they more or less likely to go on the internet and make an appointment or call me? That’s a very easy heuristic to run through. [Jaz] What’s the number one thing a clinic could do to help see results from their social media? If their aim is, we’d like to see more new patients every month to keep a healthy flow of patients and be able to do the kind of work that we’ve trained to do, and we wanna make sure all our associates are full of patients, what’s the number one Pareto principle? The 20% things that you do that make 80% of the difference. What are the Pareto principles of social media to actually get bums on seats? [Joseph] I think it is very easy. You want to be posting content about satisfied patients. One of the easiest things for us to think about: if we’re working with, say, a peds practice and we know the household decision maker the majority of the time is going to be a female from ages 25 to 50, and they’ve got two or three kids, the more content we can post about them being satisfied. There’s a saying in business: how many satisfied reviews would you need to see to be convinced that I do a good job? Even in our business, when we engage with clients, it’s like, here’s a list, a wall of a hundred testimonials, and if you don’t believe any, reach out to any of them if you want. No one’s ever really reaching out to a lot of these people, but if you think about it at a practice level, if all they see on their social media is happy patients like them, that’s the number one thing. The shortcut is, they clearly know what they’re doing with people just like me and they’re happy. I would also be happy. So that’s the number, that’s the Pareto principle of what do I need to be posting to get bums in seats, as you so eloquently put it. [Jaz] I think it makes so much sense. Social proof, it’s always about that. [Joseph] Yeah. [Jaz] I love this little overview of social media. Joseph, how can we learn more from you? How can we follow you? How can we see what you get up to, my friend? [Joseph] I’m just here putting the good word out. I did mention the social media calendar, which is apt for this episode. It’s something that we put out every single month for free, and it just goes to offices and gives them ideas, inspiration, makes it easier for them. It’s not cookie cutter, it is a framework, and then you put your customization into it. The other biggest thing is, I think it’s been viewed a couple thousand times in the last month, we have a free, everything-you-need-to-know-about marketing plan. It’s the biggest CE that we get paid to teach. It’s everything that you’d ever wanna know about marketing, including social media, how to pick a provider, marketing theory, and how we got to where we’re at today in 2025 in the marketing landscape. So yeah, that’s it. [Jaz] Amazing. If you send me that, I’ll put the link in the show notes. [Joseph] Sounds great. [Jaz] Amazing. Well, thanks for the time and helping us to understand the value of social media, but also the etiquette and, I guess, whether someone decides they still wanna be a clown or not, as long as they feel it’s right, it’s in line with their values, speaking correctly, but also not in a way that’s gonna make people think, what on earth is happening in this clinic, and not causing adverse effects without proper risk assessment, which we delved quite deep into. As long as everything is authentic and purposeful and someone’s put some thought in. It’s like when you’re going out, it’s nice for someone to say that whatever they’re wearing, they’ve put a little bit of thought behind it. I’m the worst person at clothing myself and stuff, but my wife says, look, at least a minimum, someone should say, okay, at least he thought about it a little bit. It’s the way you dress. Your social media should be the same. So Joseph, thanks so much for driving that home, my friend. [Joseph] Oh, thank you. Jaz’s Outro: Amazing. Well, there we have it, guys. Thank you so much for listening all the way to the end. About 99% of our episodes are eligible for CPD. This one isn’t. But I hope you gained value. I hope you get an idea of how to conduct yourself in social media or it inspired you to behave in a certain way or implement some strategies that we discussed today. Please do not forget to hit that subscribe button. It really means a lot. I just want to take a moment to also thank Team Protrusive for all their hard work. I’ll put all the show links so you can reach out to Joseph below and for all of the nicest and geekiest dentists in the world in Protrusive Guidance. Thanks for making a lovely community. And if you’re not already in this community, check out Protrusive app to join us. Protruserati, I’ll catch you same time, same place next week. Bye for now.

Cracked teeth — the diagnosis we all hate as Dentists! How do you decide when to monitor and when to intervene? What is the recommended intervention at different scenarios of cracks? Should we be chasing cracks and reinforcing with fibers; is there actually enough long-term data to support that approach? Over the years, we’ve had some epic episodes on this topic — from Kreena Patel’s “I Hate Cracked Teeth” (PDP028) to Dr. Lane Ochi’s Masterclass on Diagnosis and Management (PDP175). But in this brand-new episode, Jaz is joined by Dr. Masoud Hassanzadeh to bring it all together — not just the diagnosis of cracks, but their management. They explore when to intervene, the role of fibers in preventing propagation, and even the fascinating possibility that cracks in teeth may have some ability to heal, just like bone! This one’s a deep dive that will change how you talk to patients — and how you approach cracked teeth in your own practice. https://youtu.be/VHYRBnfJS3I Watch PDP246 on YouTube  Protrusive Dental Pearl Your patient’s history predicts the future! Ask if past extractions were difficult → clues you into anatomical challenges. Ask how they lost other teeth → if cracks, be proactive with today’s cracks. History isn’t just background—it’s a clinical tool. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Cracks in teeth can be diagnosed using magnification and high-quality imaging. Patient factors such as age and muscle strength play a significant role in crack prognosis. Symptomatic cracks should be treated to prevent further propagation. Understanding the anatomy of the tooth is crucial for effective treatment. The healing mechanism of cracks in teeth is possible but varies between enamel and dentin. Fibers can be used to strengthen restorations and manage cracks effectively. Long-term studies are needed to assess the effectiveness of current crack management protocols. The use of fluorescence filters can help identify bacteria in cracks. Chasing cracks should be done cautiously to avoid pulp exposure. A comprehensive understanding of crack mechanics can improve treatment outcomes. Highlights of this episode: 00:00 Teaser 00:47 Intro 03:08 Protrusive Dental Pearl – The Importance of Dental History 07:18 Interview with Masoud Hassanzadeh 08:22 Diagnosing and Managing Cracks 21:13 When to Intervene on Cracks 25:50 Restoration Techniques and Materials 28:30 Chasing Cracks: Guidelines and Techniques 36:50 Mechanisms of Crack Healing in Teeth 45:11 Exploring the Use of Fibers in Dentistry 52:43 Introducing the Book on Cracked Teeth 54:57 Percussion-Based Diagnostics (QPD) 56:44 Key Takeaways 57:21 Conclusion and Final Thoughts 01:00:07 Outro As promised, here are the studies mentioned during the discussion: Why cracks do not propagate as quickly in root dentin: Study 1a & 1b Root dentin has significantly higher fracture toughness compared to coronal dentin—nearly twice as tough, as demonstrated in multiple studies. The key difference lies in their structure and toughness. Root dentin’s unique collagen orientation adds strength, while its fewer lumens and thinner peritubular cuffs make it less brittle. In contrast, coronal dentin has thicker cuffs, which increase brittleness. Unlike coronal dentin, which fractures uniformly, radicular dentin is anisotropic—its fracture behavior varies depending on direction. These structural features give root dentin greater resistance to cracking, making it more durable under stress. Studies on decreasing crack length due to crack repair in enamel. Study 2 The importance of the modulus of elasticity of the final restoration in arresting crack propagation. Study 3 The role of fiber in restoring cracked teeth and how it can increase fracture strength—even surpassing that of natural teeth. Study 4 Decision Making for Retention of Endodontically Treated Posterior Cracked Teeth – A 5-year Follow-up Study The Cracked Tooth: Histopathologic and Histobacteriologic Aspects Historical Studies on Enamel Crack Healing– 1949 (Sognnaes): The Organic Elements of the Enamel: III. The Pattern of the Organic Framework in the Region of the Neonatal and other Incremental Lines of the Enamel – 1994 (Hayashi): High Resolution Electron Microscopy of a Small Crack at the Superficial Layer of Enamel – 2009 (S. Myoung): Morphology and fracture of enamel Don’t miss out — get instant access to all the research papers discussed here at protrusive.co.uk/cracks! Dr. Masoud Hassanzadeh has written two essential books every dentist should own: 📘 Glossary of Biomimetic Restorative Dentistry🔑 Your quick-reference guide to the language and principles of biomimetics — explained in a way you can actually use chairside. 📕 The Cracked Tooth: A Comprehensive Guide to Cracked Teeth🦷 Everything you need to know about diagnosis, management, and the science behind one of dentistry’s biggest headaches. 🌴✨ Dubai 2026: Occlusion + Family Fun ✨🌴 This Easter, join Dr. Jaz Gulati and Dr. Mahmoud Ibrahim for something truly special — a tax-efficient holiday that mixes world-class occlusion training with plenty of family time in Dubai. 🦷 What’s included? ⏰ 20 hours of hands-on occlusion (mornings only: 9 am–1 pm) 🏖️ Afternoons & evenings free to enjoy Dubai with your family 📚 Pre-learning + online content to deepen your understanding 🥂 A not-for-profit event — just dentists, families, and fun! 👉 Learn more & get your quote at: globaldentalevents.co.uk 💡 Make memories with your loved ones while making your CPD hours tax-deductible Want to level up your knowledge on cracked teeth? 🎧 Don’t miss PDP098: Cracked Teeth Management with the Direct Composite Splint Technique #PDPMainEpisodes #EndoRestorative #BreadandButterDentistry This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A and C. AGD Subject Code: 070 ENDODONTICS Aim: To provide clinicians with practical, evidence-based guidance for diagnosing, monitoring, and restoring cracked teeth, with emphasis on prognosis, risk factors, and restorative decision-making. Dentists will be able to – Differentiate between enamel and dentine cracks, and recognize when prognosis is hopeless. Apply appropriate diagnostic tools and clinical criteria to decide when to monitor versus intervene. Select suitable restorative strategies and materials to manage cracked teeth effectively. Click below for full episode transcript: Teaser: After 48 hours, they started to see that the crack is just decreasing, like it's just healing. Is it really possible? But it is possible. Like how there is a crack healing mechanism in the bone, there is also crack healing mechanism in the tooth. When I started to learn about cracks, actually the studies were not from dentists. Teaser: They were fracture mechanic engineering that they just studied about the crack, and nowadays there is a new system, it is called quantitative percussion diagnostic, QPD. There is a stress concentration in that point where the crack is started, so we have to distribute the stress in that place, in that plane. That is the important one. If we are just going to remove the crack and put the restoration on it, I’m afraid it’s just going to happen again. Jaz’s Introduction: Over the years, we’ve had some awesome episodes on cracked teeth. If you go all the way back to PDP028 with Krina Patel, the episode was titled, I Hate Cracked Teeth, and you know what? I still hate cracked teeth. They’re a damn nuisance. They’re everywhere, and it creates major consent and if the tooth goes non-vital, that kind of conversation, which no one likes. Now, years later, we did this epic episode with Dr. Lane Ochi, PDP175. You need to check these two episodes out if you want to geek out on cracks. But you know what? This episode really does a wonderful summary of cracks. Not just the diagnosis, but the actual management. Should we be chasing cracks? Are fibers actually indicated? Is there enough long-term clinical data to support the use of fibers in crack propagation? And the question of, okay, when should you actually intervene? And you know what? The most important one I haven’t even mentioned yet. So, Dr. Masoud, the way I got acquainted with him is on social media. I posted this image of a crack, a really nasty crack, and he said something absolutely ridiculous. He said that cracks have an ability to heal a bit like cracks heal in bone. Now, you said that because in this image I posted on social media, it was all about how I communicate cracks to my patients. I say to them, look, when you have a crack in a bone, the bone can heal, it can regenerate, but a crack in a tooth can never heal. Patients seem to resonate and they understand that. But he was suggesting that actually cracks can heal naturally a bit like bone. And so if you listen to the end of the podcast, you will see how that is actually possible. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. I’ve had a month in August which was pretty crazy. I didn’t do much recording of new podcasts. We were working on some of the older recordings I had done. We’ve got a huge backlog as a team, which is a wonderful position to be. We are having so much fun creating these episodes. Thank you to everyone who returns to our podcast, and of course all the new people that find us. If you’re not already, you need to join 5,000 of the nicest and geekiest dentists in the world on the Protrusive Guidance app. Go on protrusive.app, make an account. Your only requirement is you must be nice and you must be geeky. If you are those two things, you should come and join us to geek out, discuss, share challenges, share wins. It’s a nice wholesome environment we’ve created far, far, far away from the toxicity you get on Facebook. Dental PearlNow in true PDP fashion, I’m gonna give you a Protrusive Dental Pearl. This pearl helps me when I’m decision-making with my patients, and it’s all about probing further into the history of the patient. What I mean by that is when we have that patient, and we’re planning an extraction, let’s say the tooth has had it, it needs to come out, and we’re trying to gauge, will this be a difficult extraction or not? Did you know asking them if their previous extractions were difficult is actually a useful indicator? An oral surgeon once taught me this, and I think it’s true. People have certain features that make their teeth more difficult to remove, certain curves, certain densities of bone, and that’s a useful thing to have in your history. Now, similarly in cracked tooth management, it’s good to ask a patient how they lost their other teeth. So if you see a patient and they’ve lost some molars and premolars, you should ask, well, how did this happen? For what reason did you lose the teeth? If they mention cracks as the reason why they lost those teeth, those other cracks which are asymptomatic, because 90% of cracks are asymptomatic, now you have a reason to be a bit more proactive and less of the wait-and-watch and more of the, well, let’s prevent this from happening to any other teeth. Those are two clear examples of how the patient’s history, i.e. the complexity of the extraction and the reason for tooth loss being cracks, are useful in decision-making for the patient going forward. Now, I’m actually very excited to get to the main episode. Honestly, this is such a beautiful, geeky episode with real tangible clinical nuggets for you to take away. And before we start this episode, I just wanna give a quick plug to our trip in Dubai 2026. So Easter holidays 2026, we’ve got UK dentists and their families and some Aussie dentists who are gonna go to Dubai to learn occlusion with me and Mahmoud. Why are we doing this? It’s Easter holiday, it’s Easter vacation. I wanna take my kids and my wife. We want to have some family fun in Dubai, but we want it to be tax deductible. So how are we doing that? Picture this for those of us with families and kids. Bring everyone along. We’re gonna make it a very tax efficient holiday for you. We’ll be learning occlusion from 9:00 AM to 1:00 PM for the five days. So that’s 20 hours of hands-on occlusion, and the rest of the day is self-study. Go to the pool, have some cocktails while you think about occlusion. Go enjoy the nightlife of Dubai while thinking about occlusion, of course. You get to enjoy most of the day with your family or with your friends in Dubai, and it’s just the morning part where we’ll do the education. You also get access to a lot of online content and pre-learning, and we actually genuinely want you to come out having learned occlusion to a very high standard. But actually, I’ll be honest with you, this is about the education, but it’s also about having a good time in a tax deductible or tax efficient way. So if that’s piqued your interest, I want you to go to globaldentalevents.co.uk. That’s globaldentalevents.co.uk. Like I said, you don’t have to be from the UK to come to this. We’ve got some interest in Scandinavia. We’ve got some bookings from the UK dentists and their families. We’ve got some Aussie dentists coming along, and we don’t need massive numbers here.  