Protrusive Dental Podcast

Can and should Dentists carry out home sleep testing? It’s actually super easy and I have been doing it for 18 months! What happens after you screen them—do you know what to do next? This episode will teach you! Dr. Jaz Gulati shares his personal journey into incorporating sleep testing in practice—after 1.5 years of doing it, the impact has been nothing short of game-changing. https://youtu.be/H4rTkIuOHWI Watch PDP243 on Youtube Joined by clinical sleep scientist Max Thomas in this jam-packed episode, they deep dive into what it really means to go beyond awareness of sleep-disordered breathing. He breaks down the practical steps for dentists who want to do more than just refer—and start making a difference in their patients’ lives. You’ll learn how to bridge the gap between theory and action, how to screen effectively, and why you play a pivotal role in the patient’s journey to better sleep, more energy, and a healthier life. Protrusive Dental Pearl: If a patient has been seen gasping, choking, or stopping breathing during sleep — that’s pathognomonic for sleep-disordered breathing. 🛑 Don’t ignore it — they likely need a sleep study. Ask this in every history! Key Takeaways: Understanding obstructive sleep apnea is crucial for dentists. Dentists are in a unique position to screen for sleep disorders. The Malampati score is an easy tool for assessing airway obstruction. Sleep disorder breathing can significantly affect quality of life. Patient history is vital in diagnosing sleep apnea. Quality of sleep is more important than quantity. Dentists should ask specific questions to identify sleep issues. Sleep position can significantly affect sleep quality. Screening tools like Stop Bang and Epworth are essential for identifying sleep disorders. NHS sleep testing can vary greatly in wait times depending on location. Snoring is often a precursor to more serious sleep disorders. Dentists can play a crucial role in sleep disorder management. CPAP is the gold standard for treating sleep apnea. Understanding the legalities of sleep screening is vital for dental professionals. Remote monitoring became essential during COVID-19, shifting paradigms in sleep medicine.. Remote monitoring helps ensure patients are truthful about their usage of devices. Mandibular advancement devices may be more effective for certain patient profiles. Patient compliance is crucial, with many struggling to adapt to CPAP. Highlights of this episode: 00:00 Teaser 01:15 Intro 04:51  Protrusive Dental Pearl 05:52 Introducing the Expert: Max Thomas 09:39 Importance of Screening and Diagnosis 13:41 “Crowding” at the Back of the Mouth 14:46 Mallampati Score 18:54 Understanding Sleep-Disordered Breathing 25:35 Screening Tools and Techniques 32:09 Screening Questionnaires 37:24 Midroll 40:44 Screening Questionnaires 40:53 Athlete Sleep Screening and Marginal Gains 44: 20 Identifying Patients for Sleep Testing 46:15 Snoring: Risk Factor for OSA 51:44 Mandibular Advancement Devices and Legalities 55:33 Diagnostic and Treatment Options 56:57 CPAP: The Gold Standard for Sleep Apnea 01:08:33 Retesting Before MAD 01:14:41 Dentists Warning about DVLA Implications 01:17:18 Final Thoughts and Recommendations 01:19:19 Outro Resources for Screening Sleep Apnea S4S Pre-Screening Questionnaire Mallampati Score Epworth Sleepiness Scale STOP BANG Questionnaire Screening Tools The Acupebble Device  WatchPAT as an alternative Send your sleep test for reporting to Max Thomas – excellent service and affordable Max Thomas’ LinkedIn If you loved this episode, don’t miss Sleep Disordered Breathing and Dentistry – PDP139 #PDPMainEpisodes This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A, C, and D. AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Sleep Medicine) Aim: This episode is aimed at empowering general dentists with the knowledge and practical steps to actively participate in the screening and co-management of sleep-disordered breathing through the integration of home sleep testing in their clinical practice. Dentists will be able to – Understand the role of general dentists in identifying signs and symptoms of sleep-disordered breathing, particularly obstructive sleep apnea (OSA). Identify when and how to refer appropriately to sleep physicians or medical specialists after screening. Explore collaborative workflows between dentists, sleep scientists, and GPs to ensure effective patient management.

Imagine your patient is choking on a rubber dam clamp…what’s the safest way to manage choking when the patient is lying flat? Your patient’s hands are shaking and they’re drenched in sweat – is it low blood sugar, anxiety, or a cardiac event? ​​Do you know exactly what to do if your patient has a seizure in the chair? This second part of the Medical Emergencies series with  Rachel King Harris dives even deeper into real-life scenarios that dental teams may face. From seizures and how (and when) to give buccal midazolam, to managing choking in a dental chair, this episode is packed with practical, clear guidance. We also explore key steps in treating diabetic hypoglycaemia, understanding glucagon vs glucose, and how to confidently manage patients with angina or previous heart attacks—when to use GTN, when to give aspirin, and when to simply wait for the ambulance. It’s all about staying calm, being prepared, and delivering safe, effective care when it matters most. https://youtu.be/fyIIsT0dlIc Watch PDP242 on Youtube Protrusive Dental Pearl: Assign a clear lead to regularly check the expiry dates and supplies of emergency medications and equipment. This isn’t just about ticking regulatory boxes — it’s about saving lives. Little checks like this can make a big difference in a true emergency. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 00:00 Teaser 00:44 Intro 03:09 Protrusive dental pearl 04:14 Recap from Part 1 06:58 Seizures: Personal Experiences and Practical Tips 13:45 Seizure Emergency Kit: Buccal Midazolam 21:29 Emergency Drug Kit Overview 22:10 Choking: Techniques and Guidelines 29:19 Midroll 32:40 Choking: Techniques and Guidelines 34:05 Handling Infant Choking Emergencies 36:11 Recognizing and Managing Hypoglycemia 41:11 Emergency Protocols for Hypoglycemia 47:35 Managing Cardiac Emergencies in Dental Practice 58:59 Final Thoughts and Training Recommendations 01:00:39 Outro Stay up to date by reviewing the latest guidelines from the Resuscitation Council UK. Grab your Anaphylaxis Summary + Medical Emergency Cheatsheets from https://protrusive.co.uk/me. And make sure you’ve listened to Part 1 of Medical Emergencies so you don’t miss any crucial information. #PDPMainEpisodes #CareerDevelopment #BeyondDentistry ​​This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes C and D. AGD Subject Code: 142 Medical emergency training and CPR Aim: To equip dental professionals with the knowledge, confidence, and practical skills to recognize and effectively manage common medical emergencies in the dental setting, ensuring patient safety and optimal outcomes. Dentists will be able to: Identify signs and symptoms of common medical emergencies in dental practice, including anaphylaxis, asthma attacks, seizures, angina, hypoglycemia, and stroke. Describe the immediate management protocols for each emergency, including correct drug doses, routes, and timings. Demonstrate appropriate use of emergency equipment and drugs available in the dental setting. Click below for full episode transcript: Teaser: And you're saying that you deal with one hole only and it's the mouth and not anywhere else. Teaser:When you’re becoming a dentist and you have to choose between medical and dental school, you either look up one and you look down the other, and so I said, let me look down, not up. So here we are. That made me realize, and the advice on that Facebook post was, anyone age five or under choke on grapes. And so you totally agree with that? I do. I do. I just think it’s not worth it. Sweaty. Sweaty. Very, very clammy. You know, there’s pools of sweat that I mentioned with hypose. You can get exactly the same with an MI. Yeah. Nausea, vomiting, sweaty, clammy, impending