We just need enough so we can put on a good show, but also we just need enough people to have some fun. This is actually a not-for-profit course. Me and Mahmoud are not doing this for profit. We just wanna have a jolly with our families and that’s straight from the heart. I put the links in the show notes. You are gonna love this episode. Catch you in the outro. Main Episode: Dr. Masoud Hassanzadeh, welcome to the Protrusive Dental Podcast. You are speaking from the Netherlands right now. It’s so good to connect with you. Let me tell you and everyone how we ended up on here. I posted something about cracks on social media, and you said something so mind-blowing, so fascinating. I thought, I need to speak to this guy. Do you remember what you said? You mentioned— [Masoud] I know. [Jaz] You said we can heal cracks like bone. And so we’re gonna have to go there eventually because I’m really fascinated. Obviously there’s a bit of tongue in cheek there and whatnot, but I’d like to hear what’s the best thing we can do for cracks. Many years ago, I did an episode with an endodontist, Krina, who’s wonderful. We talked about how much I hate cracks, because when you have a crack, there’s so many different ways it can go. The patient can become symptomatic.  We need to have a lengthy consent discussion with the patient that we don’t know how this tooth will react. We don’t know if it can be saved or not. There’s so much we can discuss, and I really wanna get into protocols and decision-making and the different philosophies of managing cracks. So before we start with all that good stuff, Masoud, tell us about yourself. What are you doing in the Netherlands? [Masoud] Now I’m a dentist. I’m in the Netherlands, and it’s about four or five years that I have my own dental practice. I like restoring the tooth, and the crack was the first thing that actually I didn’t know what to do. When I asked other colleagues, they said, yeah, I also see them, but you can maybe put the primer, bonding on it, just flowable. Then someone said, yeah, you can put fiber on it. But it’s just confusing and there are a lot of controversies. Someone says, yeah, you have to pull it out. Especially when the patient comes for small restoration, you say, okay, sorry, this is gone. I saw a crack. But it was really hard for me, and I just tried to do my best for the patients to save the tooth. This crack, it should have a philosophy. It should have a way of restoring it. [Jaz] Like protocols to go by based on the level of diagnosis. I think there’s only one thing that for sure we can agree with cracks, one thing, and then you tell me if things have changed. If someone has a true split tooth, i.e. the fracture’s going all the way through, obviously that’s for the bin, that’s for the forceps. So that’s one thing we’d agree with. And then also if you have like five, six millimeter probing depth associated with the crack, that’s hopeless prognosis, right? Unless we’re, let’s not beat around the bush, that is hopeless. I think most of us get that and understand that. But then there’s that gray area where the crack is one or two millimeters subgingival, or the other gray areas. At what point do we intervene? Like we have MO amalgam and on the other marginal ridge we have a crack. This could be with staining, without staining, certain widths, certain durations, they’ve been there for 20 years. Knowing when to intervene for a crack is something I’d love to talk about with you today as well. [Masoud] So the first thing is we have to know the depth of the crack and where it is exactly. Is it in enamel, is it in dentine? And the second point is the age of the patient, because after age 40, 45, crack can unfortunately propagate very easily. All of the fracture cases which you see, most of them are elderly patients. Not young patients, unless there is a trauma, that’s another scenario. These two things, especially the anatomy of the tooth and also thinking about crack repair, self-healing mechanisms, are really important for our decision-making for treatment. And also about the post that you shared, that was a huge crack. It starts from enamel, goes to the deep dentine. [Jaz] Can you remind me what my post was? I genuinely don’t remember. What was it? [Masoud] Really? It was an amazing image of a crack. [Jaz] Was it an extracted tooth in the crack? [Masoud] No, no, no. It wasn’t extracted tooth. [Jaz] Okay. [Masoud] It wasn’t extracted. It was just, I think intraorally you made the picture. [Jaz] Okay, okay. Like an MOD black crack running through like that. [Masoud] Yeah. And the initiation part was really open. You see just debris and a plug inside the crack. [Jaz] Let me see if I can pull this up because Protrusive Guidance audience, YouTube audience, it’s nice to have a visual. For those who are listening, of course we’re gonna describe it very clearly, and it’s a nice little starting point to discuss this one scenario. Yeah, that’s an awesome image. That’s the power of sandblasting, right? When you sandblast a crack, when you air abrade a crack, you can see it, and then I take a photo and I share with my patients. So this post was all about how I communicate cracks to a patient. For those who are listening on Spotify, Apple, if you’re chopping onions, exercising, it’s just a really nasty crack when you remove an MOD amalgam and then you air abrade it, and you literally see the white air abrasion powder track all the way. So this is a very nasty crack, absolutely. [Masoud] You can see that this part is actually open, and your sandblast particle is just, how do you call it, it’s just— [Jaz] It’s jammed, it’s trapped in there. [Masoud] It’s like it’s trapped there. It’s just trapped. [Jaz] By open you mean we can feel it with the probe. Basically, with the probe we can actually feel. [Masoud] Yeah, so these are actually huge cracks and it is really hard to make a decision at this point. What are you going to do? Are you going to remove all this healthy tissue here to overlay that? Are you going to chase the crack? Are you going to follow it? Why should you follow a crack? I think these are very important questions to answer. [Jaz] Sometimes you’re looking, the patient’s got this non-specific pain. You’re like, could it be a crack kind of thing? A point you mentioned before we hit record: we only start noticing cracks when we wear magnification and we look really closely. Otherwise, we’re oblivious. We really don’t see these very obvious cracks because we’re not wearing magnification. I also see everyone saying since COVID, we’re noticing so many more cracks. I think you are right, what you said earlier. Can you just say what you said earlier about how we are documenting better and stuff? [Masoud] There are studies that show just 8 to 9% of the cracks are symptomatic, like pain on biting or cold sensitivity. The other ones, like 80 to 90%, are just asymptomatic, so we just see them during restoration. Nowadays you see on Instagram, like the image that you shared, with high quality photography, with magnification, with microscope, with good images, most of the time the crack is the first thing that we notice. It doesn’t feel good. Everyone says something is wrong with this tooth, you have to do something, and you can’t just put your adhesive system on it and put the composite or make a beautiful overlay on it. If you also check other posts, when there is a crack, there are always comments: how about the crack, what do you think, what’s the prognosis, what do you expect from your restorations? These are the things that you start to think. When I started to learn about cracks, actually the studies were not from dentists. They were fracture mechanic engineering. They had the tooth and they just started to break it. [Jaz] Like flex it, load it. [Masoud] Flex it, see the strain and stress on the tooth and how it’s going to break. They gave us a lot of information about crack initiation and also crack propagation on a tooth. We also have some good studies from dentists. They try to treat it in different ways, especially the crack, and share their follow-up after five years and 10 years, which restorative restoration is just the best or restorative manner for many of the teeth. [Jaz] All these answers to be revealed in this podcast, I hope. So let’s start with the basics. One of my mentors, Lane Ochi, taught me that cracks in enamel are not so worry-ful. Cracks in dentine are the ones to worry about. So sometimes, let’s say you have a lower first molar. It’s got a DO amalgam, and on the mesial you see a crack. Now we see the crack obviously in enamel, and it could be stained or it could be not stained. But without removing the amalgam, how can you be sure whether it’s only in enamel or is going through the dentine? [Masoud] It’s hard. Maybe meta transillumination can give us information. Nowadays there is a new system. It is called quantitative percussion diagnostic, QPD, quantitative percussion diagnostic. They are giving very small percussions to the tooth, and they have AI information. If the percussion is 100, then it’s good, but if it’s 80 or 70, then there is a gap. There is an opening inside the tooth. [Jaz] It’s kind of like when you test, I don’t do this, but when you test an implant for integration. [Masoud] Yeah. [Jaz] It gives you some data. Oh, that’s so cool. [Masoud] Same system as it too. But it can be also because of a gap in a restoration. So if there is a gap, the information will change. [Jaz] False positive. [Masoud] Yeah. So the first thing is crack or the gap, but it’s still really hard. So always in old articles, the first recommendation is removing the existing restoration. [Jaz] I think that could be aggressive because there are some guidelines. For example, if you see a crack, and obviously like you said, 90% are asymptomatic, but if it’s not stained and you can just about see it with magnification but you can’t see it with the naked eye, then maybe that’s gonna be okay. But when it becomes stained, at that point we know that it’s big enough to allow stained particles and bacteria to go through. That is one thing I’ve seen cited in literature, that if it’s stained— But my patients in their sixties, they all have cracks. If we chased every single crack, literally we’d be seeing like two patients a day and that’s all. That’s how I say it to my patients: you have cracks, exactly two cracks. [Masoud] It’s just, the crack belongs to tooth, so we have to know which crack, when we have to interact or not. Another point is use a fluorescence filter. Fluorescence filter shows us where bacteria are. So if you have a crack you doubt, you can just use the fluorescence filter. [Jaz] This is black light, this is like a UV torch, right? [Masoud] It’s not UV. It’s a fluorescence mode. You can have it on your microscope. [Jaz] Fancy microscopes. [Masoud] Yeah. There are also cheap ways, like in your loupes, or you can just have an extra oral light and then check it. If there is bacteria, the byproducts of bacteria become red, and in this way you can see if the crack is red or not, or is there bacterial biofilm in the crack or not. I also shared some posts about how you can check it, and that really makes it easy to check the cracks, and then you can start to remove it. There is also a study from, I think, Ricucci, and he says when the crack is connected to oral environment, it is actually filled with bacteria and biofilm, especially if the crack is in dentine, because dentine is more flexible. It can open and close, so there is space for bacteria to invade. When it is in enamel, it’s more rigid, it’s harder. So the crack faces are mostly just touching each other. It’s called closed crack. In that way, there is almost no space for bacteria to invade inside the crack. That is also one of the reasons that we are not removing the cracks in enamel. [Jaz] But like you said, it’s difficult to tell. Let’s look at some metrics then, some clues. Some clues could be that the crack is stained, that we’re gonna use the fluorescent lighting to see if there is bacteria inside. But we also have to look at the patient. If they’ve got big strong muscles, if they’ve got a history of losing teeth before due to cracks, that is a very significant prognostic factor for me for should we treat this asymptomatic tooth or not. If they’ve lost teeth to cracks before, this is a really big deal. Of course, if the opposing tooth has already been extracted, then that crack is not gonna propagate, so you don’t need to worry about that. You have to remember that this tooth, this crack is in the patient’s mouth, and look at the patient as a whole. [Masoud] Yeah, that’s right. I had a patient, she broke the second upper molar and there was no restoration on it, and it was just fractured. After three or four years, I saw a vertical crack on second upper molar. I said, yeah, we have to do something, otherwise you’re just going to miss this one. Indeed, big muscles. [Jaz] Big masseters. [Masoud] High force patient. [Jaz] These patients I’ve seen. I remember seeing quite a few. I document these cases really well because it always fascinates me when I get that. A few times a year I see a first premolar usually, or a second molar with a virgin crack without any restorations, and they come in irreversible pulpitis. It’s like, what’s going on? You start drilling into the tooth and you see this crack opening and opening and opening, and it’s fascinating. They all have this thing in common whereby either their premolar is very cuspy, the angles are very acute in their premolar, and you can imagine that’s flexing. Steep cusps, that’s been a risk factor I’ve noticed. The other one is, of course, these clenchers, these high force patients with large muscles, because muscles matter. Force transmission will be different for each of these patients. [Masoud] Yeah, and also their distance to TMJ, because there is also a nutcracker effect. On the distal side of the second molars, upper and lower, we always see a vertical crack. Usually if the patient is like 50, 60 plus, just make an intraoral image and put it in the document of the patient. It’s always there. Also the upper premolar, because of its position, its anatomy, it’s just always going to break vertically from the furcation stress plane. [Jaz] Often see the palatal cusp completely come away, and then when you take that fragment out, you see four millimeters of root come out with it. I think all dentists have seen this. We get that a few times a year. It gives us another reason to remember that just because it’s asymptomatic doesn’t mean we should just leave it. We need to make a timely intervention. So let’s circle on this and make some clear guidelines for dentists. Masoud, when should we be intervening? What’s the best evidence that we have so far about intervention? Obviously we spoke about patient factors, the muscles, the history, the anatomy of teeth, but any other guidelines: you can intervene when this happens? [Masoud] The first point will be symptomatic pain on biting. It’s called rebound pain because the fragment is going to move and dentinal fluid is going to fill the gap. During unloading, the fragment will come very fast and it will cause pain. If the crack is symptomatic, it should be treated because it shows that the crack is propagating. The second one is also cold sensitivity. It can also be the same reason. The other ones are all dentinal cracks, especially if the patient is 40 plus, because dentinal cracks are structural cracks and enamel cracks are non-structural cracks. So if the patient is 90, there are a lot of cracks in enamel, we don’t need to treat them, only if the patient wants good aesthetics because the craze lines can get stained, become black, and maybe they don’t find it beautiful. But the dentinal cracks are structural cracks and they can propagate. The reason is in its anatomy and histology, because dentine has its own mechanism to stop a crack. It’s not like dentine has no mechanism and the crack can just go. This crack can be there for 10 years, 20 years sometimes, but dentine has its own mechanism to stop the crack. At some point it’s not working anymore.  The reason is when the dentine tubule becomes closed, it is called sclerotic dentine, and all the collagens work together to create crack bridging to stop crack from propagating. But the collagens, when we get older, they are gluing to each other. It is called cross-linking. In that way, the crack can propagate more easily. When there is a crack in a young patient, if he or she is not 40, I will not remove it. I will also check if there is bacteria or a plug inside it, but if not, I will just leave it there. [Jaz] Unless, and I love that you said that. However, I have this 19-year-old patient. She’s now 23, but when I first intervened on her, she was 19. She had that first rule that you said: she had symptoms. This is a high force patient, very rare to see a 19-year-old high force, huge masseters. Destroys her Essex retainers in a year. Now she’s wearing appliances, and it’s taken her three years to destroy that virgin crack in a molar, symptomatic. When I traced it, you can see the crack beautifully. Once I restored it with a class II composite, because actually it didn’t warrant anything more than that, the similar thing happened a year later, symptomatic on the left symmetrical molar, and now things have been stable for some years. As a rule of thumb, yes, young patients’ dentine can probably handle it, but there are times where it may become symptomatic, and in that case we need to go case by case, I think. [Masoud] Yeah, and I think in that way we also have to remove the reason. What was the reason? Was it bruxism? Was it because of the anatomy of the antagonist or the tooth? Because there is a stress concentration in that point where the crack is started. So we have to distribute the stress in that place, in that plane. That is the important one. If we are just going to remove the crack and put the restoration on it, I’m afraid it’s just going to happen again. [Jaz] I love that you said this, and I’m nodding. What we had to do in this patient is, she had these crazy wear facets, so I had to do some adjustment. I had to do some selective grinding. This is force modulation. We might be removing microns of enamel to save millimeters of dentine and keep the teeth going as much as possible. Instead of having the occlusion on a very steep incline, I had to flatten it a bit to make sure the stress distribution is better. I had this plunger cusp type on the opposing, I had to reshape it so it’s a bit more gentle. I had to remove a very steep incline and flatten it. I’m so glad you said that because if you just replace it, it will also have a marginal ridge fracture, which this one did, a tiny little marginal ridge fracture, which wasn’t a big deal, but it just goes to show that you have to do some sort of force modulation. [Masoud] Yeah, or maybe using nightguard. [Jaz] She does. [Masoud] She’s a bruxist. I think also the final restoration is really important. There is a recent study from 2021. If the modulus of elasticity of the final restoration is close to enamel, the crack underneath will not propagate. It will just stop propagating. When you are restoring with composite, your modulus of elasticity is about 20–22 maximum, but the enamel is about 80. So if you use a restoration like a ceramic restoration, gold, with gold they also got good results. I don’t know if it would be possible to share also these studies. I can send it to you. [Jaz] Oh, please. Our colleagues love to geek out on the studies. Send as many over. We’ll put it as a downloadable document. [Masoud] I will send it to you. They restored a cracked tooth with different kinds of restoration, and they checked when the crack is not going to propagate. They saw it’s happening when the modulus of elasticity of final restoration is close to the enamel. Actually the biomimetic concept: just try to mimic the nature. [Jaz] Like lithium disilicate, for example. In that specific patient, she was 19, so I did a direct. But if she was 20 years older, I would’ve gone for my usual protocol: good bonding under rubber dam with lithium disilicate, and maybe even at that stage be a bit more in terms of capping cusps where appropriate. We can talk about that as well. [Masoud] Yeah, because the form of the cavity is also important. In young patients, most of the time the cavity is not that huge. There is no place for indirect restorations. If it’s a small class I or really small class II cavity, I would also go for direct composite. But in huge restorations or multiple cracks, most of the time they’re just following each other and you see multiple cracks in one tooth. In that way, I think we have to choose the final restoration very clearly, a very good final restoration. [Jaz] So gold is approved, makes sense, and good bonding with ceramics. Are you including zirconia in that? [Masoud] Actually not, because zirconia has very high modulus of elasticity. It’s about 200 gigapascal and enamel is about 80. The second one is the bonding, because you lose your bonding strength in zirconia a bit faster than in lithium disilicate. These are the reasons that I’m not using zirconia. I’m using mostly lithium disilicate. But I see also dentists getting good results with zirconia and I understand that. [Jaz] Okay, fine. So we talked about which cases to intervene, why to intervene, why most of them are asymptomatic, but you gotta pick and choose the ones where it’s more likely to be in dentine. Look at the patient as a whole. Let’s talk about operative procedures: chasing cracks. Back to the image that we shared, to what degree should we chase cracks? Because if you keep chasing, you’re gonna hit the pulp and then you’re gonna do an endo where you could have avoided the endo. That’s an easy one for us to understand. But are there any clear guidelines? We have caries removal endpoints. Do we have crack removal endpoints? [Masoud] That’s right. If it’s a non-vital tooth, I would remove all of it if it’s possible. If it’s a vital tooth, I will save the pulp. I will not expose the pulp. I will do my best to not expose the pulp. I will leave the crack on the center part and I will put fibers on it. In the peripheral zone, I try to remove it. Unfortunately, most of these cracks are stopping at bone level, so it means that you have to deal with a very deep margin elevation or very deep margins. These are really hard to get a good adaptation between the matrix and the margin of the tooth. It’s really deep, it’s really dark, so you have to be sure that your light is going there for polymerization. Most of the time they have a really high C-factor because it’s like a tunnel, a very narrow tunnel. The composite is going to shrink very badly. These are things that we have to think about: try to minimize the C-factor or the shrinkage stress and know that we have to deal with very deep margins. The first reason that I am going to remove a crack is if it has a connection with oral environment, and if there is plaque there, it will invade inside. That will be the first reason. The second one will be crack propagation, because the crack tip has the most stress there. There are some studies, finite element analysis, if there is a crack, the crack tip is just red, all the stress is there, so it will propagate. By removing it, I can’t be sure that it’s not going to propagate anymore. [Jaz] I think to add to that, Masoud, I went through ebbs and flows of chasing cracks, not chasing, because I hear both camps. I hear what they’re trying to say. I think whenever there’s two extremes, you have to go down the middle and your answer’s somewhere down the middle. Basic things like if you’ve got a crack on a marginal ridge, if you don’t at least address that crack, then that’s where you’re gonna get caries. It just makes sense. Also, you need to have access for your bur, access for your matrices. So that interproximal bit has gotta go, the proximal wall. Then you’ve got to look at biological limits, pulp being one, but also connective tissue being the other. Kind of like how we don’t go into the pulp, the crack will get thin enough and you might accept, now the crack is thinner and I’m not gonna chase this anymore because you’ll compromise the restorative seal or result that you can get. The other thing to consider there would be, when you are chasing these cracks, the most important part of the crack is the tip, like you said, that’s where the energy is. But if we can reduce the height of these cracks, we reduce the energy that goes to that tip. I think if you follow those principles of making the cavities cleansable, restorable, preserving pulp vitality, I think that’s a good middle ground. [Masoud] Yeah. So if I also adopt and I can’t remove it anymore, and it is white crack, I’m also stopping. Sometimes it’s so deep, my bur is not going to remove it anymore. I can’t touch it anymore. The good point is, thanks to the study of the engineers, when the crack is in root dentine, it’s not going to propagate that fast. Crack in coronal dentine propagates faster than in the root dentine, and this is really interesting. [Jaz] I didn’t know that. [Masoud] Yeah, I also didn’t know that. When it is in the root dentine, it’s just not going to propagate that fast. I will also share this study. I used all of this in my book. When I read it, I thought, this is mind-blowing. [Jaz] Well, let’s go to that thing then about healing cracks. You’re at that scenario where you’ve removed the height of it, you’ve cleared away the caries, you’re now not gonna expose the pulp, and you’ve reduced the height. You may be gonna cap some cusps, remove that couple millimeters of the cusp to make it lower in height so it’s less flexing. That all makes sense. But then at that point, how can we wave that magic wand and heal the crack like bone? You said we can heal the crack like bone. What do you mean when you said let’s heal the crack like bone can heal? [Masoud] When I read it for the first time, I thought, is it really possible? But it is possible. Like how there is a crack healing mechanism in the bone, there is also crack healing mechanism in the tooth. The difference is the crack healing mechanism in the bone is because of regeneration. You have a multi-step physiological process: inflammation and hematoma formation, bone remodeling, and at the end regeneration, and it is because of the blood supplies, because of the blood vessels there. In the tooth, in dentine and enamel, we don’t have blood supplies. We don’t have blood vessels, only in the pulp. But interestingly, there is a crack healing mechanism in the tooth. It is different in dentine and also enamel. Knowing the histology and anatomy is really important. The studies also show it is different in inner enamel than outer enamel because of the inorganic and organic matrix of the enamel: hydroxyapatite, the protein. The crack healing mechanism is different in inner enamel and outer enamel. The first study is from 1949. He is called Sognnaes, 1949, and he thought the enamel tufts are actually cracks that are getting healed. Then no, it’s just hypocalcified intrinsic defect. After that, in 1994, Hayashi thought that there is mineral deposition inside the crack, especially enamel cracks, and these are medial cracks on occlusal part of the crack, and there is mineral deposition inside the cracks. Myoung in 2009 saw even the protein-rich fluid can go to the crack and it can cause adhesive interlayer. It means two crack faces are going to glue to each other because of the protein-rich fluid. In 2013, Rivera and Arola, an engineering group, saw even that the length of crack is just going to decrease because of the healing mechanisms of the enamel of the crack. [Jaz] Increase the crack length? [Masoud] Decrease. Sorry, decrease. [Jaz] Okay, I’m with you. Now it’s making sense. It’s good to clarify. It shows you that I’m listening. Crack length is decreasing now, I get it. Now I’m totally on board. Before we move on to dentine, you say all these wonderful things, but this is all just happening with saliva and the oral environment, or is there something we can do as dentists? Because we like to do things. How can we accelerate this? How can we create an environment conducive to enamel crack healing? [Masoud] That’s a good question. What’s the important point? It’s saliva. So be sure that your patient has not xerostomy. Stress can reduce saliva. That is the important part. After that, it is starting from the first moment that there is a crack. After 48 hours, they started to see that the crack is just decreasing, like it’s just healing. Can I share that study with you? [Jaz] Yeah, talk about it. [Masoud] Indentation Damage and Crack Repair in Human Enamel. [Jaz] So it is legit. He’s not talking out of his ass. He’s being honest. This is cool. This is the geeky stuff we like on here. [Masoud] Look at this. [Jaz] We are seeing the crack length decrease after 48 hours. But this is in vivo or this is in vitro, like they extracted tooth? [Masoud] Yeah, this is extracted tooth. They don’t have it intraorally. [Jaz] You can’t measure that intraorally. [Masoud] No. I think intraorally, if they want to see, we have craze line and we have internal craze line. I think it would be possible to see that the internal craze line is going to get repaired, starting to get removed, disappear. [Jaz] There’s really nothing for us to do. There’s no special toothpaste. It’s just good to know that human enamel can have these self-repair mechanisms as long as you have a healthy patient, i.e. good saliva. [Masoud] Yeah, and also if we have a healthy pulp, because interstitial fluid has also effect on crack healing. Crack can propagate if it’s dehydrated, like in endodontically treated tooth, or when there is xerostomy. So it’s really important to keep the pulp vital. [Jaz] That’s what they say because it becomes brittle. All the chemicals that we use for root canal and everything, the tooth itself, when extracting a root filled tooth, it just feels different, feels more sclerotic, feels drier. That’s got to have something to do with it. Fine. Then are we gonna talk about, is there any healing mechanism in dentine? [Masoud] There is also the healing mechanism in dentine, and it is also remineralization. The other very important point is the collagen matrix. The dentine is filled with the collagen matrix, and this collagen matrix is like a scaffold for ions, for phosphates and calcium, to come inside the crack. The problem in dentine is because it’s flexible, so the crack is opening and closing, and that makes it really difficult for crack healing mechanisms. If the patient is old, 40 plus, the tubules become closed, so there will be no interstitial fluid to remineralize. Also the collagen matrix starts to glue to each other because of cross-linking, so there will be no scaffold for the ion transport. That will be the problem. Dentine has also its own mechanisms to get repaired. [Jaz] But there’s nothing we can do to promote this bone-like healing. [Masoud] No. [Jaz] And obviously most of the cases we see too late. [Masoud] Image you shared, there is no mechanism there. It’s really over. [Jaz] Well, let’s talk about that right here because you mentioned fibers. I don’t use fibers at the moment, but if there’s enough good clinical long-term evidence, I will. Of course I will join the party. You sound like you use fibers over cracks. Can you mention that? To someone who’s never used fibers and never done it justice by looking into it that much, I’ll be honest, what’s up with that? What are fibers doing? Is it robust enough? Is it strong enough? Do we have any good long-term data that the cases managed with fiber versus the case managed without fiber? Obviously so many different variants and you can’t control for what the patient eats and clenching and that kind of stuff. But as a whole, where are we at with how far into its acceptance in the literature and acceptance into widespread practice we have these fibers, which we see so nicely on social media layering over these cracks in a criss-cross pattern? [Masoud] When there is a crack, there is a lot of stress there, so we have to do something. We have to redirect the stress. We have to distribute the stress, so it’s not just going to concentrate in one place. The fibers are the best way to do that. Putting the fibers on the crack. In a vital tooth, the best way is laminating, like putting one piece of fiber on it. In an endodontically treated tooth, the best way is annular layering, like in a circle form shape inside the pulp chamber. There are two types: we can use glass fiber or we can use polyethylene fiber, the Ribbond. It’s about how they are, bidirectional or unidirectional. The fibers like Ribbond, we have to pre-wet it. It’s not ready to use. But the glass fibers are mostly treated, they are ready to use, and we can put it on the crack or where we want. We can use fibers in dentistry in three ways. Strengthen the restoration: if it’s a huge composite restoration and financially it makes it a bit difficult for patient to pay for indirect, you can put fibers inside your restoration.  In that way you can strengthen your final restoration. We can protect the hybrid layer. The hybrid layer, the first minutes, is really sensitive to stress like shrinkage stress, and by putting fiber on it we can create a fail-safe protocol. It is not going to fail at that point anymore. And we can also strengthen the tooth, especially if there is a lot of sound tissue gone or removed, or if there is a crack, we can strengthen it with the fiber. I recently read a study. They checked the fracture strength of natural teeth without restoration and also checked the fracture strength of a tooth with a crack, upper premolar. The intact tooth had about 1,200 Newton, but the tooth with the crack was about 400 Newton. So it was three times more brittle, it can fracture easier than the natural. So in this way, with the fibers, you can redirect the stress which is coming to the crack. [Jaz] Do they have any such scenarios where they take that premolar and now chase out the crack as you would do, and then put the fiber on it, then restore it, and then put it under the same loading? It would be nice to know how many Newtons it can take. We’d expect it to be more? [Masoud] Yeah, it’s about 3,000. [Jaz] What? [Masoud] It’s about 3,000. You make it stronger than a natural tooth, actually. [Jaz] No way. You have to send this paper. That’s pretty cool. There’s process-based reasoning and there’s outcome-based reasoning. Process-based is like, by doing these fibers, by doing this, we’re strengthening the tooth. But what we care for more is outcome-based reasoning. For example, because we did this, my teeth are lasting 30 years, whereas before they were lasting 20 years. We’re doing this more complex thing at an added expense, added time. We know there’s more risk involved in terms of you might mess it up, more time consuming and stuff as well. Whilst that sounds awesome, where on the benchtop we can get that data, and I think that says something, that’s pretty cool. I didn’t know that, and I think there’s a lot of things in dentistry which we look at, we don’t have any clinical reasoning for, but it makes sense in a physics way, and a lot of occlusion is like that as well. A lot of the adjustments I do are based on that, so I’m not averse to it. But it’ll be nice to have any clinical data to support how it may be superior and therefore it can justify the added expense in terms of time and materials to a patient. Where are we now in terms of waiting for that kind of data? [Masoud] Not really that much. Endodontists are sharing more cases, more follow-ups, especially in crack removal. One is Philipson. I think I also had contact with him for writing my book. He shares that with removing the cracks, he sees that the teeth are going to live for 10 or 15 years, and this is why he’s supporting the idea of crack dissection. He’s dissecting the crack from 10 millimeters.  He says, okay, after dissecting the crack, there is the solid pocket from 10 millimeters. He’s putting Biodentine or MTA there. The x-rays look very crazy. I will never do it, but he just wants to save it. He made very good publications about it. It is really amazing to see how crack removal works. But in terms of using the fibers and the long-term follow-ups, unfortunately I couldn’t find anything the way we have about the crown and cusp overlay, like removing all the cusps and onlay and then you see good results. We also have a study with crack removal, I think it’s an Australian study. It also shows in five years, 100% survival after removing the cracks. [Jaz] What do you mean by that? Sorry, 10% increase or 10% survival overall? [Masoud] They had no failure. The teeth were not extracted. All were just still in the mouth. [Jaz] They had 100% survival. [Masoud] 100% survival. [Jaz] Okay, cool. But then that’s a very aggressive way. Based on what we’re learning from that study, should we be adopting that? [Masoud] That’s a good study. There are not that many studies. Unfortunately, like in adhesive dentistry you have thousands of studies. When you search about the primer or bonding, you get a lot of stuff. [Jaz] But in that case, you said they have to do endodontics, which makes sense. If you’re chasing all the cracks, you’re gonna be doing endo more often than not. As Pascal Magne says, the root canal treated tooth will never win the Olympic Games of restorative treatment. Whilst that’s an interesting study, I don’t think I would change my way. I wouldn’t go too aggressive totally chasing all the cracks. Would you agree with that? [Masoud] Yeah, I would also not do it. [Jaz] In five years we need more, we need up to 20 years plus. We need to compare it to, is it better than what we’re already doing? I think you’ve mentioned some great points. Masoud, you’ve answered all my questions. It was really fun to speak with you. I would love for you to tell us about your book. You mentioned your book a few times. I’ve seen it on social media. Tell us about it, because it is no easy feat to do a book. I’m doing a book at the moment. I know it’s no easy feat. Tell us about it. [Masoud] Yeah, this is my book, The Cracked Tooth. [Jaz] Oh, sweet. Is this a different one to the one that you had on? [Masoud] No, this is the one. I also published another one that was the Glossary of Biomimetic Restorative Dentistry. [Jaz] That’s the one I saw. Oh yeah, that’s the one I saw. Okay, cool. [Masoud] This is a new one from this year. This is only about cracks in tooth and what we have to know about it, with all references at the end of each chapter. [Jaz] That’s amazing. Oh man, that’s so geeky. I love that, Masoud. Well done. That must have taken so much time and effort. Really well done, mate. [Masoud] Yeah, it took almost three years to do it. First I had to study a lot and I had to make all the connections with the engineers. Actually, how does it work? I really didn’t understand. There is a Paris law in fracture. In that way they can measure crack propagation, but the problem is they have a continuing mechanism. It means point A and point B have the same chemistry and physiological properties, but in the tooth each half millimeter is different. So it makes it really difficult for the engineers to calculate the real crack propagation in a tooth. They have to divide it to deep dentine, intermediate dentine, superficial dentine, inner enamel and outer enamel. With my book, my idea was making a very small book at 90 pages to share with my colleagues, to share my information with them, but it became 400 pages. Still there are studies, some of them I read some weeks ago and I said, maybe I should put this study also in my book. [Jaz] Volume two, that kind of stuff. Masoud, is this on Amazon? [Masoud] This is on Amazon, yeah. [Jaz] Alright. Please send me the link. I would love to share it with Protruserati. I think what you said was making a lot of sense. I like that. The only unanswered question I have is the very first few things you mentioned about the percussion-based diagnostics. Is that like a special tool you have to buy? [Masoud] Yeah. It is called InnerView. The links are very interesting. The first dentist who called the crack in dentine structural was David Clark. David Clark wrote a study in 2003 with Challis, and Challis invented this instrument. It is called InnerView. In this way, you can measure if there is a crack in a tooth or not. I will show image of it. [Jaz] I like the idea of gaining objective data. It’s why I bought the T-Scan in occlusion. I like the timing data, the force data. This is another thing that can help you, like transillumination, to get more data of should you intervene, should you not. I like that. [Masoud] Yeah, it is really— [Jaz] Is it an expensive toy, Masoud? [Masoud] Yeah, I think it’s about two or three thousand. [Jaz] Yes, it’s an expensive toy. [Masoud] Two or three thousand dollars. [Jaz] Is there an AliExpress version? No, I’m just kidding. [Masoud] I know there is a first version and another team tried to make it, but it’s not that easy to use. The idea of InnerView is you have a pen and you’re going on each tooth and you can test it. [Jaz] It’s like you’re describing a Tooth Slooth in a way. [Masoud] Yeah, like that. But this one is going to tap or send a percussion on the tooth and get the info back from the tooth. It is now waiting for ADA approval from USA. I think they’re waiting this year or next year to bring it to the dental shops. [Jaz] Amazing. Now that I know about this pricey device as well, this data is cool. I didn’t know about that before. I didn’t know that root dentine is more resistant to cracking. That was fascinating. I didn’t know about the epic impact of these fibers on these extracted teeth. That’s really cool to know. I didn’t know you had that book on cracked teeth. That is awesome, and I’ll put the link there for everyone to check it out, to see all your hard work. Masoud, thanks for sharing so generously with the community. We really appreciate people like you doing the work that we don’t want to do, all the hard work and reading, then sharing all the answers with us. We really appreciate you. You’re the kind of guy whose homework we copied. [Masoud] Thank you. [Jaz] Thank you so much, Masoud, for all your work on cracked teeth, and I’ll put all the papers that you send in the blog link. I’ll put your Instagram. Please tell us about your Instagram. [Masoud] On Instagram, I started just sharing normal things. I had just 100 followers. Then I started to share my daily challenges. Look guys, this is the thing that I am dealing with and I have to do. Now it’s about 400, 500 posts that I made with really difficult situations, and I always get good answers or good reflections, feedbacks: hey, you are sharing the things that I maybe didn’t know how to do. Now I have more ideas. With the last years, I make all the images with the microscopes. They are 28, 29 times magnified. It gives more information. You can really see the mantle dentine. You can really see the inner enamel. You can see the outer enamel.  You can see the histology difference between these two, also where we call the dentinal enamel junction. I also share images with fluorescence mode, fluorescence filter. You can see where the bacteria are and where you have to remove. Not all the length of the crack is filled with bacteria. When it is closed crack, there is no room, even in dentine. I shared a case when I started to chase the crack, and each millimeter I made the image with fluorescence mode. You see after two or three millimeters, it’s not red anymore, it’s just clear. But the crack is still there. So it means the crack spaces are so tight connected to each other, so there is no space. [Jaz] So it’s like the width of the crack is getting less, which makes sense. The crack would be higher, more open at the top, and as you go more cervical, it would get thinner and thinner, and that makes sense. [Masoud] It is called transition. We have three types of cracks. One is closed crack. All the crack faces are just connecting, like crack in enamel. Second one is transitional crack. These are like the first point, the initiation part is open, but close to the tip the crack is closed. The other one is totally open crack. In dentine, we see most of the time transitional crack. The first point is open, and near the crack tip it’s closed. When it’s open, there is space for bacteria and biofilm to go there. [Jaz] Amazing. Everyone, do check out Masoud’s Instagram. I’ll put the link below. Masoud, thanks so much, my friend. Have a delightful Friday, and I can’t wait to publish this. I’ll give you a shout out, my friend. Thank you so much. [Masoud] Thank you. Thank you. Thank you, Jaz, for your time, for invitation, and sorry for messing up a bit with the increasing and decreasing. Jaz’s Outro: It’s totally fine. I was thinking in my head, okay, when’s the right time to intervene? And you nailed it. Thanks so much for a wonderful summary on cracks. Well, there we have it, guys. Thank you so much for listening all the way to the end. I know you want the papers. Scroll down below. If you’re on Protrusive Guidance, they are all there.  If you’re on YouTube, check out the WordPress link and again, we will have them all there for you to download. The easiest way is to head to protrusive.co.uk/cracks. That’s protrusive.co.uk/cracks. Our manager, Alex, is going to zip all these papers that Masoud sent us and send them to you. We’ll also send you a link to his book on Amazon. I think it’s amazing that he’s done this, and if you wanna geek out with him more, check out his book. I’ll also put his social media. Of course you can get CE for this. You’ve done the hard work. You’ve listened, you’ve watched, you can get CPD or CE credits. We are a PACE-approved education provider. The only way to get CE for this is on the Protrusive Guidance app. You need at least the CE plan, which is amazing value. Dentists are getting 100 hours of CE every year just from listening to the podcast while they’re commuting and answering the quiz on the app. If you wanna get the full fat version and get access to Vertipreps for Plonkers, the 21-day Photography Challenge, Rubber Dam, premium clinical walkthrough videos, all that good stuff is on the Ultimate Education Plan. Check it out on the Protrusive Guidance app. Once again, if you’re fancy coming to Dubai with us, it’s globaldentalevents.co.uk. You click the button to get a quote. You have to say how many people are coming. Is it you and a spouse, or you and spouse and kids, or just you?  Then you get some hotel options and flight options, that kind of stuff, and you get a quote that’s going to be tax deductible because it’s for work. Remember we are going to learn occlusion and have some fun. So globaldentalevents.co.uk. I’ll put the link, everything you need in the show notes. Thank you so much for listening all the way to the end. Honestly, it means so much to have your listenership and engagement on all the platforms, including Instagram and stuff. Thank you so much and catch you, same time, same place next week. Bye for now.

With the final places remaining for our Occlusion Getaway, we present the official FAQ Podcast! Dreaming of combining occlusion learning with a luxury getaway? Want to earn 56 hours of CPD while soaking up the Dubai sunshine? Looking for a course where you can master PRACTICAL occlusion in Restorative Dentristry and make it a family-friendly, tax-deductible trip? Easter 2026 is set to be unforgettable. Join Dr. Jaz Gulati and Dr. Mahmoud Ibrahim for an extraordinary Occlusion Excursion in Dubai — a blend of serious CPD and sunshine that redefines what “continuing education” can be. We’ve always believed in mixing work and pleasure, and this time, we’re taking it to the next level. Think luxury, learning, and laughter — all under the warm Dubai sun. Watch IC062 on Youtube 🦷 What Makes This Course Different? 56 hours of CPD/CE credits, including 20 hours hands-on in Dubai Full online occlusion curriculum and live webinars before you travel Morning workshops (9 AM–1 PM) and free afternoons to explore Dubai Bring your family (Easter school holidays!) or come solo — many dentists are already flying in from around the world. REQUEST A QUOTE – Limited Places Remaining as of November 1st 2025!: https://globaldentalevents.co.uk/  Spaces are limited and flights are rising, so secure your place early.👉 Easter 2026 – Occlusion, sunshine, and CPD in Dubai. 📅 28 March – 4 April 2026 📍 Dubai, UAE 👨‍⚕️ Dr. Jaz Gulati & Dr. Mahmoud Ibrahim, Organised by Global Dental Events Highlights: 04:06 Meet the Organizers 05:59 Why Dubai? 10:40 Delegate Experiences and Expectations 13:21 Course Pricing and Tax Benefits 19:05 Course Itinerary and Logistics 24:49 Final Thoughts and How to Join

Do all whitening gels work the same, or is the brand actually important? Are lights and in-office “power whitening” just marketing hype? And what’s the deal with the infamous white diet – do your patients really need to give up coffee and red wine? In this episode, I sit down with Dr. Wyman Chan, the man who literally hung up his drills in 2002 to dedicate his career to whitening alone. With over 20,000 cases under his belt (and a PhD in the science behind it), Wyman shares his three golden rules for whitening success: trays, communication, and conscious bleaching. We’re also joined by Dr. Niki Shah, who brings his own insights into whitening and patient care, making this a conversation packed with both science and clinical experience. Wyman introduces his latest invention—Magic 3, a fizzing gel that reveals and removes plaque while calming gums. Plus, Wyman busts some of the biggest whitening myths (sorry, “white diet”) and explains why he no longer bothers with internal bleaching. If you’ve ever wondered how to make whitening safer, more predictable, and less stressful for you and your patients—this is the episode you’ll want to tune in for. Protrusive Dental Pearl Innovation in Hygiene with Magic 3 – What is Magic 3? A colorless plaque indicator gel developed by Wyman Chan. Fizzes on contact with plaque. Cleans teeth, removes superficial stains, and softens soft calculus. Clinical Application Alternative to scaling/polishing for routine patients. Nervous patients who dislike ultrasonic scalers. Children (6+) – safe as a Class I medical device. Orthodontic patients – helps prevent white spot lesions. Learn more at https://protrusive.co.uk/magic3 https://youtu.be/ImpHJP3Wxec Watch PDP245 on YouTube Need to Read it? Check out the Full Episode Transcript below! Key Takeaways: Teeth whitening success depends on tray design, formulation, technique, and compliance. Conscious bleaching helps minimise sensitivity. Sensitivity is due to peroxide reaching the pulp. Patients should adjust wear time gradually, starting short and increasing if comfortable. Communication and treatment planning are crucial to match whitening regimes with lifestyles. The “white diet” is not scientifically necessary – normal eating and drinking can resume within minutes. External bleaching alone can be effective, even for single dark teeth. Tetracycline-stained teeth can respond to whitening with the right protocols. The brand is less important than protocol consistency and clinician experience. In-office light-assisted whitening adds risk, cost, and chairside time without proven benefit. Allergic reactions are more likely caused by gel additives, not peroxide itself. Emerging products, such as peroxide-based gels for plaque disruption and gingival health, may complement whitening in the future. Highlights of this episode: 00:00 TEASER 1:00 INTRO 3:13 PROTRUSIVE DENTAL PEARL 07:05 Dr. Wyman Chan Introduction 13:32 Niki’s Journey in Dentistry 17:03 Whitening Products and Techniques 23:09 Three Keys to Whitening Success 30:03 Addressing Sensitivity in Teeth Whitening 37:43 MIDROLL 41:04 Addressing Sensitivity in Teeth Whitening 46:15 Whitening as Treatment Planning 49:10 Myths and Misconceptions 01:00:27 Lights and In-Office Whitening 01:03:13 Introducing Magic3: A Revolutionary Dental Product 01:16:10 OUTRO Discover Magic3 and Dr. Wyman Chan’s inventions If this episode piqued your interest, continue the whitening theme by listening to PDP199 “How To Eliminate Sensitivity During Teeth Whitening”. And don’t miss the upcoming visual follow-up to this episode! #PDPMainEpisodes #BreadandButterDentistry This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes A, C, and D. AGD Subject Code: 780 – Esthetics/Cosmetic Dentistry Aim: To deepen dentists’ understanding of teeth whitening by exploring evidence-based protocols, tray design, and methods to reduce patient sensitivity. It also aims to challenge common myths and introduce innovations that can improve both patient comfort and clinical outcomes. Dentists will be able to: Evaluate the importance of tray design, communication, and conscious bleaching as critical factors for safe and effective whitening outcomes Identify the common causes of whitening sensitivity and apply strategies to minimise or prevent pulpal irritation during treatment Assess the evidence behind common whitening myths, including the “white diet” and the use of heat/light for activation. Click below for full episode transcript: Teaser: What is the three most important features in getting a good whitening result? Number one, because- is it true that patients should try a white diet when having treatment? Teaser:I heard of that when I was started bleaching 30 years ago- because I don’t have the drill anymore. They say I can’t do internal bleaching. It’s just because I give myself restriction. I have no drills at my clinic. If you’ve got a good protocol, it works- like I can show you some cases just two weeks. It’s amazing result. Get from a C4 to B1, just two weeks. Two weeks for Tetracycline staining. This is a colorless plaque indicator. Remove plaque at the same time. Also reduces gingival inflammation. They say we have nothing like that. Is this solution a substitute for mechanical plaque? It’s substitute for mechanical cleaning. To me, there’s no need to do polishing. Jaz’s Introduction:Protruserati. We have got THE Wyman Chan and how I pull this off, this is the guy who I’ve been watching the whitening space for so many years, and actually he kind of disappeared. Where did Wyman Chan go? Was on the lips of every UK dentist for so many years. But guess what? He is back. Alright, lemme tell you about Wyman Chan. This guy hangs up his drills in 2002 to solely focus on teeth whitening. That’s it. Imagine that. Right at a time where teeth whitening wasn’t even like a proper thing. So since then he’s been like whitening the teeth of celebrities and all the famous people will go to a central London clinic, get their teeth whitened by him using his formulas, his patented technology and his knowledge. Like he’s a PhD and he’s so passionate about teeth whitening. The guy’s done over 20,000 whitening cases. I was actually thinking. I don’t even think I’ve seen 20,000 patients in general in my career so far. So that just tells you the volume of teeth whitening he’s done and he’s like a mega geek. Like what he doesn’t know about whitening is not worth knowing. So we take advantage of that. I literally ask him all of your questions that you submitted on Protrusive Guidance, the usual stuff like is the light thing, is it a fad or is there some science behind it? Do you need to adopt a white diet two hours after whitening to make sure that you get a good effect from teeth whitening? Like that’s all standard. We actually talked about it before, but we revisit it in this episode. But of course, every episode we have a game changers and there’s a few game changers. About three, well, there’s more than three, but the three that are top of my mind right now while recording this introduction. One is that for non vital bleaching, imagine you get that black central incisor. Usually the way I would treat it is make sure that the root canal treatment is good, and then re-access the access cavity of course, and place my gel inside and whiten from inside and also outside. Now, what Wyman Chan discusses is a protocol of not doing the internal part of non vital bleaching, doing it externally only, which is very fascinating. The other cool thing he teaches in this episode is this concept of conscious bleaching, which I’d never come across before, but it makes so much sense. It is the number one thing that reduces and eliminates sensitivity. And I’m a little bit upset that no one told me before. It just makes so much sense. I can’t wait for you to listen to this episode and learn about what is conscious bleaching. Dental Pearl:And the final game changer is today’s Protrusive Pearl. Hello, Protruserati. I’m Jaz Gulati. And every PDP episode we give you a Protrusive Dental Pearl, something to reflect on, something to digest, something to apply to your patients right away. We have all sorts on here. And today’s pearl is about innovation. Wyman Chan is just like this awesome guy in whitening and he has got so many patents I didn’t even know about this. And one new invention he’s come up with is called Magic three. So remember I said that Wyman Chan went missing? What I meant is he went to China, okay? He went to to Asia, developed a whole bunch of things and protocols, and does loads of teaching there. And he is launched some products there as well as in Dubai. And now he’s bringing Magic three to the UK. And so in a nutshell, ’cause I don’t wanna take up too much time here, I really want you to listen to this episode, but essentially Magic three is this like colorless gel. It’s this clear gel that you put on the teeth, and then if there’s plaque anywhere, it’ll start fizzing. So they call it a colorless plaque indicator, which sounded really crazy to me. I still calling that my head around it and the way I understood it and seeing the product myself, it just fizzes when there’s plaque. So it is indeed a a plaque indicator in that way you’re looking for fizzing. What it does is it cleans the teeth. It replaces your polishing stage. For many patients it replaces your scaling stage. So if these are regular patients that you’re seeing every six months in hygiene and you haven’t got like mountains of this hard calculus, then this gel actually replaces your hygiene work. And the reason why that piqued my interest is ’cause I get patients coming to me all the time and they say they just don’t like the ultrasonic scaler and my poor hygiene is that I work with. They get frustrated ’cause that’s how they were trained. They want to use the ultrasonic scaler. The Piezon, they wanna get in there and clean. But these sort of subset of patients. They just don’t like it. They come from a generation of being used to hand scales like 30 years ago and they want that again. So it was like a penny drop moment for me when I thought, okay, so actually what Wyman Chan is showing on the website for Magic three is that it’s good for nervous patients who don’t want that feeling of having a scale. It’s good for children ’cause you can actually use it on age six and above ’cause it’s a class one medical. You can use it for anyone who just doesn’t like the feeling of the scaler. I personally don’t even like the feeling of the ultrasonic scaler. And you can use it on orthodontic patients in the prevention of white spot lesions. So any orthodontic practice, any hygienist working orthodontic practice, this is something really worth paying attention to. Because to me it becomes like a kind of business model and a model of how you work your practice. A practice philosophy. So for example, I’ve worked in clinics that have adopted the EMS airflow model. So every hygiene chair has got this EMS airflow, and they all get airflow as a set protocol that you do. You disclose the teeth and then you blast it all the away. And a lot of patients like it, some don’t. But the whole experience of the airflow, a lot of patients end up loving. Now, of course, there’s upsides and downsides to that. Quite often the machine can, quite often I’ve seen on the WhatsApp groups that the machine’s having issues, they have to repair it and service it, and not all patients like it. So you have to go back to your usual hand scaling. But I think the practice where I work at the moment in reading, which I’m about to leave unfortunately, but I think that would actually work really well. So this magic three treatment would be incorporated as part of the hygiene is what I’m thinking. And all patients would have it. And the way you do it, you apply it on the teeth, there’s a special retractor they put on, and like one dose is applied to all the teeth surfaces, all the gingiva, and it’s left for like 10 minutes and the patient wears a mask over it. So this patient is just relaxing. There’s no discomfort, there’s no pain, there’s no scaling. And then once it’s rinsed away, all the superficial stains have gone. The teeth feel silky and super clean. These are the patient’s own words and any soft calculus has actually become even softer. So it’s really easy just to pick away the scaler and any plaque is gone, any gingival inflammation is starting to settle already. So I was quite amazed talking about this. So we are recording another episode, just all about that and that’ll be a video only episode. Wyman Chan is literally launching this product tomorrow at the Dentistry show. So if you’re listening on the published day, then literally tomorrow this product is being launched. If you want to learn more, including a special discount just for Protrusive members only if you think that your practice hygiene model would benefit from this or as a certain subset of like nervous patients or children that you see that would benefit from this, then head ever to protrusive.co.uk/magic3. That’s protrusive.co.uk/magic3. And all the coupon code and discount details as they change month to month will be on there. Now let’s join the main episode. I’ll catch you in the outro. Main Episode:Dr. Wyman Chan, welcome to the Protrusive Dental Podcast, Niki Shah.  [Wyman]Oh, thank you, Jaz. [Jaz]Thanks for joining us, guys.  [Wyman]Well, thank you for inviting me. I’m really honored to be here. Hopefully we can share some of my work I’ve done with you guys with your community.  [Jaz]I’m actually really starstruck, right? Because, so the first time I ever heard about you, I was a dentist student, was at that conference, and a dentist I really respect, called Zaki Kanaan, was doing a demo for whitening. And then he was mentioning your work and I got like a, I probably Googled you at that point. I was like, wow. He’s like doing whitening for all these celebrities. Okay. And so that was like, that was an amazing thing to see. And then, you know what he told me about this technique, which apparently no one else can do. ‘Cause you owned it apparently. And then we had to ask permission for you. So maybe this is myth busting or not. Okay. But essentially when you’re doing whitening to get super sealed tray, you score using the ultrasonic around the gingival margin on the models when we’re using the stone models. Right? And then you make the tray on that and it has an extra seal then is that true that, that was stemmed from you and then someone had to ask like you had, like you own the patent for it or how does that work?  [Wyman]I own two patents in the UK. Just for the trays. Just for the tray design. Just that was a part of that. We have a seal. And we score the models. Not with the ultrasonic scaler with something else, but you can do that with a ultrasonic scaler as well. We use the tools, which is very how we say it is fun. And I like to share this, whoever use my design, please use them. But just say that, who is the inventor? I’m more than happy to share. So, I’m very, very happy that Zaki actually shares my invention. Please tell-  [Jaz]But he did credit, he said that you, to ask and credit. So that was very good of him to do that. So he did in the proper channels. Shout out to Zaki.  [Wyman]But the trays are really amazing. I wish you, you guys just use them. Use them there. It’s free. Please use.  [Jaz]Okay. Super. Well, let’s just for those people who may not have heard of you, right. I just found out a few moments ago in the preamble that actually Dr. Chan, Niki, did you, I mean, you probably knew this already, but he hasn’t done actually dentistry for many years. He’s just been like, some people will only do dentures. Some people will niche into implants. Very rare you find someone niches into teeth whitening. So we need to figure out what’s the origins of that. So, tell us about your story origin and then I think I’ll ask about you as well.  [Wyman]I hang up my drills in year 2002. That is over 23 years ago because at that time, in 2002, I opened dedicated to whitening clinic in central London. And I was very focused. At that time I encountered lots of difficulties and a lots of problems. Really lots of problems.  [Jaz]I mean, at that time, correct me if I’m wrong, at that time, technically teeth whitening was a deal.  [Wyman]Technically it was illegal technically whatever you do, it was illegal. Yeah, so we were all doing something illegal, especially me. I have a dedicated white in center, was really, really high, high profile. I was really, it is really good that the police never locked it my door. So I was really, really grateful. But until 2012 it become legal, it was good. So why did I hang up my drills? Because when I was opening the center, I was really love teeth whitening. I thought that it was such a easy way, I would say to work is stress free if you do it properly and if you do it properly, there’s no complaint. And the procedure is so simple, really simple. I mean, they’re much easier than doing any form of dentistry, easier than scan polish, in my opinion. But I encountered so many problems that our colleagues encounter now. So I use all the system, probably available at that time. And then I went back to the distributor and sometime I wanted to show, I asked the manufacturer, I say, I encountered this problem, that problem. They always come back to me, we never heard of these problems before. Must be you. And then I started forming a group with like-minded dentist who are really interested in teeth whitening as well. And we found that they, we all facing the same problems. That’s the denial among the manufacturers. So I have nowhere to turn to, and that’s why I say that, okay, I’m gonna hang up my, my drills, I’m going to do research. That’s when I’m starting research and progressed to that. Actually, in order to solve the problems, I went on to do a PhD and I got my PhD. The title is Safety and Efficacy of Teeth Whitening Processes.  [Jaz]Probably like we all reference it without knowing one of those things. [Wyman]Yeah. Because I encountered so many problems. So I was so lucky that in my years of research and studying my PhD.  [Jaz]Where did you do that? Which institution?  [Wyman]I did that at Bolton University. Which is the like a chemistry. Mainly I do a lot of chemistries. It’s in the institutes of material science and innovation. What a place to do it. So lots of material science and lots of innovation as well. So I did five years in Bolton, but before that I was doing a lot of research because I encountered so many problems that I could not solve because I committed to open a show. [Jaz]If you can spend five years in Bolton, there’s no problem you can’t solve. [Wyman]Yes. No, we’ve very lucky. I’ve got a good team, good supervisors. Good chemistry. So we solve a lot of problems, so I’m happy. I’m here to share with you my journey in the last 23 years, 25 years.  [Jaz]There’s no question that you haven’t encountered. And so we guys, we got like a gazillion questions from you guys, the community. You guys been voice noting me. You guys have been screenshotting me. You guys have been telling me on Instagram, on Protrusive Guidance. And Niki, you are the man who made it happen. Thanks for connecting us. Hold back and just tell us about yourself.  [Niki]Okay, so, I graduated in 2011 from Barts in the London, actually with Dr. Sunny. Dr. Sunny and me are very, very good friends. And our stories are a little bit similar, so if people have heard, we went through the same process of hating dentistry so much, got seven, eight years in and realized what are we gonna do? We can’t become a bank or something, now we’ve gotta do something in dentistry. That was in 2019 and I was really struggling with composite dentistry at the time. So it was been almost two years since I saw Dr. Sunny went to his house and we were talking, and at that time we were listening to Dental Town Podcast, Dr. Howard Farran. And there was one particular podcast by Dr. Dennis Brown in there and the Greater Curve, the famous Dr. Brown, famous Dr. Brown. And we just decided, we’ve got together. We said, listen, we are struggling to get good composite, you know, restorations. Let’s just approach the team and see if we can get it into the UK and if they’re interested, we can actually teach dentists on how to use the system ’cause it’s completely different. So we did that in 2020. The pandemic hit that actually gave us a little bit of time to step back and actually work on the business. And to Sunny is taking DRE from strength to strength. My focus was a lot on clear aligners at the time there. So my sort of what my character is like, if I feel that there’s a problem in something, I try to approach who I feel is the best in the industry to solve my problems. So with aligners, I’d actually done the six months smiles course there. They were great. But I didn’t do many cases, as we were sort of going with Sunny and [inaudible] at the time. There I got introduced to two brothers from Australia, Stuart and Richard Whiteley, who developed a company called Proligner. Very simple aligner company. Used the best two materials. Zendura Reflex and PET-G, had a seven-day turnaround time. And they have a pay as you go payment plan. So if you’ve got simple cases, 30 pounds in the aligner, 85 pounds for treatment plans. My profitability went up. So from there I started teaching and mentoring other dentists in clear aligners. I’m nowhere near an expert. I’m not a specialist, just a humble general dentist. Over the past eight years doing clear aligners, I started finding a lot of my patients after I finished clear aligner treatments, wanted teeth whitening.  [Jaz]I mean something that you just, like throw in there like, oh, you got whitening included. [Niki]Absolutely. It was just a free thing. Oh, here’s some polo whitening. Take it with you. Do it for the next two weeks. There, I really didn’t know what I was doing. This last year I spent quite a lot of time in Malaysia, where my wife is from, and one evening I was sitting there and I happened to see a live demonstration of Dr. Wyman Chan doing something where they were prophylactically cleaning teeth using a gel. It caught my eye and the kind of person I am, I have to find out more. So then I actually messaged Dr. Wyman Chan’s team on Facebook to say that I’m really interested in what Dr. Wyman Chan has been doing in Dubai and China. Would there be any possibility that I may be able to be in contact with him? I’m currently in Malaysia. And one of your colleagues actually mentioned that, oh, Dr. Chan is from Malaysia himself as well, and luckily put me in contact with Dr. Chan and I got back from Malaysia about six weeks ago and met up with Dr. Chan and here we are today. So that’s been my journey, sort of my family background is products and business, so it’s kind of like I like to find products, bring them into the UK and then form sort of company around it.  [Jaz]Perfect. Well, Niki, thanks so much for connecting us and so very nicely from that products, right? Let’s talk about products, because the one question we have in the community, Wyman, I’m sure you get this all the time, right? It’s a bit like when a pharmacist gets asked, is there a difference between Ibuprofen two milligrams versus Nurofen,, the branded one, right? So in a similar vein, my question to you is there are a gazillion brands of whitening. I once heard a rumor that all the gel is made in one factory in China. And then it either gets in this brand A brand B, brand C. Okay. Like a lot of products are. To what degree is that true? And to what degree does the brand matter more than the fact that it’s just hydrogen peroxide or just carbamide peroxide? Is the brand actually make a difference?  [Wyman]See, teeth whitening, it’s very special. To me, it’s very special. It’s not just the products. It’s not just the brand. It’s the combination of the brand of products and the technique. Protocols most important is a technique and a protocol. And the training, because we’re not taught teeth whitening and undergraduate school. So we go up there like a jungle, which is-  [Jaz]Wild west.  [Wyman]Yeah. Wild west. We try this product, these products. I’d like to give you a example for, to answer your question. I love red wine. Red wine, they are red in color. They all for 12.5% to 30% alcohol. They produce on many different countries. Some wine is only two pounds a bottle, some can be 20,000 pounds of bottle. Is there any difference in the wine? It depends on who’s using it, who’s drinking the wine. To an average person, there’s absolutely no difference because firstly, there’s no training. They don’t know what difference, what to look for. Number one is-  [Jaz]How to taste it.  [Wyman]How to taste it. I mean the teeth whitening as well. What to look for, what kind of things to look out for. So that is one thing that we not touch. Similar in drinking wine. If nobody is, you haven’t been to any wine course courses to learn how to taste the wine, how to appreciate the wine, how the wine is made. And it’s very different. That’s why the French call it ‘terroir’. It’s what is in the ground, what is in the soil. So it’s the teeth whitening as well. It can be, let’s say 16%  carbamide peroxide, there’s so many ways to make 16%  carbamide peroxide, so many ways and so many ways to apply them. And so many ways, like we can do it many, many different systems as well. So are they the same? Are they not the same? The chemical is the same. But the way to make it could be very different.  [Jaz]So really, if that’s the case, then yes. Where it’s manufactured, how it’s manufactured, how it retains its freshness, and therefore I’m hearing that the brand actually does matter. But here’s the problem is that, as dentists, we see who is the best marketer, right? We don’t see who has the best manufacturing protocol. Whose gel is the freshest, we go by ads and conferences and who is in our face and who gives us the first three or five cases. So I’m gonna ask you very bluntly, in the UK and or in the US and around the world, for all our listeners in Australia around the world, which is the best brand?  [Wyman]There’s no ‘best’ brand. Yeah, no. Including mine. There’s no best brand. I think we as a dentist is that, let go back to the wine again. Why some people are so good. This connoisseur is all about practice. They drink it a lot. They have to keep on tasting it. This is called clinical experience. The same with teeth whitening. If you just do one a month, which is average in the world, average, if you do one a month, you’re on average. If you do two a month, you’re doing a lot. You’re doing that double. So it’s average one. I mean, one, it should go back to the password. If you use your password once a month, you’ll forget it. The same with teeth whitening. It’s just forget all the protocol. You may have to look at instruction.  [Jaz]The nuances.  [Wyman]Yeah. And then you can start over again. It’s all about practice. The more you do, the better you are. I have done 20,000 teeth whitening case myself. At the heights I was doing like 50 a week, 200 a month. Do a lot.  [Jaz]And these were high profile people. I mean, I’ve seen photos of all the celebrities at your clinic and stuff, and these were not like I mean, everyone’s important, but like you are seeing the people who are like gonna be on tele or gonna be in a concert the next day. Right?  [Wyman]Yeah. I treat everybody the same. It doesn’t matter.  [Jaz]Yeah, of course.  [Wyman]Who they are. They come in, they’re all patients of mine. So I treat them exactly the same. My protocol exactly the same. My man is exactly the same. So I charge them exactly the same. So I don’t charge people reach you more money, it could be transparent. So it’s all down to clinical experience. The more you do it, I don’t think it matter what you do, what which brand you use. The more you use it, the better you’re gonna get out of the brand. It’s just like the wine the more you’re gonna get out of, then you get to know, the more you taste, then you know which one you like. Which brand you like, like which shuttle of wine that you like. It’s all down to experience. You have to do a lot, a lot of that to find out. Unfortunately I would say 99.99% of us not doing enough to find out. So we will never find out.  [Jaz]Okay. Well that’s interesting ’cause people are always on our brands, but the protocol, how you apply and the experience. So when it comes to occlusion, I talk about the Pareto’s principle of occlusion. What’s the 20% of things we do in the occlusion world that have the 80% of the result? Right? So if we talk about, if I was to ask you what are three things that are so, so important, ’cause I’m sure there’s hundreds, but which are the three most important things in the protocol that will yield the average dentist higher than, better than average results? Because they did these three things well. Can you give us a flavor of what those three things would be if you had to, like of all the a hundred things, including the brand, including maybe the trade design, including anything part of the lights, no lights, what is the three most important features in getting a good whitening result? [Wyman]Number one, which is obvious that because 99.9% of the dentists in the world doing teeth whitening, home whitening, I’m talking about are using bleaching trays. So the bleaching trays got to be amazingly well made and have to be made properly. So please use my trays. It’s free. This is number one.  [Jaz]Okay.  [Wyman]I know that a lots of dentists, because we have a lab called Perfect trays, do a bit of advertising here. We make trayss for 5,000 dentists in this country, but only 20% of the dentists are using my job. And they’re using other job. They’re very happy. They must be very happy. So as the dental professionals, I always advise my colleagues, always do something that works with you. Work on your hands, don’t change. If you’re happy with something, don’t change. Why get outside your comfort zone? Unless you want to experiment. So I see there 80% of the dentists using my design trays with other whitening brands and they have no complaints. Keep on sending the trays to us. So they must be doing something right. So number one is trays, really.  [Jaz]So can we expand on that then? Okay. So I mean that was one of the other questions. The trays. So maybe we’ll come back to it ’cause I don’t wanna distract you from the three points, but dentists would like to know. What is the the ESSIX retainer style trays? Harder, softer or reservoir? No reservoir. These are some of the bank of questions that everyone sent in, but number one, tray design number two?  [Wyman]Number two, you got to choose what kind of bleach you’re going to use. There are many, many different bleach around. You have carbamide peroxideite base and you have hydrogen peroxide base, and then you go to -, I’ve been doing teeth whitening for so long that we have to offer a regime to our patients that they can do it. It’s no point prescribed something that they can’t do it. So we spend time. I think the time is really important. Communication is really important. We need to communicate and find out from our patients. And can you do it? Can you wear the trays overnight? If you can’t, then can you do it in the daytime? If you can’t do it in the daytime, then, what else can we do? So we’re gonna find out that prescribe something to the patients that they can carry out. There’s no point prescribe something to the patient that they cannot do. Totally a waste of time with somebody. Money and you won’t get results because the patient’s not going to do it. Number two is communication. Find out the needs. How to do it. I think that is important-  [Jaz]And like making it practical for them. Practical, pragmatic for them. For example-  [Wyman]Easy user framing.  [Jaz]Yeah. So for example, 99.9% of my aligner cases, if we’re doing any whitening in aligners, like as we get an advantage towards the end, it just makes sense ’cause they’re wearing the aligner at the overnight anyway to wear at night because it’s annoying for them to now take off the aligner one more time. Additional to eating and stuff to do that. And that works for my patients because they’re more likely to comply. Their compliance is good. That’s an example. Now, for the baby dentist, for the younger colleagues, maybe dental students listening, watching. And I’ll say, I’m not saying this as an expert, I’m saying it, I’ll say it, and then you correct me if I’m wrong. Hydrogen peroxide breaks down about half an hour to an hour, and then that’s how long you use it for. Carbamide peroxide up to five hours. Therefore, we use carbamide peroxide, slower release at nighttime and hydrogen peroxide for that kind of power hour during the day. Anything you wanna add to that and correct me? [Wyman]No, you are correct and that’s where we come to point number three.  [Jaz]Ah, okay. Nice. Okay.  [Wyman]It’s based on the the bleaching time, the contact time. I advocate, actually a coin of a phrase called conscious bleaching against unconscious bleaching, because a lot of us are giving them 10% carbamide peroxide my peroxide, which is supposed to be the gold standard according to the ADA, American Dental Association. It been there for so many years. I think it should be upgraded. And a lot of people are using 16% carbamide peroxideide peroxide, which is equivalent to 6% hydrogen peroxide. The maximum strength we can use in the UK. I like conscious bleaching because if it hurts you, you know, somebody pinch you, you know it hurts. Like if you are unconscious doing at night, you are forced your fine asleep, you’re gonna have the pain the next day. And then you talk about over bleaching and that is very painful. So I prefer daytime bleaching, which the patient in control. If the patient feel anything that is not right. For example, certain tinge on the nerve, you know that is all bleach, you stop straight over, take a trays out, wash off, that’s it. You won’t have anymore pain. So it’s conscious bleaching.  [Jaz]Okay. Perfect. So number one, trade design. Number two, make it pragmatic for the patient and that involves communication. And number three is conscious leading. I’ve never heard of that. I’ve heard of-  [Wyman]Conscious bleaching.  [Jaz]But now we have conscious bleeding.  [Wyman]Not unconscious.  [Jaz]Has to be conscious. Okay, great. Niki, anything from you before I carry on with more questions?  [Niki]No, it’s just mainly the thing was again with the different gels that you have. Dr. Chan, I think one thing, that you forgot to probably mention was the fact that you’ve got a dual barrel action. So the gel is only activated once you push it through the plunger. So I mean, Dr. Chan probably will explain that his gels have a patented activator in them. Double barreled. So it’s only activated once you push it through.  [Jaz]Okay. It’s like a metal primer with the A and B bottle that only gets.  [Niki]Yes.  [Jaz]Okay. Interesting. I didn’t know that.  [Niki]And I thought that. So I’ve used Dr. Chan’s gels. I’ve only been in contact with Dr. Chan for two months. I’ve done five patients using hydrogen peroxide, daytime bleaching, and for the first time I have had zero sensitivity. I actually asked them, I want to know even if you feel a twinge at any time. Zero. Nothing. So, one of the main reasons Dr. Chan is so popular is because he does tooth whitening painless.  [Jaz]So that’s the second patent then is it? That gel activator, is that the second you had the first patient trade on?  [Niki]No, in fact, I have 15 patents.  [Jaz]Okay. All whining related?  [Niki]Whitening and some other things.  [Jaz]Love it. Okay.  [Niki]So mainly need them in dentistry. [Jaz]Okay, great. Well, on the topic of sensitivity then, right, well, I’ve got a couple of questions. One, you talk about concentration percentage. Let’s just tackle that first before we go to the big one, which is sensitivity. Let’s say you are anywhere in the world, doesn’t have to be UK. Because obviously we, in the UK, we have the issue of the maximum concentration being 6% hydrogen peroxide, or as they say, 16 but technically is it 18%? Because if they-  [Wyman]16.67.  [Jaz]Love it. Okay. 16 and two third percent. carbamide peroxideide peroxide, it breaks down into 6% hydrogen peroxide and urea and water.  [Wyman]Urea and water.  [Jaz]Okay, good.  [Wyman]Oh, no. Urea and hydrogen peroxide. carbamide peroxide micro peroxide.  [Jaz]Oh yes, yes. Fine.  [Wyman]Urea and hydrogen peroxide. [Jaz]That’s the one. Okay, fine. So, but we do that ’cause we’re here and there’s these rules. But when you do whitening other parts, well, you had free rain and you had to make the rules again, would you keep the existing rules or would you change it because you feel in that conscious whitening for that one hour a day, you would want the patient to have a higher concentration of gel? [Wyman]I would like to have a high concentration of gel because I’m an inventor. I invented all the gel myself, the formula. ‘Cause I’ve spent a lot of time doing in research, I have many different type concentrations carbamide peroxide, my peroxide, hydrogen peroxide, the best gel, the really best gel. I mean, it’s so magical. It’s 10% hydrogen peroxide. Unfortunately, we cannot use it in the UK. That’s why the reason I left UK because of that.  [Jaz]Wow.  [Wyman]I was so upset and so disappointed. I cannot use my best invention, so I have to take it somewhere else. And then someone, and unless someone else can use my best invention.  [Jaz]I can totally relate to that. Because if tomorrow, they said in the UK we’re not allowed this specific type of rubber dam that I like, I would move country as well. [Wyman]We all have something. Right?  [Jaz]What’s yours Niki? What is it that they removed it tomorrow you would move country for?  [Niki]Well, what would I remove move country for? It’d be something sports related. Definitely. It has something to do with cricket. If they got rid of something that from, or TV or something, I’ll be gone. [Jaz]Okay. So, that answers that 10% hydrogen peroxide. You are the expert, we’ll take your word for it, but sensitivity, that’s one thing that I’m sure 80% of the questions asked you are regarding this. It’s the number one complication for teeth whitening. And so what should we know? You have the floor everyone’s really interested in your expert advice here. How can we ensure that our patients have their teeth whining as comfortable as possible? Because if it’s comfortable, the compliance will be better. The results will therefore be better. And they won’t be like, what we do as colleagues is, oh, if you get sensitive, do one day on, one day off, or rub this toothpaste in. And all sorts of advice we give. I don’t know which of these advice is appropriate. Because you just said sensitivity wasn’t happening in your patients. Maybe you’ll tell me that since if the patients are feeling sensitivity, then maybe what we’re doing is actually wrong. Maybe you’re saying zero sensitivity. I would be surprised if you say that, but maybe that is the proper way. So I’m actually genuinely interested. Sensitivity. I want your take on it.  [Wyman]It can be zero sensitivity, but it need a lot of experience. But to make it minimal, really the sensitivity. Sensitivity, so minimal, let’s go back to the three things. Number one is the tray design really important. The tray design. You see my tray design with a little dimple. That is really, you only need a tiny bit of gel. That’s all you need.  [Jaz]So they’re called like dosing dots or reservoirs also same things, right?  [Wyman]Same thing. My invention. Everybody copies it. Good luck. I don’t mind. I like to share. Just create Dr. Chan in the future.  [Jaz]Yes, of course. Absolutely. You had it here first, guys, if you’re doing these dosing dots, you have this man here, the hank. [Wyman]And also the seal as well. You score the model or all those helps this the moment.  [Jaz]And then people market it as super seal and all these kind of things. Why don’t you sue all these guys?  [Wyman]Now why not you sue? I want to share.  [Jaz]Good. I knew you’d say that. That’s why-  [Wyman]I wanna get out. In fact, another company asked me to sue another company. I said, why would I want to do that? I want to share. I say, I would like it because you stole it initially. And then I never complaint. And then you stop using it. Now someone is using it. So I say, I don’t complain anymore. Everyone is using it. What’s the point of complaining? So just use it. It’s wonderful. Number one is the trays really important. Number two, conscious bleaching. Because if you wear the trays, go to sleep, you asleep, it hurts you, already in your sleep. By the time you wake up, it’s too late. It’s painful. Because what it hurts is over bleaching. It’s a gel as a peroxide got to the pulp and cause pulpal inflammation.  [Jaz]Doesn’t that happen anyway? Isn’t that supposed to happen in about 15 minutes, the gel will reach the pulp. [Wyman]Well, it depends how much pulpal inflammation you’re gonna have. If you do conscious bleaching, you know it straight away because you feel it, then you stop, you remove everything. You just stop and rinse your mouth out. If you are asleep, you don’t know what’s going on. It’s been hurting your pulp for so long, maybe four hours. Maybe six hours.  [Jaz]So what you’re suggesting is-  [Wyman]Conscious bleaching.  [Jaz]With conscious bleaching, if someone’s doing it during the day and 20 minutes later they start to feel something, take it out. Take it out. And then that’s day one done of whitening. Is that what you mean? [Wyman]So the next day do 18 minutes. [Jaz]Okay, perfect.  [Wyman]Yeah, because it hurts you at 20 minutes. You do less than 20 minutes.  [Jaz]This is great because, you read the packet, it says half an hour to an hour it, and then that’s what you give to everyone.  [Wyman]No, it hurts. That means the bleaches got to the pulp. That’s why it hurts. that’s like a simple, it’s all about diffusion. Not too much signs, a little bit of signs diffusion. If you paint the gel on the teeth on the surface of the teeth, it takes time to diffuse all the way through the enamel to the dentine and get to the pulp. It will get to the pulp. A little bit get to the pulp, it not gonna hurt you. A lot of the bleach get to the pulp is gonna hurt and very painful. That’s why I’m an advocate of conscious bleaching. Do it consciously. When it hurts, you take it out straight away and look at, oh, I’ve done it for 30 minutes, so next time I can guarantee you do it for 29 and a half. It will not hurt you. Except just a little bit it get to the part where it hurts. So you can adjust your time. So if it doesn’t hurt you the next day, it can increase a little bit more time, you get a better result. So you just play with the time to the dentist. That’s why I advise my patients. We want you to be safe. Start with a short time, maybe 15 minutes. It doesn’t hurt you the next few days. Going to 20 the next few days, 25, 30.  [Jaz]Just progressive.  [Wyman]Yeah. Just use highest constriction you have. Why use 3%? Why use, if you can use the 6%. It’s the same price. I couldn’t understand why dentists buying 10% instead of the 16% carbamide peroxide by, or hydrogen peroxide. 6% instead of 3%. You pay the same price. Why not get to 6%?  [Jaz]Okay. And this modify the time.  [Wyman]Modify the time. You get a much better result.  [Jaz]Okay. That makes sense. But here’s the thing, right? So let’s say I put my whitening jar on, like, I’ve whitened before and then, get sensitivity. So are you saying that I’ve over bleached?  [Wyman]Over bleached. Yes.  [Jaz]So even the next, like that evening, let’s say I whitened during the day that evening, I drink some cold water. I feel it in my tooth. Like hours data is because I over bleached?  [Wyman]Yes. Over bleach. Yes.  [Jaz]Okay.  [Wyman]This is powerful inflammation. Well it’s different from dentine hypersensitivity. Totally different.  [Jaz]And then so over bleaching is, the formula of over bleaching is time too much time, potentially too much concentration. Okay. If you’ve done that. Oh, sorry, I remembered my trail of thought now. So what are the dental features that you can look at and you’re gonna warn that patient extra. For example, if the patient’s got deep caries, I would say to them, look, I’m warning you that you may need a root canal because you have deep caries. Whereas I wouldn’t really emphasize so much if they had a small caries lesion. When it comes to the whitening. What are the features that you are looking for? Thin enamel, for example, or micro cracks in teeth, for example. Are these all things that you may say to a patient actually because of these features that you present with, your bleaching time will be less. Can you give us some, shed some light on that?  [Wyman]Yeah. I think the anatomy of the tooth is very, very important. And the amount of enamel, over the dentine is important. If we have abrasion cavity at the cervical margin exposed dentine , if you put gel in those area, it can get to the pulp in no time because dentine a lot more power than enamel. It just goes straight to the pulp and it hurts within a minute or two. So we avoid applying gel on the exposed the dentine, or maybe best just to seal the tubules, open tubules or expose dentine first before using, using some GI That’s, I normally do. You don’t have to do like-  [Jaz]Class five restoration with GI Yeah. [Wyman]Just not to fill it, just a thin layer. Just to block the tubules.  [Jaz]Okay.  [Wyman]So and then you can apply gel over because you can do it by accident. So if you put on enamel, usually, the pain is not there. Enamel is very thick and very, very dense. If the patient may feel sensitivity, if you do, it just will always advocate conscious bleaching. If you do consciously, the patient will know, oh, I’ll do it for less time. It’s only once they fill it. And it’s not painful. It’s only a tiny pinch, not painful. Okay. If you do it overnight can be very painful because you’ve been over bleach for so long that you do not know, because you fall asleep. You do not know. Because the pain is very mild. And only get stronger and stronger as the inflammation in the pulp is nowhere to go expand. That’s where they get really painful.  [Jaz]Why is it that, I have some patients and their teeth look virtually the same to me. Like it’s very similar, but one will come back saying, she’s had an absolute nightmare. Like the teeth are way too sensitive. And let’s say they both did it for one hour or half an hour and there’s, yes. Let’s say we’re over bleaching for one person, obviously, ’cause they’re getting sensitivity, but the other person comes back saying, is this even working? Well, my teeth are whiter, but you warned me so much Jaz, but I’m not getting in sensitivity. Do we understand the pathophysiology of it to a degree of why is it that some people will get it more than others when they might, it’s not obvious exposed dentine or those factors.  [Wyman]Yes. In fact this was my PhD thesis. Probably you read my thesis somewhere. Yes, it is. It depends on the porosity, the density of enamel. Because we cannot tell, I devise a way that we can tell the porosity and the density. That’s what I taught now in China, I used to teach this here, must be over 5,000 dentists probably everyone forgotten what and touched them. So hopefully go back to the notes. I get them notes. It’s just look at the porosity and the density. The process is very simple. So I don’t wanna go into that today.  [Jaz]Sure.  [Wyman]Because I trust for that course.  [Jaz]Sure. No, appreciate that. [Wyman]I think it can easily distinguish.  [Jaz]Okay, fine. So the porosity, something, you when we’re looking at our eyes, they look the same. But your porosity is once you discover the prosti is you can predict.  [Wyman]That’s right. You could to do some, I would say that’s, just do a little bit of work to find out. Okay. Little bit what to find out. It’s very, very easy. I touched that many, many years ago here.  [Jaz]And patients, do you recommend any special toothpaste or desensitizing agents for your patients? [Wyman]I never use that.  [Jaz]Wow.  [Wyman]Never use that. I never use desensitizer. I never use any, because if you do conscious bleaching, you don’t need them. You’ll need them when you do unconscious bleaching, please do your bleaching consciously from now on. It’s the same thing. [Jaz]Because that was like a huge question. The community is, okay, which products, which desensitizing agents I use? Should I use pro relief? Should I use this one? Whatever.  [Wyman]I don’t use any.  [Jaz]I love that. Excellent. Well, I’m gonna take a moment to-  [Niki]Sorry, can I just say one thing? I mean, a funny thing is like when Dr. Chan is the first person who introduced me to treatment planning for whitening. According to me, whitening was simply taking impressions on people who wanted whitening, get the trays made, giving them the bleach. Hope I see you in three weeks in the teeth. That what Dr. Chen runs a treatment planning surface for whitening cases. And how many cases is it that you’ve done now in China, Dr. Chan, that you’ve-  [Wyman]About 10,000 cases. It’s a slightly mis line. A treatment plan? Yeah. In China.  [Jaz]And there is a plan because there’s a sequence and you every case is different and there’s a protocols.  [Wyman]Every case is different. And then we refine them. Like aligners. If something’s going right, we refine them, as we go along. So there’s lots of refinements.  [Niki]It was just wonderful concept that treatment planning and whitening. So, I’ve seen pictures from dentists coming from China where Dr. Chan will tell them step by step, okay, you need to use 6% there. Okay, we need to calm down in this area. Use 8% here. It’s amazing. Amazing. Something I’ve never thought was even something that we didn’t. [Jaz]I think it’s great you mentioned that, Niki, because I remember being a foundation dentist and I was telling, ’cause you’re right, we at undergraduate level, we don’t get taught whitening. So I remember going to my foundation trainer, like one or two months into it saying, look, I need, I think I need to go to the whitening course. Do you think I should go? And this was a bit when you left the UK. Yeah. So, this is when he left the UK and he laughed at me. He says, it’s just whitening. He’s like, just make some crazy and get some gel in there. Like, so there’s a culture, there’s a thing that is easy, but actually there’s so many nuances, right? There’s so many nuances. And you’re right about the treatment planning. Uh, I’ve got, because we got how much-  [Wyman]Can I add onto to your-  [Jaz]Please. [Wyman]I think that is whole research looking at a porosity density. But everyday life, you don’t have to do that because it’s cumbersome. It takes a lot of time and a lot of chairside time to how I say, to assess the porosity density of enamel, but just use what I just said. Conscious bleaching. That’s all you need. And the trays, that’s all you need. And then just adjust the time accordingly, because it’s really cumbersome. It’s not easy and you’ve got to be able to recognize it. And just like drinking wine again, you got to practice and practice and practice otherwise in front of your eyes. You can’t even know, you don’t know what you’re looking at. So stick-  [Jaz]I think if you drink enough wine, you won’t be able to see where it looks like. It’ll stick to something simple.  [Wyman]My trays and conscious bleaching, that’s it. And adjust the time accordingly. You can do it really very comfortable for your patients. And don’t go into too much the details, because that is complicated and take up a lots of chairside time.  [Jaz]I’m so excited to get this out to the community. By the way, this is already, so many gems in there. Dr. . Hello, Dr. Esther from Protrusive community. Is it true that patients should try a white diet when having treatment? [Wyman]I heard of that when I was started bleaching 30 years ago, after I done my PhD. It’s not necessary. I’m a coffee drinker. I’m a red wine drinker. Look at my teeth. Look at my teeth. They’re barely white, OM3. You don’t have to, if you notice signs I don’t want, let me go a little bit of into science then if you don’t mind. When we bleach the tooth, make it white, it’s the color of the dentine that reflects through a translucent enamel that we see in the color of the tooth. And dentine is usually darker yellow in color. So to make the tooth white, you have to bleach the dentine whites. Once you bleach the dentine white, doesn’t matter. Whatever you drink and eat. No. It doesn’t matter what you drink and eat. It’s absolutely, it’s actually no factual – what do you have to wait? Just wait for the pellicle layers to come back. Maybe take about five minutes. If you want to come back faster, have some chewing gummy coming in a minute. That’s it. You can have a cup of black coffee, a glass of red wine a minute after you do your bleaching.  [Jaz]Well, I’ve seen this advice about try a white diet. In like magazines and stuff, so it’s all BS. However, on courses for whitening or on aligner of courses where someone also wants to give some whitening advice, it has been said by educators that for two hours after whitening, avoid anything brown, avoid anything staining. Is that true or is that false?  [Wyman]Scientifically it doesn’t make sense. I can’t say it’s false or true, but some company actually advocate that two hours, no colored food and some company actually saying that for the whole cost of bleaching why you’re doing the bleaching you can only have white food. [Jaz]So what does Wyman Chan do?  [Wyman]No restriction. Zero.  [Jaz]I love it.  [Wyman]You can eat and drink whatever you want. No restriction.  [Niki]Just give it one minute.  [Wyman]I think I need to be safe, 10 minutes for the particular layer to form a thick layer on enamel.  [Jaz]Perfect. This is gonna be a tricky scenario that we face. Okay? So, non-vital teeth, let’s say you have like a single central, which is a bit more yellow or black. And I appreciate that. That’s a very significant detail. You can’t be blase about it ’cause the protocol will be different. But the crux of it is, this is from Ian. Thank you Dr. Humphreys for this question. How best to proceed with non-vital whitening when the patient also wants the other teeth whitening. So, for example, when I have such cases, I’ve done it before where I get my target tooth whiter and maybe slightly whiter than the rest, and then I start the whitening all the others, whereas other people say, just do ’em all at once. What in your experience works best as a rule of thumb? ‘Cause I appreciate that. Just like back to your point, Niki, that actually everything needs treat on planning. But to make it generic, is there a specific way that you recommend to approach this?  [Wyman]A single discolored tooth is discolored tooth and the less discolored tooth also discolored tooth. So, and normally I teach just do it at the same time. The more discolored tooth will whiten, will bleach faster. The whiter teeth will bleach slower. They’ll catch up. I haven’t seen a case that hasn’t catch up. I’ve done a lot of cases. They all, at the same time. They’re all external bleaching. I don’t do internal bleaching anymore.  [Jaz]Say that again in case someone missed it.  [Wyman]So I don’t do internal bleaching anymore. There’s no need for internal bleaching. This was the gem I was waiting for.  [Jaz]This is okay. This is pretty cool. Okay. As someone who has done, I’ve got some great photos. I can show you internal bleaching cases and I’m very proud of them ’cause you said show your bad case show good case. Now for the visual feature of this podcast, what we’ll do that. But I’m amazed. So we’ll save that for the visual podcast. So make sure you guys tune in to that one as well. [Wyman]I’ll send you some amazing cases..  [Jaz]Yeah, without having to actually open up the access cavity again. That’s fascinating. Okay, cool.  [Niki]So, sorry. Where it becomes even more useful is, so where it becomes even more useful is your dark tooth that hasn’t had endo –  [Jaz]Metamorphosis.  [Niki]Yes. That’s where it becomes really useful, because an endo tooth already has a cavity at the back of the tooth there. So, I mean, walking bleach technique, you can do that. But there are dentists out there who are advocating for those dark teeth to do endo and then walking bleach technique. You don’t need to do that anymore. [Wyman]Now, I used to do internal bleaching. I’ve got very good result. I learned that, but then I started experimenting because it’s very technique sensitive doing internal bleaching, really technique sensitive and also taking up a lot of chair time-  [Jaz]But also it can be iatrogenic. ‘Cause every time you open up an as cavity, can you guarantee that you’re not removing some more dentine, some more enamel? You will be scratching a little bit. Absolutely right.  [Wyman]I’m not a restrictive dentist, so I’m just look at the bleaching side. But now I just offer another alternative way of bleaching that tooth. I think we are so lucky to be a dentist. We can do certain things in so many ways. In many ways of doing certain things. So I just add another option to the dentist to choose. If they learn internal bleaching, please do them.  [Jaz]Well, it’s also something like for some reason, obviously we’re going talk about in the next episode, but for some reason they’re not getting the result that they usually get from when they do the access cavity, do the internal, they still have that option to go inside, but if you start outside, there’s more minimal. It just makes a lot of sense to me.  [Wyman]And it’s non-invasive.  [Jaz]Yeah. I mean, why not? I mean, with non-invasive and chair time. It makes sense.  [Wyman]Chair time is my, because I don’t have the drill anymore, I can’t do internal, my bleaching because I’m. This is just because I give myself restriction. I have no drills in my clinic. Absolutely. No drills.  [Jaz]There we are.  [Wyman]How can I do internal?  [Jaz]That’s the proof. This man doesn’t even own a handpiece.  [Wyman]I don’t have a handpiece. Fast, slow. I don’t have a handpiece.  [Jaz]Excellent. Peroxide allergy. Is it a real thing? And how common is it?  [Wyman]I came across that on a couple of my patients. They claim that they allergic to peroxide, so I send them to hospital and then they done a lot of tests. So, it happens to be the makeup. This was bought a week before.  [Jaz]So they, what?  [Wyman]It’s a makeup they bought a week.  [Jaz]It’s makeup. Okay. Cosmetic thing. Yeah.  [Wyman]I read a lot of literature. There’s no proof that peroxide give us an allergic reaction. The reason is that because peroxide is not a foreign substance. We produce it in our body. If allergic to peroxide will be in real trouble. [Jaz]Well, I have a patient who, she tried, we tried whitening for her. And then she’s starting to say her lips start to swell. Her lips were swelling. What do you think was going on there?  [Wyman]For example, if you use 16% carbamide peroxide, my peroxide, what’s the other 84%?  [Jaz]What’s the other 84%? Okay. So it’s not the peroxide, it’s what else is in that gel that’s causing it. Okay. Do we know of any common agent that-  [Wyman]No, we do not know because has no research is done in that field. But to come really to prove it’s allergic by peroxide, there’s none. The literature there, there are hundreds of thousands is none. [Jaz]Okay. So if that’s happening, maybe changing the brand of the whitening, maybe effects just, and also the hospital, the true test. Yeah. And ’cause we cosmetic-  [Wyman]Always send them to the hospital to do some testing with the product is what they can test it on.  [Jaz]Yeah. Okay. Perfect.  [Niki]It’s quite similar to sort of patients saying they’re allergic to adrenaline and the anesthetic there, but there are some patients who are adamant that they are allergic to adrenalin. [Jaz]That’s true. That’s a good point actually. Very similar. Okay. We have some questions about light, which I’ll come to. There’s also some questions about, yeah, more about sensitivity. Tetracycline staining. I have read some guidelines that it’s a three to six month worth of whitening treatment. Is that something that is predictable? Is this something that you’ve treated before with success? And anything, any tips you want to give to dentists who want to not do veneers and crowns on these tetracycline stained teeth and they want to use whitening?  [Wyman]I think probably wait for the V show. If I ever saying anything now, you will not believe it.  [Jaz]Wow. Okay. So even more excitement for the visual episode.  [Wyman]Seeing is believing, I mean, tetracycline teeth, they’re just staying on the dentine mainly on the dentine. Because we take the tetracycline antibiotics into the bloodstream and get to then it get to the pulp and then it affects, when the dentine is forming it, it affects the dentine formation. If we take it earlier, it can affect the enamel as well. So it depends on the age. It’s bleaching. It’s discolor tooth. If you got a good protocol, it works. Like I can show you some cases just two weeks. It’s amazing result we get from a C4 to B1 just two weeks. [Jaz]Two weeks for  tetracycline staining.  [Wyman]Yeah. And then we have amazing result four weeks.  [Jaz]Alright, let’s wait for the visual one guys. So you guys have to tune into that. That’s fantastic.  [Niki]Just one thing about  tetracycline staining.. ‘Cause I asked, first thing I asked Dr. Chan about sort of tough cases,  tetracycline staining,, but something Dr. Chan told me that’s very poignant. In 13 years, I’ve seen two tetracycline cases in my whole 13 years. This was a problem that was in the seventies and eighties and nineties when there was a lot of tetracycline antibiotics being taken and a massive problem in the far east. So in China where Dr. Chan practices and teachers there. That’s still a massive problem, but that even then, because the younger generation now, they’ve not been exposed to tetracycline. So it’s a very rare thing that we are gonna get tetracycline staining, especially this side of the world.  [Wyman]Yeah. It’s very rare in the West now. It was, we started prescribing tetracycline in 1965. And then we stopped in 75 because we dentists discover a group of children got very discolored teeth. And banded as well. And then, we start the doctors, the GP started tracing back and everyone had  tetracycline.  [Jaz]One day it’ll be like in a textbook that there, the once upon time there was COVID, once upon a time there’s text cycling state.  [Niki]I was saying our kids are gonna learn about COVID and history books like we learned about the Cold War.  [Jaz]And we’ll learn about text cycling in the dental history books as well. Uh, okay. The last question I have then, before we then take a break and we pivot into the visual one, which I’m very excited for, especially the  tetracycline, is all to do with light. So when I qualify as a dentist, there was this various brands that had the lamp, that whether it was heat or whether it was light or photo initiated, all these things and then coinciding with a time where the legislation changed and now you can only use a certain percentage that almost vanished. And so is like, what I’ve heard is that that light is a gimmick. What I’ve heard is that that light, the light is just marketing and there’s no science back. Even the warming is not so significant. So I guess what I wanna know is, do you you use photo initiation or light as part of your protocols? [Wyman]Are we talking about in office bleaching here?  [Jaz]Yes.  [Wyman]I don’t do in office.  [Jaz]Okay, so-  [Wyman]I don’t use light.  [Jaz]Is it in office, even like when you’re consulting dentist, you are giving ’em advice. Like they start a new clinic and they say to you, Hey, I wanna start offering whitening. Should I even include in office as a treatment modality? And sounds like you’re gonna say no, but why is that, why do you not offer it yourself?  [Wyman]I would say no, because it take up so much chair side time. It’s really not worth it. You’ve got to charge so much money for the chair side time. And it’s how much can you charge? So it’s not, not how we say it, it’s not profitable, it doesn’t make sense. And it’s very technique sensitive. The sensitivity is from chair side. There’s a lot of things can happen at the chair side. I don’t wanna go into it. A lot of things can happen. The pain was created during the chair side treatment, not home. So avoid that.  [Jaz]It did make sense. And then therefore we don’t need those. [Wyman]You don’t need to do chair side. Especially, I’m so pleased with new regulations. We can also can use 6% so we can get rid of the chair side. We don’t need chair side. And it’s very, and those other countries can use 40%. It’s so risky. I mean, look at that.  [Jaz]I mean, in Singapore when I was there, we using high percentages. [Wyman]Look at the damage you done on those accidents. You really are talking about massive damage, burning gums. Burning lips. And the gums peel off. It’s not worth it. Just not worth it.  [Jaz]But then as part of your protocols, when they take the gel home and the tray in your trays is there, and I learned that yes, the gel’s very fresh ’cause it’s got the activator. But is any form of light therapy used in your whitening protocols?  [Wyman]No, we don’t use light.  [Jaz]Listen, if Wyman Chan’s not using light, do you need to use light, doctor? I want you to really look in the mirror and reflect on that point guys, for anyone who has any question about light. Okay. Because the man has spoken. Now, before we wrap this up, I want to ask about, is it okay if ask about Magic 3? Is there something you want go into-  [Wyman]Of course. Yeah.  [Jaz]Right. So Niki’s showed me some images of inflammation or inflamed gums, abscesses managed using a gel formulation containing peroxide. And it was like, it looked amazing. Okay. And so you are the inventor of all this?  [Wyman]Yes, I’m inventor. Yes.  [Jaz]Tell me about like what the problem was that you faced that, what was the problem that you thought, okay, we need some sort of solution. What problem are you solving with this and where is the journey in this product development so far? [Wyman]Okay. I spent a lot of time in China. I’m working with one of the group practices, which is mainly an orthodontic base practices. And then, and they have about 25 clinics and they do a lots of clear aligners and some fixed as well, a lots of clear, they have very good, lots of ’em about my PhD and professors in Peking university. And I worked with them and initially I didn’t see a lot of children. But then as we get closer, get a bit friendly with the orthodontist, and then they came to me say that and show me some cases and said they have this problem, which is the white patches and white patches. And then they show me that the children, even though how well they would motivate them to do good oral hygiene and to success, can’t do it. Children are children. They just can’t manage the good oral hygiene as which we fix braces. And that’s when one of the professors, actually, when we’re talking, we spend lots of hours. Drinking and talking.  [Jaz]Red wine.  [Wyman]Red wine. Red wine, yeah. And we actually spend hours on what we can bring and what we can help the population. And then he come over, say, we’ve got all this problem with plaque control. He said, can you, say mechanical cleaning is difficult. Can you make something chemical so that to help them before hygiene. So I say, oh, okay. Because I look at, because I’ve done a lots of work, I know plaque control. I look because those cases, especially when you see those cases, you don’t get results. There are lots of plaque on the teeth. The bleachers couldn’t get to the teeth. So these are the cases, you don’t get good results. So that’s why I always very keen and plaque control, make sure the teeth that I’m gonna bleachers plaque free, if they pull a plaque, they’re not gonna work. Mm-hmm. They’re gonna-. The, peroxide. And it’s all wasted. And that’s when I started looking into it. And what I have, my formulation I have is all too strong, it burn gums, all those. So I come up with Magic 3. Magic 3 is 3% hydrogen peroxide base. And I modified the formula. Then I got a, I actually make into a medical device, a Class one. So that everyone can use it and 18 can use it.  [Jaz]Under 18.  [Wyman]Because it’s a medical device. Class one, it’s registered and when I make this product, I send it to the MHRA. They say they have no such thing. So because I say this is a colorless plaque indicator, remove plaque at the same time also reduces gingival inflammation. They say, we have nothing like that. So they refer me to organization, so called GMDN to Global Medical Device Nomenclature. So I went there, I joined the members. I say, I got these products. I want to register as a Class one, but the MHRA say, they haven’t got such products, said, no problem. We’re gonna look at it and we’re gonna give you a new number and then you apply. And we did. It took us two months. We got, they actually make a new number for us. Yeah, so it’s brand new, it’s innovation. So we got a Class one in this country. I’ve got a Class one in China as well. So this is amazing. It’s a colorless plaque indicator. Have you heard of something so ridiculous before?  [Jaz]No. So the traditional case, bright pink, bright purple.  [Wyman]Exactly. So you see, the way I look at it is that it’s not only indicate plaque colorless and it’s also rainbow plaque at the same time. So the reason I brought this up, I thought about it for, for about a couple years to bring this up. So I look at the traditional plaque indicator. They are colored and the mixtures of this closing material with the plaque or bacteria or the plaque itself. And produce color. And then we have to use mechanical means to remove them. To me, I think you give them poison and then you get them antidote. That’s not, see, and that’s why we do not, I mean, how can we trust patient by discolor the teeth and then will remove the color and charge them? I think that’s all right. So then I come up with a colorless, it produce the effervescence. [Jaz]So that’s how it indicates it. Indications not through color, but through fizzing.  [Wyman]Fizzing, bubble. A lot of bubble. I can shoot you some visual. At the same time, when it bubbles, it breaks down the clock. It’s gone. And at the same time, it reduce gingival inflammation because all the anaerobic bacteria is gone. Actually, we put it in the sulcus, we apply and I show you some cases. Amazing the 10 minutes information just disappear. 10 minutes, gone. Gone.  [Jaz]Now what I’m saying in my head, ’cause I want challenge, I want to question. I’m remembering, Professor Zjilstra-Shaw from Uni Sheffield, she used to say to me that, I know it’s not a mouthwash. I know it’s not a mouthwash, but she used to say, it’s like when you go to the car wash, no matter how much solution chemicals they use until they get the elbow grease, until they get the sponge and they mechanically clean your car, it will be super clean. So it won’t be super clean unless the, until you get the mechanical. Is this solution a substitute for mechanical plaque removal?  [Wyman]It’s a substitute for mechanical cleaning. To me, there’s no need to do polishing anymore. No need to do-  [Jaz]Does anyone need to brush their teeth anymore?  [Wyman]If they use it every day, they don’t need to brush your teeth. [Jaz]That’d be an expensive thing to do, right?  [Wyman]Very expensive. Yes, they can do it. That is very expensive. Really expensive.  [Niki]That’s what you use, right? Magic 3 on your cell phone.  [Wyman]Yeah. So you can use it, but it’s very, very expensive because the product’s expensive, but I still-  [Jaz]So what problems are you solving then? [Wyman]I’m solving that with children to kind of brush their teeth properly.  [Jaz]And thus they will not get white spot lesions because the oral hygiene is improved because you’re making it easy for this uncompliant or difficult population who struggle and then the elderly as well, I imagine.  [Wyman]The elderly and in fact, everyone. Those people who doesn’t like brushing their teeth basically. And then, and especially if we have any gingival inflammation and the reason why the patient do not brush their teeth with the gingival inflammation because the bleed, they still scared to brush. So if you can get rid of bleeding and show them that oral hygiene is too important, I don’t want them to use the Magic 3 every day, maybe once a week, once a month, and go to see the dentist every three to six months. Just a prophylaxis as far as Magic 3 just a prophylaxis system.  [Jaz]So it’s like those anxious patients, right. They haven’t been the dentists in years. And then to even go near them if they use a gel to get their bacterial load lower and then less pain when they’re actually having the mechanical means. Is that what you had in mind as well?  [Wyman]Yes. It’s no pain. It’s no mechanical means that means we can remove plaque, no noise. No vibration, I think to the dentist across.  [Jaz]Oh, the anxious patients. That’s amazing.  [Wyman]No aerosol. It’s a no brainer.  [Jaz]So next pandemic.  [Niki]Dr. Chan never shot during the pandemic?  [Wyman]No, no aerosol. and it’s not only just remove plaque, it’s remove plaque chemically so we don’t have to use mechanical means. It dissolved the plaque away. Probably seen a lot of chemical, dissolve the stains away. Similar stuff just dissolve the plaque away. It just use water to just three, one water. Just wash it. It’s nice. The teeth for the first time, you will see your patient’s teeth shines. They shine, they’re shiny. [Jaz]But I mean, if they’re using it for 10 minutes, then it’s not there to whiten the teeth at all. It’s for biofilm removal and inflammation. And Niki, you told me abscesses, that’s an interesting one. Tell me about that. Pericoronitis makes sense.  [Niki]Pericoronitis totally a lot of sense. [Jaz]But abscess is.  [Niki]It acute germs. Anaerobic. It’s anaerobic germs.  [Wyman]When you get rid of the germs, you can reduce the inflammation. Mainly it’s to reduce the inflammation. Gingival. We’re not talking about periodontal. That’s gingival.  [Jaz]Okay. Okay, fine. And in terms of evidence-based, where are we at now? ‘Cause obviously it’s a new product. Where are we at now in terms of the future? In terms of evidence based?  [Wyman]Evidence based recognition. So I think the best evidence will show a lot of cases, case studies. I think if you don’t do it yourself, see it in front of all eyes. You can read a hundred of papers, you still don’t believe it. You actually need to do it. Try it. If it doesn’t work, just say, well, okay. I’ve been cheated. If it works wow, to say it works.  [Jaz]I mean, Niki showed me his own cases. So I’m very interested in this. When do you think this will be available in the UK?  [Wyman]It’s available now. So I launched that, I actually launched that in Shanghai about a year ago, which is a show. And then I launched that in the Dubai. And then, now we’re gonna launch this in London in the Dentist Show. Dentistry show.  [Jaz]You had it here first. [Wyman]We’re gonna do live demo. Please come and see us and be a model as well. And if you have any gum inflammation, come and see us. We get all them for you, I mean, gingival inflammation.  [Jaz]Amazing. Well, how can we find out more? Like obviously the Dentistry Show. Have you got like a website or more information? Anything you want to basically, ’cause we have a very curious, geeky community. Or just say, wait till October or in the future I can add the links or – [Wyman]Yeah. Wait till October. Just come and see us. So you won’t miss us. It’s gonna be a big crowd.  [Jaz]Amazing.  [Niki]And you’ll be able to see it live.  [Wyman]You’ll be able to see Magic 3 treatments being done live. If you wanna be a model, by all means, let us know and you can come and get it done yourself there. We’ll be also presenting sort of the different uses of Magic 3, while the dentist patient is having the Magic 3 treatment done. So the funny thing is, I’ve been using it for five weeks in my practice in Romford. I started off just by telling people, look, I’m gonna do your cleaning a different way without torturing you. I’m still charging you banter, nothing else. But if you’d like it, tell all your friends. Three weeks after doing that, we had people come into our reception. I want hygiene them, but I want the magic treatment. I want the magic treatment. My receptionist was not clued on at the time. She said, we are a dental practice. We’re not a magic center. And then my other dental nurse had come out and said, no, no, no. That is for treatment that Dr. Chan is doing there. So we haven’t made it sort of common knowledge that’s available. Really the Dentistry Show is when we are gonna make it available for everyone. But it is available now.  [Jaz]Thanks for allowing this podcast be the first one to talk about.  [Wyman]Amazing community. Definitely. They deserve it. They do.  [Jaz]Okay. Awesome. Well, I’ll put, when you do have more links available, I’ll add them in the future, obviously as we build on the content. But I look forward to have you seeing you in the dentistry show to actually see it in action. I know you’ve probably got some with we will talk about the video. But anyway, you have to join us guys. You have to join us in the video segment of this podcast. Okay, so this one was for anyone on Spotify, apple, and obviously community on Protrusive Guidance and YouTube to listen into. But the next one is not amenable to Spotify or Apple or audio. Next one’s been very visual. I will show you the case of like a common problem I’ve seen whereby the incisal half is, is gray, like is this amenable to whitening? And I’ll show you a case that I think a patient lied to me. And I’ll show you that. I think she, she was telling me she’s whitening, but she wasn’t whitening. Okay. And I will, you tell me if you agree. So if you want that guys, you stick around for part two of this must listen to, must watch episode. Niki, Wyman, thanks so much for this one. Catch you in the next one.  [Wyman]Thank you.  Jaz’s Outro:Well, there we have it. Guys, thank you so much for listening all the way to the end. Thank you also for our guest, Niki, for helping to arrange this and supporting and helping Wyman Chan with the Magic 3 launch. Before I talk more about that, again, you can get CE or CPD credits for this episode. We are a PACE approved education provider. If you’re watching this on the app, scroll down below, answer the quiz, claim your CPD, and if you’re watching on YouTube or listening on Spotify, get yourself on the app. Come on, especially if you listen to all the episodes you can rake in the 52 new hours of CE every year. That’s just the new CE, not even including the masterclasses and the old episodes. So you’ve been a long time lurker. It’s time to finally say hello to your community at protrusive.app. Hope you enjoy this particular episode, asking all of our whitening questions. You can get involved, right? Like when you are like on the community, we give you opportunities to ask questions to our guests, just like today’s episode. Now, don’t forget, if you’re interested in Magic 3, which has really piqued my interest, head over to protrusive.co.uk/magic3. There’s a special promotion for October and there’s an ongoing discount just for Protrusive members, so to take advantage of that is protrusive.co.uk/magic3. I’ll also post it on the centric relationship section of the app so you don’t miss out. Thanks again my friends, and catch you same time. Same place next week. Bye for now.