doom. So again, a bit like anaphylaxis, they say they feel like they’re gonna die. Blood pressure drops usually. Not always- But here’s the thing where this is happening, right? I’m going back to- Jaz’s Introduction:Welcome back to Part Two of Medical Emergencies to get you that big fat tick for your annual CPD requirement for medical emergencies, and hopefully in a way that you can leverage the time of commuting so it doesn’t feel like something extra you’re doing. Also in a way that was conversational, something that was easy to listen to, and hopefully the retention will be really good. And to enhance that retention, don’t forget, we have got our premium notes, like a revision summary done for you notes for every episode for our premium subscribers. If you’re not on the already, head to www.protrusive.app. In the last episode, we covered the most common medical emergencies that we see or could see vasovagal syncope, anaphylaxis, which is worrying and common nowadays, but with serious consequences. And we talk a lot about oxygen, like which medical emergencies should we be giving oxygen for and how do you actually give the oxygen? The thing is right, we as dentists, we hardly ever administer oxygen. We only are told to do it when there’s a medical emergency, but I want to cover it because when push comes to shove and we need to deliver the auction, I’m hoping you found it useful to hear and to watch for those of you’re watching how to actually activate the damn thing. And what it all looks like and works like. So that was all covered in part one. In this part two, we’re covering seizures, how to handle a patient that is having a seizure, including how you might actually deliver the buccal midazolam. What does it actually look like and feel like? And interestingly why in many scenarios you may not even need to give it. Then we moved to choking. And we all know about back slaps and abdominal thrust, but we simulated choking and we discussed choking specifically for your patient that is like laying down the chair the exact steps you should do when your patient’s in your dental chair and why. Therefore, you may need to do a one handed abdominal thrust. And so you get to hear about that and watch that again, if you’re watching on the app. The last two things we discussed were diabetics and how the whole glucose and glucagon works and how to administer each one, as well as our cardiac risk patients. These ones are very common patients that make me a little bit nervous. These are patients with a history of angina, history of heart attacks in the past, and so therefore, should we be avoiding using adrenaline containing local anesthetics. And what should be doing if they’re having some sort of an episode in your chair. So once again, we’re joined by Rachel King Harris, or today’s part two, Deep Dive into Medical Emergencies. Dental PearlHello, Protruserati. I’m Jaz Gulati and welcome back to your favorite Dental Podcast. Every PDP episode I give you a Protrusive Dental Pearl. In the last one it was to download for each condition the kind of like cheat sheet prompts that when you open up your medical emergencies drug box, like it’s so reassuring to see the step by step what you’re looking for, what to do next. It was like a really helpful thing. I think every single medical emergency is boxing. Every dental practice should have this. So that was last episode’s Protrusive Pearl. This one is a bit more simple, but equally important is that are you checking the expiry date of your meds? Who has been allocated as someone who takes a lead on this? Not only is this important to satisfy CQC or regulatory requirements to make sure your practice can run and stay in business. But this is life saving stuff. So who’s the person who’s checking monthly or quarterly to make sure that nothing is running out of date and that all the supply is there and it’s working and you haven’t run outta oxygen or your glucagon’s not outta date, and all those things. So make sure you have a clear lead because that’s how you Protruserati, these little things are the big things. Hope you enjoy the episode. I’ll catch you at the end. I’ll give you more instructions of how to claim the CPD. Main Episode:Rachel, welcome back again to the Protrusive Dental Podcast for part two.  [Rachel]Thank you for having me again. [Jaz]So in the last episode, we covered the common things. What I wanna do is make a really tangible piece of content with your help. So we covered the things that most likely common to happen. Okay. So, vasovagal syncope, ie the faint, super common, went deep into that. We went into anaphylaxis and I think we covered it really well. We also talked about the oxygen, about what is the right dose of oxygen? Can you actually do harm by giving oxygen? And generally the consensus was, no, actually, it’s a good thing to have in practice. And I also took out the drug kit and it was really nicely how it was organized. And that might be inspiration for other practices. So one thing I did promise from the last episode, part one, is like the other, attach some downloads. So the laminated sheets you can actually put in your emergency drug kit box. But I wanna do in this episode cover the other more common ones. And also like I was thinking, should we do angina and should we not? But actually more important angina might actually be choking ’cause something that we might actually see out in the community. And also, like I’m using products all the time, which could are always a choking risk.  [Rachel]Absolutely.  [Jaz]Appliances. I remember using one of our drills before, like diamond drills and it was probably my silly error, but when we actually put, it’s a friction grip. So you put the diamond in and then we release a chuck and then it stays. And so I always, since then, I always check, every time I put my bow in, I always check to make sure it’s in. But I must have not checked that time. And I was, as I’m drilling, and it sort of flew to the back of the throat, now remain calm, got my tweezers, picked it out. Like literally kissing the uvula. Yeah. And took it out. But sometimes I can go in the wrong hell or someone can start choking on something.  [Rachel]Exactly.  [Jaz]And so to know how to manage it is important for what we do.  [Rachel]It’s a good life skill.  [Jaz]And it’s a good life skill out in the community. So I think let’s definitely talk about choking. And if we go through the emergency drug kit, I just wanna do an overview of that. Before we also talk about a few other common ones. So, I promised the emergency drug PDF, and we’ll put that on there. So as you open this kit, we see one for fainting, which we talked about last time. Interestingly, there’s a glucose gel over here. What do you think about that? Do you think it’s important for us when we see a vasovagal syncope or a faint to give a glucose gel?  [Rachel]It’s not something that we would do. We would probably, as I’ve said in the last episode, one is that we would just raise the leg. We wouldn’t go for the glucose gel.  [Jaz]But you kind of see it’s like the hardly- [Rachel]Is it a placebo?  [Jaz]Yeah. Yeah, probably.  [Rachel]Yeah, and then if so, if it makes the patient feel better, then that’s fine. It’s not gonna cause any harm. But obviously if they’re diabetic, it could cause harm. If they have a normal blood sugar that you could then shoot quite high. So just use with caution.  [Jaz]Okay. They do. We talked about anaphylaxis last time. Okay. So if you haven missed that first part episode, check it out. Where we went through what’s inside here and what to do in terms of ampules and stuff. We have all the sort of guidelines and cheat sheet, which I’ll make available to you guys. Seizures. Okay, so while we’re on this, let’s talk about that. Then we’ll come back to choking later. So, seizures, how many have you seen in your sort of time as a nurse?  [Rachel]Lost count.  [Jaz]Wow, that many. Why is that?  [Rachel]Because we get a lot of patients that not necessarily come in. We have, there’s two groups, right? One’s that come in in something called Status, which is where they’re continuing to seize, so they haven’t come out of their seizure. And then we get patients that come in through other medical reasons, but can also make their epilepsy worse. So then they all end up having a lot of seizures in hospital. And just through being in the wrong place at the wrong time. I also have seen people having seizures in the community that I’ve caught over to help because as a medical professional, you don’t walk past somebody that’s in trouble.  [Jaz]Do you find that as a medical professional, that you are a magnet for these issues in the community? [Rachel]The amount of text messages I get with people showing their kids’ rashes is unbelievable. Yeah, I feel like I’m 111. So yeah. It is. And you know what, if me responding to a message about a rash in a text makes that parent feel, my friends, feel better about going to bed that night, then more than happy to. But you’re right. You probably get, can you do my root canal? It’s the same-  [Jaz]Pictures of teeth, awkward pictures of gums in like a really poorly taken image. So.  [Rachel]So yeah, I have actually come across a fair few sort of people just being in trouble out and about are just on my journey day to day. And seizures is one of them. So-  [Jaz]I mean, nasty stuff, unfortunately, one of my cousins had his first seizure recently and if I showed you photos of him, it’s not a pretty scene. You’d think that he’s going into a fight. And so this is a very scary thing when it happens. Or we worry about in the dental practice if a patient has his seizure. How can you make it safe for that patient?  [Rachel]Correct.  [Jaz]How do you make sure you don’t panic? And then how do you recognize it and get them the correct treatment? So let’s talk about that. How many seizures happen and it’s like, oh, that my first one? Do you see what I mean?  [Rachel]Well, interesting you say that. ‘Cause actually just a personal story. My nephew started having seizures at a very, very young age. I think he was about two or three, but we didn’t realize they were seizures. Because not all seizures drop, go unconscious and start shaking. They can sometimes be conscious when they’re having them and they can just literally move. And what he used to do was his leg used to just shake like this, but just one of his legs and we just associated with, he did the toilet. So for years went by, unfortunately, but fortunately they did find and he had a tumor in his brain. And he had it surgically removed a couple of years ago. Gosh. And he’s been seizure free now for two years. [Jaz]Amazing.  [Rachel]But it went on for years. But they don’t all look like seizures, is what I’m trying to say.  [Jaz]So in the dental practice that we think that, keep everything safe, move everything away. Because we’re imagining someone really going for it, wailing around, but it’s always like that. [Rachel]And some patients can tell you they’re about to have one, which actually can be quite helpful. ‘Cause they can say, I’m about to have a seizure and you can actually prepare the station if they are. The biggest thing for dentistry is the equipment that you have around, because we talk about danger, like check for danger. Now, what’s the most dangerous thing? Is all your instruments, they’re sharp. They are literally by the patient’s head. So the key thing with seizures, above all else, forget the medications. Forget is actually maintaining safety, your safety and their safety. So have a quick look around your surroundings. Make sure that you’ve clear-  [Jaz]So for us, that’s moving away our bracket table where the instruments move out the way, move the suctions stuff out the way.  [Rachel]Yeah, making sure that anything that they may thrash their head against, ’cause you don’t wanna cause a bit of a head injury if they are- [Jaz]In that classic group. [Rachel]Yeah. And then once you’ve maintained safety, then you can move on to, okay, how are we gonna support this patient? The only thing about the suction that’s quite helpful is if they bite down on their tongue, the tongue being a very big organ will bleed, bleed, bleed. So actually your nurses are perfect. Because they are the kings and queens of suction, should I say? They’re great. So actually having suction nearby is quite helpful, particularly in your area. But it’s about maintaining their airway if they stay in that seizure for a prolonged period of time. It just depends-  [Jaz]What would collapse that airway from seizure? Just, oh, blood. Blood and blue ears. Okay.  [Rachel]And the fact that like, some of them aren’t in a very conscious state, so the tongue may fall back. So unless you open up their airway using head tilt, chin lift, or if you do pop them into the recovery position, make sure that you stabilize them. But also, if you notice, when you put people into the recovery position, what people tend to do is keep their head down. What you need to make sure you always do ’em in a recovery position is pull their airway up-  [Jaz]As a stage one.  [Rachel]Yes.  [Jaz]But here’s the thing though, like from memory, I thought if someone’s having a seizure. You let them do it and you don’t kind of touch them. And so what you’re suggesting is that you may need to put them in a recovery position. So what would that look like in a dental practice, let’s say it’s happened to us and is it easy to diagnose a seizure?  [Rachel]If it’s a very, yes, it is. If it’s a very obvious seizure, whether sort of shaking quite vigorously, my first thing to do was maintain safety. So move all of your equipment out the way, call for help ’cause you need support.  [Jaz]Ambulance?  [Rachel]Definitely. Yeah. And then what I would do personally is I might just leave them on their back but keep their airway open. Some people like to get patients on their side and that would involve kind of you maybe having to get more than one hand. ‘Cause of course what you don’t wanna do is your back or anything. So you may need to turn the patient on the side, but just make sure if you do do that, you keep that airway open. And really with seizures it’s about just reassuring them because you know if they can hear you and stuff-  [Jaz]Can they?  [Rachel]Yeah. Some patients-  [Jaz]So when, okay. Yeah. I dunno where it’s like, if you’re having any seizure, I dunno how receptive you are to what’s happening around.  [Rachel]Hear what exactly what’s going on. [Jaz]I never thought.  [Rachel]Yeah. When they’re having a seizure, so afterwards they’ll say, oh, like, I remember the dentist was really kind or, so it’s just about, it also makes us feel better as medical professionals to reassure, it’s okay, we are here and then-  [Jaz]Yeah. I’m so glad you said that, Rachel. ‘Cause in my mind if someone’s having seizure it, they’re not with it.  [Rachel]No.  [Jaz]And then once younger. Not that we ever say anything inappropriate in that scenario, but to give that empathetic tone. Don’t worry. We’ve got you. They’re gonna do this. You know-  [Rachel]And even just catching them, just having your hands on them.  [Jaz]I’m gonna put my hand here, I’m gonna do this and what you’re doing. [Rachel]Okay. Yeah. So reassure. And it is a little bit of a waiting game because with seizures we don’t usually intervene for five minutes. And then we would very much.  [Jaz]But you pull the ambulance though.  [Rachel]You called the ambulance-  [Jaz]You can’t get oxygen on. Or should you?  [Rachel]You can pop the SATs probe on, see if they need it. You don’t necessarily need to give them oxygen. If their SATs start to drop, yeah, then definitely get the oxygen out. And then actually the ambulance are very good at guiding you through what to do with seizures. They’ll usually say, wait until it gets to the five minute mark, and then they’ll advise to give your drugs, which is where we come to with your seizure pack. [Jaz]Well, the seizure pack. So firstly, let’s open up to everyone. Guys, this is a really cool way that the practice I work in manages the drug kit. It’s got the A for laminated card for epileptic fits and seizures, and so it says irregular jerky, movements rocking, shaking, stiffness, change to vision, hearing smell, change to breathing rate hallucinations, lost consciousness. It says Midazolam Okay. Here’s what we need to do. And it says, located on the top of antibiotic cupboard in staff room.  [Rachel]Great. So it even tells you where it’s-  [Jaz]Perfect. ‘Cause I would’ve forgotten. Yeah.  [Rachel]I’m not sure. It might be worth looking up, but in hospital Midazolam is a controlled drug, so we have to keep it in a twice-locked cage. [Jaz]In a locker. Yes. So it’s a locked. So you have to get in through back lock first staff room, and then we’ve got a key. Yeah. So-  [Rachel]Because the CQC will want it to be (stored) properly.  [Jaz]Yes. And so since, since we had the CQC, we’ve now got that on board. Uh, right. So what I’ll do then is let me go get it and let’s look at the pack. Okay. So I found my key very quickly. I’m very proud of myself and we have two, I didn’t expect this, but we have two buccal midazolam. So one brand is called Buccolam. It’s 10 milligrams. And it says four prefilled oral syringes. This one expires this month which is why we have another one. And it’s called MidaBuc. Same thing. It’s 10 milligrams in one mil, but this is a five mil. So I dunno how this is. We’ll have a look. Alcohol free, sugar free. We’ll have a look. But what I like about this already is, the management here made it very easy. They’ve written the dose very clearly on here, on a sticker by pen. So age 10 plus give one mil, five to 10, give three quarters of a mil, one to five, give half a mil, and so on, so forth. So it’s nice and easy there, which is good. And I’m looking at it now and it’s a bottle which has a little bit of liquid. I mean, it’s mostly empty in in there. And I’ve got four what looks like Calpol, type syringes in there and goes up to one mil. Any comments?  [Rachel]No, just that obviously being that Buccal Midazolam, it’s a very good drug. The downsides are, it’s costly. A lot more expensive than the alternatives. And the second thing-  [Jaz]What are the alternatives?  [Rachel]We use rectal diazepam.  [Jaz]Oh gosh.  [Rachel]But I remember coming to speak to you once Jaz and you saying that you deal with one hole only and it’s the mouth and not anywhere else. [Jaz]When you’re becoming a dentist and you have to choose between medical tool and dental school. You either look up one and look down the other and so I said, let me look down, not up. So here we are.  [Rachel]So I’m not sure you are gonna wanna go down the rectal right?  [Jaz]Let’s not talk about that. [Rachel]So when I suggested it to the team and said you could save yourself a bit of money and you wouldn’t have to have the stress of having it a locked, locked cupboard. It was very much a no thanks. We’ll stick with the Buccal Midaz.  [Jaz]So rectal, we’re not gonna go there. But, if we’re not giving rectal, so obviously in dentistry you also use Midazolam for IV sedation. [Rachel]Yeah.  [Jaz]So like, but to have to think in that scenario when someone’s having a seizure to then access venepuncture, it doesn’t make, obviously someone’s already in the middle of an IV procedure. Yeah. I mean it wouldn’t happen ’cause they’d be having them as in the system. But really the main way dental practitioner is, should be doing it, is Buccal Midazolam. [Rachel]Yeah, absolutely. And it’s easier for you and it’s so easy because of the fact that it’s buccal, so you don’t have to start cannulating them. It’s a lot, that’s a smaller dose, which also helps. So you’re not gonna kind of hopefully over sedate. But you do need to be mindful. And that’s why they don’t really like people in the community giving more than two benzodiazepine in the community. And that they would then tell you to stop and wait for the ambulance. ‘Cause obviously knowing that it’s got sedation effects is it can sort of effect-  [Jaz]Respiratory suppression.  [Rachel]And then you end up causing them not to breathe and then you go down a whole different route. So there is a limit to how much you can give in the community, which is the right thing to do because I know you wanna get them out of the seizure, but what you don’t wanna do is cause more problems for yourself.  [Jaz]Well, and like you said, is that, look, if you notice this, very quickly and then you get all the team on board. You call the ambulance for the first five minutes. There’s actually nothing to do except reassure and calm. And then by then the ambulance kind of remotely taking over and guiding you. And so, and when I learned about buccal midazolam, I thought it’d be like a gel. And you point your finger and then you deliver to the mouth is up.  [Rachel]It’s a bit, no, so, well, you’re probably thinking of that because of the whole glucose gel where you do kind of rub it round the gums. But no.  [Jaz]It’s a liquid.  [Rachel]It’s a liquid. The other thing is that most-  [Jaz]This is nice. This one actually, by the way.  [Rachel]Nicer.  [Jaz]Wow. Buccolam. Guys, I’m digging Buccolam way more than Midazolam.  [Rachel]Yeah, that’s already pre-filled.  [Jaz]Like a, very nice. Look at this. It’s all like pre-filled, all fancy pants. And just squirt it. [Rachel]No wonder it’s 40-odd pounds for- Yeah. Yeah.  [Jaz]Just squirt it into the mouth around the side. I mean buccal.  [Rachel]But the good thing is, and in majority of cases, and I won’t have the exact statistic, but most seizures should self terminate within the five minutes.  [Jaz]So in most cases you won’t actually need to give that. [Rachel]Yeah. You’re hoping. Yeah. So hopefully-  [Jaz]And all the ones that you’ve seen.  [Rachel]Wow.  [Jaz]How much times do you have to get the gloves out?  [Rachel]They are in it. Most days we would not probably cannulate them at that point and even try and avoid that. But yeah, if they’re coming to A and E, they probably are more likely to be in status because they would’ve tried at home to get them out of it. And the fact that they’re in A and E means that they’re struggling with them.  [Jaz]But epileptics in the community and they’re home. Do they keep buccal midazolam in their home and they’re allowed to?  [Rachel]Parents keep buccal midaz so they are allowed, they’ve got care plans and they would give them a dose of before even some of the parents who’ve children frequently have seizures, don’t even come into hospital. They just know how to manage their children at home. And the older you get, you get different methods of managing it. ‘Cause it’s not, I wouldn’t say common, but parents are actually, funnily enough, one of the best in terms of your children. They’re the best carers. They know their children’s condition better than even hospital staff because they’ve been living with it for years. So, so yeah. Buccal Midaz is a very good drug. It’s just, it’s expensive and it’s hard to-  [Jaz]It’s expensive, but it’s mandatory. We need to have it.  [Rachel]Correct.  [Jaz]So there’s no way around it. And both these products, seeing them today for the first time. I mean, I know I’ve heard about it. You talked about it, but it was actually nice to-  [Rachel]It’s a good thing that it’s your first time seeing it. ‘Cause otherwise that means you had have used it.  [Jaz]Exactly. So this is all good and I’m learning as well. It was nice. See how it’s live again, I’m really happy with the fact that the dose is written here. It’s really helpful. It says here, age 10 plus two mil because this is for the Buccolam. It’s a different dosage-  [Rachel]It’s a different strength, maybe?  [Jaz]Maybe. Let’s have a look. Contains 10. So there’s two mil of the buccalam contains 10 milligrams.  [Rachel]This is 10 milligram of-  [Jaz]So the main thing is for the adult dose is 10 milligrams. [Rachel]You need to make sure that whatever you order you to make your life easier, that you write it down almost like what your, do your dental nurses check your box? Do they the ones that check it and keep it?  [Jaz]Practice manager and Chris and there’s a Zoe Okay. Lead as well. So plenty of people. And I’m looking at our cheat sheet again. And yeah, it matches nicely, which is good. Brilliant. Well, I think it’s one of those where it’s good to know and keep the environment safe. We need to have this drug buccal midazolam. It’s good to see it and we talk about it, but it’s nice to know that probably we won’t need to give it because the ambulance will guide you. And then involve them the care. So top tip to call the ambulance right away.  [Rachel]Yeah. And the other thing is-  [Jaz]Don’t wait. Don’t think that, oh, let me just give you some Buccal Midazolam.  [Rachel]Yeah. And also just remember that actually safety comes first. So making sure that your patient is not freshing around, that you’ve moved all of the dangerous equipment around, and that you reassure.  [Jaz]Yeah. For me, the biggest takeaway in this conversation is just talk to the patient because for me, for some reason I thought, someone’s having a seizure, they will be outta it. [Rachel]Yeah. Whereas my nephew, William, he always was like fully aware of like what was going on around him when he was having them. So we used to just talk to him. Yeah, yeah, yeah. Tell him it was all right.  [Jaz]That’s really good to know. Hopefully I’ll never see one, but now I feel better if I was to, right. So I’m going through the medical emergencies box again. There’s a heart attack stuff, which we may not get to ’cause it’s very niche and I just want to, in the time that we have, we may cover it ’cause it’s important. But I’m just want basically talk out loud about what’s in my kit. Stroke. Okay. And in the stroke there was no meds in the stroke, so that’s fine. Low blood sugar. And so I see the glucose gel inside here and that looks like out of date you are gone, but it’s labeled out of date. Because it then kind of tells you in look in the fridge kind of thing. So fine. We may get to talk about that today. And then the last one here is asthma.  [Rachel]Which we kind of covered, didn’t we? [Jaz]You covered a-  [Rachel]Yeah. Okay.  [Jaz]But I just wanted to do an overview of what’s inside the emergency drug kit and we’ll see how the rest episode goes. But let’s talk about choking. ‘Cause something that we’re gonna help out in the community and patients sometimes choke on what we use. So in the dental practice and in the community, what is the current standard of care that the recess guidelines are recommending to us?  [Rachel]So recognizing choking is the first thing. So if this was you, Jaz, what do you think? If you were choking, what was your kind of, what do you think your instinct would be to do to try and tell someone you were choking? [Jaz]Make some sort of sound or wave my arms or-  [Rachel]Classically hold onto your neck. ‘Cause that’s kind of what we’ve noticed in seeing patients is that they grab hold of their throat and then they kind of point to their back, which kind of indicates like, help me because pure choking, you wouldn’t hear any airway sounds at all. So if you’ve got some airway sounds, you’ve got partial, and actually we’re at a better place. But if you’ve got complete silence, the patient’s probably is choking on something, whatever they’ve- no, it tends to be nothing.  [Jaz]Wow. Wow. That’s good.  [Rachel]Yeah. I mean, you might get something initially, but if it’s completely blocked, then there’s no sound at all. So the first thing you’re gonna ask them is, are you choking? And if they don’t answer you and they’re kind of doing this, you can then- [Jaz]They might nod though.  [Rachel]Well, if they’ll nod probably, or they’ll just kind of, ’cause they’re so panicked, I think you’re in this position where you literally can’t breathe. You are gonna be so scared. So yeah, they may nod and say yes, you know, not say yes, sorry. But they may nod to tell you that they’re choking. The next thing you are gonna do is ask them if they can cough. Because what you’re gonna try and get them to do is cough themselves to try and get it out. But if they can’t, then you need to intervene. So best position is if they’re standing up, we’ll get them to stand up and then tilt them as far kind of forward as you can. So that gravity helps.  [Jaz]So if then they’re in the chair, they’re choking on something, you need to bring the chair up.  [Rachel]You bring the chair up and actually try and even get them even more forward than that. So, I don’t know if those of you who are watching-  [Jaz]So what we’re just describing, we was driving to those who are listening, bring the chair up to the lower position and then get the patient to lean forward. And now you’ve got space here too. And give them back slaps.  [Rachel]Exactly. And the advice is give up to five back blows. So obviously if they spit out on two, don’t feel the need to keep going with the good measure.  [Jaz]Depending on how much you like.  [Rachel]Exactly. So you’re gonna support their chest so that they don’t go flying forward. And then between the shoulder blades you are gonna deliver.  [Jaz]But I’m just gonna pause you before you get to the stage again. Like the other medical emergencies we’re like, it’s a team effort. So, but here, I mean-  [Rachel]You might not have any for the room.  [Jaz]Yeah, that, but also like at this stage you just want to get the back those in. There’s no ambulance just yet on.  [Rachel]I mean, if you had one of your dental nurses in the room, you could shout with. Not shout, but you could ask her to go and call the ambulance.  [Jaz]Okay. So it’s still fair to -?  [Rachel]Yeah, absolutely. But you need to get on with this part. ‘Cause this is, you know-  [Jaz]And it’s worst case scenario to get the obstruction out, then tell the ambulance, oh, we’re sorted now. And they’d be happy to hear that.  [Rachel]Unless you do abdominal thrust and they should still go to hospital because you could have caused a bit of trauma. [Jaz]Okay. So basically abdominal thrust equals should definitely go to hospital families. Okay.  [Rachel]So yeah, up to five black blows each time, checking to see if the objects come out. When you get to five, if they’re still choking, then you need to move to abdominal thrusts.  [Jaz]Which used to be called the Heimlich maneuver. [Rachel]It used to be known as the Heimlich. Apparently the family didn’t wanna be associated with choking, so they changed the name.  [Jaz]I associated it with the resolution of shape, not the choking itself. Come on.  [Rachel]So the position is, and this is the bit that people always get confused, is you are aiming above the belly button below the xiphisternum, so below the rib cage, essentially. So it’s this space here. For those of you that are-  [Jaz]What was confusing?  [Rachel]Just because people dunno what a xiphisternum is. If you are a layman and you’re not medical, and what’s a xiphisternum to my husband?  [Jaz]I’ve had sternum, but I’ve never had some xiphi.  [Rachel]Xiphisternum. Yeah. I can’t remember how you spell it. [Jaz]Even I haven’t. Yeah. Okay.  [Rachel]It gets confusing. So when I explain it to people, I always say, just aim for above the belly button.  [Jaz]Above the belly button?  [Rachel]Yeah. Okay. Make a fist and then just above in that space I just told you about, and then with your other hand, you’re gonna wrap round, and then you are gonna do an inwards and upwards motion. In and up, up to five times.  [Jaz]Now, let’s talk about the patient in the chair. As they’re leaning forward, yeah. You’ve done the back blows, at this point now is this something that you expect me to deliver? Like from-  [Rachel]If they could easily get up, if they weren’t frail, you could ask them to stand up. The difficulty is if they’re frail, it’s gonna take you so long to get them out of the chair and stood up. That actually you may then need to-  [Jaz]So push comes shove, just do what you can.  [Rachel]So what I would do is I then sit them back in the chair. And essentially come round to the front and then with the palm of your hand in exactly the same position. I’m gonna do an inwards and upwards motion.  [Jaz]Okay, so this is like a modified correct racial technique of the ratio. So this is a modified abdominal thrust using one hand.  [Rachel]One hand in and up. Just dodge a bit of food that might come out and get you if you are from the front.  [Jaz]Or the dental instrument or whatever, obstructing.  [Rachel]Because obviously you are right in front of them now, so you are in.  [Jaz]We’re using wearing loops and glasses and that kinda stuff anyway, so we are good and mask and stuff, so fine. And so do that five times.  [Rachel]Up to five times and then if that doesn’t work and the object is still in the mouth, then you go back to tilting them forward and back to, so you alternate every five, five back blows, five abdominal thrusts, five back blows, five abdominal thrusts until the object comes up.  [Jaz]But if you’ve done even this one handed abdominal thrust, they really should be able to get the stuff out. They should be-  [Rachel]Ideally.  [Jaz]Looked after.  [Rachel]Unless they used, and you can’t do anything about that. If they say, I don’t want to go to hospital, I’m fine, then that’s-  [Jaz]Your advice should be, your guidelines would be-  [Rachel]You might cancel the ambulance and then you’d let them get their own way up there. Because they won’t need a time to call ambulance.  [Jaz]But the most important thing is that while this is happening, like I can imagine like, one person is dealing with the actual, the abdominal thrust, the other person, the phone’s right there speaking to the ambulance, right. Put ’em on speaker kind of thing. So that makes sense.  [Rachel]And then hopefully it comes up. If it doesn’t, eventually they’re gonna become hypoxic and they’re gonna collapse into cardiac arrest. And then you would go down your CPR with airway defib management.  [Jaz]Okay. That’s very helpful. And this is actually a very serious thing because I know a friend of a friend, unfortunately, who passed away at an airport, he was literally just eating a donut. Yeah. And then he started choking and he died. And so this is the-  [Rachel]I think we talk about grapes, we talk about sausages, we talk about blueberries, steak, red meat seems, but we don’t talk about the other things that still, I mean, I was just speaking to a GP earlier and they said that their husband choked on bread. So, yeah. It’s not always your, we are very good at chopping up grapes, but-  [Jaz]Yeah. And I’m so glad you mentioned grapes, right? Because my wife is really particular about my kids and the grapes and stuff, but I was a little bit blase, right. Because my little one just loves to grab it and go for it. Yeah. And I’m not gonna chase him to take the grape off and cut half. However, literally two days ago on my Facebook, I saw a radiograph of a great stuck in the airway, but it was like partially obstructing it so the child was able to breathe. Uh, sorry. Yeah, yeah. They done that shifts. Exactly. So that made me realize, and the advice on that Facebook post was anyone age five or under choked on grapes. And so you totally agree with that?  [Rachel]I do. I do. I just think it’s not worth it. It’s funny ’cause I don’t chop my grapes for my 8-year-old now unless she goes to school and then I do because for some weird reason, if she’s around me eating grapes, I feel fine because I always say sit down, don’t talk when you’re eating them. But at school, I don’t trust that she’ll shove ’em in her mouth and chat to her friends and then get up and go and get something. So I still chop them for my 8-year-old.  [Jaz]Okay. [Rachel]Once it’s there. You can’t ignore it, can you? And you never-  [Jaz]Now that I’ve seen that radiograph, honestly, I like, once someone listens to this and they got like young children, they’ll realize that. Okay, now-  [Rachel]So sausages are a big one and I think we don’t talk about them as much, but I guess we all just need to sit down and not talk when we eat. And do have good-  [Jaz]Mindful eating.  [Rachel]The only difference between what I’ve just discussed is for the under one. So for your under one, we tend to not do abdominal thrusts because we don’t wanna cause any injury to their liver. So we move to chest thrust. So exactly the position where we do CPR. So sort of lower, further sternum. Between the nipples. For an under 1-year-old, we would do two fingers and we would do five short, sharp chest thrusts. So kind of one-  [Jaz]While they’re into-  [Rachel]Kind of over your knee kind of head down. So you’ve still got gravity. And then if you imagine the baby’s kind of on my arm, I’d be doing like one, two on their chest. She like me to get more mannequin out.  [Jaz]You got baby mannequin?  [Rachel]Yeah.  [Jaz]Alright guys. Rachel will describe what she’s doing with the baby mannequin, again, as she’s doing it. But I just wanna see it, for those of you who are maybe watching this. But she’ll describe it. Oh, I go, we got a baby mannequin as well.  [Rachel]So here’s my little mannequin. So essentially you would still start over your knee, so get yourself into a sitting position there.  [Jaz]These face down, face down over your legs. [Rachel]And the reason you wanna sit down is not ’cause you’re feeling lazy, it’s because actually you don’t wanna drop the baby. So get them into the kind of over the knee position between the shoulder blades. Same as sort of adults. You’re gonna deliver up to five back blows each time checking to see whether that object has come out. Once you get to five, you’re gonna rotate the baby over supporting the head as you do so, and you’ve still got gravity on your side. And then mid nipple line, you are gonna do five short, sharp chest thrusts. And then if they still, no luck-  [Jaz]In this position isn’t like, if the food’s in-  [Rachel]I know what you mean. It will go to the roof and then you can turn them over and it’ll fall out.  [Jaz]So you’re kind of almost holding the baby upside down.  [Rachel]Yeah. ‘Cause you just kind of want, and also what you don’t wanna do is do this. ‘Cause then obviously you might.  [Jaz]Yeah, yeah, yeah. So you’re sat down to prevent the baby falling where the baby is. Almost upside down. Vertical. And then if the food comes out, you can just turn ’em over-  [Rachel]Send ’em over, and you could give them a gentle squeeze of their cheeks if you want. We try not to start rooting around in people’s mouths with fingers because we could push the object further down cause no problem.  [Jaz]Yeah, great. I’m very happy with covered choking because again, it’s like you said something, a life skill for community. So beyond just dentistry. So I thought it was worthwhile covering.  [Rachel]It’s a very good life skill, and actually a lot of the stories I hear isn’t, again, isn’t even in A and E, isn’t even in the hospital. It’s not in the dentistry, it’s not in the GP practice. It’s at home with your young children. Because they’re naughty, aren’t they? They love to explore. And my daughter used to have this thing where she’d stick things in her mouth, look at me and run away ’cause she thought it was hilarious. And I have to try not to react. If you react, she runs faster. So yeah. They’re little pickles.  [Jaz]Yep. You’re definitely saying things. I’m seeing day to day my household.  [Rachel]Yeah.  [Jaz]Right. Great. The next one we wanna cover Rachel, is hypoglycemia because I think you made a wonderful point before we started to record. A lot of patients think it’s okay and they that they should be skipping breakfast. I dunno, from the medical background, go for GA or whatever and they think, oh, I shouldn’t eat. Whereas before and a plan extraction appointment, I’ll tell my patients, please eat. I want you to have energy and feel good. So unless that’s normal for you. Okay. So patients come in maybe potentially starved. And then this may lead to a hypo, but does that work for all people or people who are diabetic and just tell us more about-  [Rachel]Maybe diabetic.  [Jaz]So why is that?  [Rachel]Because they find it difficult to regulate their blood sugars, so that’s their condition. So it depends on whether you’re a type one or a type two diabetic. Type. One more relying on sort of insulin type two could be diet or tablet form of insulin instead of injecting. That’s a general sort of description of it. But the tricky thing is, is that, I mean, I’ve been there before where I’ve had a morning appointment with the dentist and I’ve not wanted to eat just ’cause I don’t want any food in my teeth even. And then like, I brush my teeth now so I’m not gonna eat. And what we worry about with diabetics is that if they have to eat regularly to maintain their kind of blood sugars, they may have even given themselves their own insulin that morning, particularly if they’re a type one diabetic. So they might have injected themselves with insulin. They’ve not eaten to kind of balance out the insulin, and then they’ve come in thinking it’ll be fine, and then suddenly their blood sugars have dropped. And the effect of that can be, people can manage it with no symptoms at all. Or some patients can really show symptoms of a hypoglycemic attack. [Jaz]Classically, it’s like that someone’s drunk. You think they’re drunk?  [Rachel]Absolutely. So you can get confused.  [Jaz]Oh, without the smell of being.  [Rachel]Yeah.  [Jaz]Okay, fine.  [Rachel]So you can feel confused. You can be clammy. Sweaty, and I dunno if you’ve ever seen it, but patients that I’ve seen that are having a hypo usually get these like pools of sweat on their head. They’re like little circles of sweat. Confusion. Some patients can be aggressive ’cause they’re not quite sure what’s going on, so they can get quite aggressive. One occasion where me and my husband were driving around where we live. We were following this car and the lady, it was a lady in front of us and she was swerving all across the road, and my husband being in the job that he’s in, just assumed straight away she was drunk or intoxicated or under the influence of something. So he said to me, right, you need to call 999 now, she’s drunk and intoxicated and you need to tell them that we were in pursuit of a drunk driver. So I was like, we’re in pursuit of a drunk driver.  [Jaz]He’s a copper. Yeah?  [Rachel]He’s a copper. And so we followed her and she was pulling out on roundabouts with not checking. She was mounting curbs. And he was furious in his head. He was like, right, she’s in, you know. Anyway, so we called her in. They sent out a response team. They ended up boxing her in ’cause she was so unaware. She ended up meeting boxing in, she got out of the car and we were kind of sat further back in the car, in our own car and I said, oh, she doesn’t look well, Dan. And he was, he was like, wow, that’s because she’s under the influence anyway, it turns out she was the type one diabetic and her blood sugar was something like one, oh, she’s severely low. And she was probably borderline going into a coma. And fortunately one of the police officers had a can of coke in his car. Gave it to her when she came round.  [Jaz]Oh, the brands of her diet. Sodas do exist.  [Rachel]Yeah. And when she came round, she was mortified. ‘Cause she hadn’t even, she wasn’t even aware that she was driving like that. It had almost gone so far down the line.  [Jaz]Wow.  [Rachel]So she was completely oblivious to the fact that. She was having a hypo and it was, you know, of course my husband had to sit there when the officer came over and said, well, I thought she might be unwell, but they might not be able to tell you is the kind of story, the purpose of that story is they might not be able to tell you they’re having a hypo. Not everybody knows they’re having one. So just be mindful that taking a history, asking them are they diabetic? If they’re acting slightly great.  [Jaz]Yeah. So if a non-diabetic, your body’s adaptive mechanisms and homeostasis really wouldn’t let your blood sugar get below four.  [Rachel]Exactly. Yes. But whereas when you’re diabetic and you can’t regulate and your pancreas isn’t working correctly, that’s when you need help. And my worry is just the fact that if I feel like I don’t want to eat before coming to the dentist, how many other people feel like that? And then you might have be presented with somebody that does have a low blood sugar and you don’t have the equipment to check it. The good thing about medicine these days is a lot of people have these sort of internal devices that measure-  [Jaz]Tried one for a week, John give it two weeks. It wasn’t Zoe, the Libre.  [Rachel]Okay. Yeah, I’ve heard of it. [Jaz]Libre. Yeah. It was brilliant to get an insight-  [Rachel]To what Spike and what, yeah.  [Jaz]So I had this birthday cake and I was waiting for the spike. It never came. I had a Cajun chicken wrap from Costa and it shot up like the moon. So yeah, it was really interesting.  [Rachel]It helped, really helped. My dad did the same thing and it really helped him to know, but you know, so you could always even ask your patient, do you have a monitor on that? We can have a look on your phone. ‘Cause again, they might not be aware. So if you can identify or even just take a clinical history that you think that they are having a hypo low, that always helps me remember hyper high. Then administer your emergency hyperglycemic pack, which you, I have seen, you’ve got glucose gel.  [Jaz]Okay, let’s get that out guys. So labeled as low blood sugar and again, in this zip wallet, this a four zip wallet. I’m gonna open this one up guys. And I’ve got administration of adrenaline that shouldn’t be in there. Okay. That was probably me. Okay. So I’m gonna put that one where it belongs. Okay. So hypoglycemia, shaking, trembling, slurred speech, tingling of lips and tongue hunger, palpitations, sweating, double vision, unconsciousness. Okay, so that, that’s all there. And then it says drug glucose, stroke, sugar, different forms. So, non diet fizzy drinks, glucose powder and water glucose tablets, glucose gel. And then in severe cases, GlucaGen® HypoKit.  [Rachel]Glucagon.  [Jaz]It should be gone.  [Rachel]Yeah, but it’s this-  [Jaz]There’s a typo in this guy. [Rachel]So this one’s got writing all over it, essentially. But in your practice, you’ll have something called, well I call it-  [Jaz]Hypertop.  [Rachel]Well, it actually does say Glucagen, but oh, glucagon. There you go. Glucagon, hydrochloride.  [Jaz]Oh, that’s a brand name. So glucagen is like the brand name.  [Rachel]And Glucagon is a hydrochloride. So yeah. The good thing about this is it’s not pre-filled, but it’s got the, in fact, I can open it. Yeah. It’s got a little powder. And then it’s also got a syringe with some water in it. And what you do is you administer the syringe into the powder, give the powder a bit of a shake, and then pull back and drop as clean. [Jaz]So you open the lid of the needle though?  [Rachel]Yeah.  [Jaz]You put the needle into the powder?  [Rachel]Correct.  [Jaz]And then you make the like antibiotics. So like with children’s antibiotic. Okay. If I know all too well about that. Okay. And then you draw it up again.  [Rachel]And then you administer it.  [Jaz]Okay. And does it say the dose here.  [Rachel]You give it subcutaneously or intramuscular. So you took the whole thing.  [Jaz]Like, adrenaline?  [Rachel]Yeah.  [Jaz]Okay. And then I’m just trying to find the dose. Inject one mil for an adult.  [Rachel]Yeah. And this is really helpful for your patients that are, you are worried that aren’t safe to swallow. So if you look down your little signs and symptoms, if you are getting to the point of unconsciousness, you’re not gonna want to give oral sugar because the patient could end up in the lungs, they’ll aspirate sugar in the lungs is not great. So you would move on to your IM.  [Jaz]So you move straight to that.  [Rachel]Correct.  [Jaz]But here’s the thing, then let’s try and understand. At what point should we thinking go get a biscuit or go get a sugar drink.  [Rachel]So I guess it depends on if they’re alert and they can swallow normally, then absolutely go for the kind of oil. [Jaz]So we’ve got like water, so the dextrose is powdered or whatever it’s and give that to them.  [Rachel]All your gels here?  [Jaz]Yes. The gel. Yeah.  [Rachel]Let them swallow one of these, rub it around their gums and let them swallow the deck with the dextrose gel. They’re really great. You can also, it’s simple things if they’re like low, but actually they’re not severely low and they’re not even confused yet. But, they tell you that their blood sugar’s like 3.5, they’re not feeling great.  [Jaz]Okay. So the instances where I’ve done this we’re without really thinking much of it and actually putting the label of hypo is patients who just, they’ve skipped breakfast, but I know it’s not normal for them. And before I start my extraction, I was like, look, can I just give you this? And I’ve done it preemptively.  [Rachel]Yeah. Digestive biscuit. Cup of tea with some sugar in juice.  [Jaz]Yeah. Orange juice.  [Rachel]Yeah, orange juice. The best things for people having a hypo usually is jelly babies because they are very good at bringing it up quite quickly. If you speak you-  [Jaz]You saying both swears by jelly babies before a race.  [Rachel]Yeah. Well I can imagine. Maybe that’s what we’re missing out on. Well, having spoken to some of the diabetic nurses that I work with, there is, they say that sweets are much better than chocolate. ‘Cause chocolate, the carb count is quite high. [Jaz]Dairy. Is that okay with it?  [Rachel]I don’t know. I think it’s more to do with the carb count in chocolate and it gives spikes and whereas apparently jelly babies are better.  [Jaz]There we go.  [Rachel]So that’s what I stick with. Buy yourself a packet of jelly babies. Keep ’em in your drawer. I know dentist-  [Jaz]They’re not gonna survive a day in past-  [Rachel]But they will in dentist. Because you guys don’t have sugar.  [Jaz]We never ever have a waiting room, uh, sorry. A staff room full of sugar.  [Rachel]So, yeah. So in terms of what I would give, if they’re awake and alert and their swallow is fine, I would always go for, just start with your cup of tea and your sugar, digestive biscuits, jelly babies. If you feel like they’re quite severe, or that’s not gonna work. You can go for your glucagel-  [Jaz]Now, again, I’ll ask you this question again. You are assessing this, it’s kind of dynamic and you are giving the glucose gel at this stage. Is it worth calling ambulance at this stage? For me, I think it’s preemptive and perhaps it shouldn’t be. At this stage- [Rachel]If they know their diabetes really well, then no, because they know they’re, these patients, if they’re well controlled usually, or even just they know themselves, I would be guided by them because actually they might get hypos quite a lot and they know exactly what to do and not necessarily need to go to hospital. If you’ve given them sugar and it’s still low and just still not happy and you’re gonna be sending home a patient with a low blood sugar, then I absolutely would advise.  [Jaz]So maybe, so put it this way, if you’re thinking to give glucagon, is that a good point for your nurse we call in the ambulance while you are, while someone’s looking after and while you gone. [Rachel]I think you’re giving IM sugar or glucagon. Yeah. Then you need to-  [Jaz]That makes sense.  [Rachel]Am I really happy to discharge this patient back into the community?  [Jaz]Good point. Yeah. Okay.  [Rachel]‘Cause you don’t wanna be lying there at night worrying about did they get home okay. Or you know, it’s a tricky decision.  [Jaz]Have you ever had to administer glucagon?  [Rachel]Oh, lows. Yeah.  [Jaz]Okay. So again, it just like the adrenaline.  [Rachel]Yeah, exactly like that. I tend to either do subcut in the tummy or-  [Jaz]You don’t do subcut though, do we? We do intramuscular.  [Rachel]You probably are more used to, or in the arm. You could go in the arm. But to be honest, we’re a bit luxurious and hospital, ’cause we have IV fluids, so we would probably skip the glucagon and we’d go straight for the IV dextrose glucose because we have access to that. But for you guys’s, that’s a brilliant.  [Jaz]So because we’re already, we’re taught for the adrenaline to go up out thigh, we can do the same thing. [Rachel]Yep. Correct.  [Jaz]And then let’s say-  [Rachel]As I am.  [Jaz]Yep. Point. So we do that. And then how long do we wait for to see a response?  [Rachel]Oh, I’d probably give it a good 15 minutes for it to kind of kick in. And then I-  [Jaz]By this point you’ve called the ambulance ’cause we’re now in glucagon territory.  [Rachel]Yeah, yeah.  [Jaz] And you get them guidance from there as well? [Rachel]And then I would see how they respond to it. Obviously you’ve only got one chance with glucagon, but meanwhile, what you don’t wanna do is overload them. Like, you see them pick up, but then you’re still shoving jelly babies in their mouth ’cause of course you’ll get a massive spike. So I would genuinely just give the glucagon, see how they feel. Have they started to react to it? Have they started to come round a bit more? They’re a bit more alert. They’ll usually say, I feel much better. Because of course when you’re having a hypo, you feel dreadful. Whereas when you start to get sugar, you feel a lot more human. So be guarded by your patient. If they’ve got a monitor, great. Obviously- [Jaz]Nowadays, with these diabetic patient, like I said, the technology is amazing.  [Rachel]It is.  [Jaz]To have that.  [Rachel]If they accept it.  [Jaz]That’s true. Right. So last one guys, let’s discuss an important one. Something that often worries me because the one that worries me the most day in, day out is my patient who I’m doing some sort of surgery on. And they have like a heart stent or history of myocardial infarction, or they’re on loads of blood pressure medicines and a history of angina and that kinda stuff. And I worry about that. I kinda can, anything that I’m doing exacerbate and flare up or cause myocardial infarction. So the one we worry about is them having adrenaline in our anesthetic. And that causing their heart to race. And then actually putting their heart under stress. And there’s actually lots of mixed opinions in dentistry about this. So some people think that there’s no point in worrying about it ’cause adrenaline is natural and the body market up and that. Exactly. And actually, if you cause pain to that patient, then that’s gonna cause an adrenaline spike anyway. And that’s probably worse. Yeah. Whereas other people say that actually avoid all these anesthetics that can train adrenaline, use adrenaline free anesthetic. But of course, regardless of anesthetic, it doesn’t work as fast and it’s just how long it actually lasts for in general is shorter as well. Yeah. But that’s just one facet of it. Just generally doing, working any treatment on these patients who are cardiac risk. It doesn’t have to be anesthetic. They could present with some sort of symptoms in the chair.  [Rachel]They could.  [Jaz]So tell me about the classic things that we should be looking out for in our patients. So obviously the first one being the medical history. Having that kind of kind of stuff. But you taught me, Rachel actually, and I think it was you that taught me this the first time someone has a heart attack, I think half of them actually pass away. Is that right?  [Rachel]Oh, I’m not sure I told you that. Maybe someone else told you that.  [Jaz]But is that right there?  [Rachel]I’m not sure, to be honest. I wouldn’t know whether that statistic was right. But I mean, let’s talk about the classic symptoms. Should we cover that? So you can have an MI myocardial infarction anywhere. And it would just happen to be very unfortunate if it ended up happening with you. Do I think that having a procedure could increase the cardiac workload? Yes. Do I know enough about whether giving them adrenaline would push that further? Not so sure.  [Jaz]It’s just something that we think about as dentist.  [Rachel]But in the end, I think you can scare yourself so much that you then end up, do you undertreat? I dunno, that’s a question for you.  [Jaz]I do think though, for these cardiac risk patients, I use a plain anesthetic and I feel as though it works a lot.  [Rachel]Lots of people use a plain anesthetic now. I’ve actually not seen a dentist surgery that has adrenaline anymore in their anesthetic in a while. But you’re absolutely right. You’re taking a good history as you do that every time a patient comes that yes. You are asking them if they have any cardiac history, whether they have angina, whether they have heart failure or anything like that. And then what do you think the key or the classic symptoms of a heart attack are? Or a myocardial infarction if you’re using the correct term?  [Jaz]So, pain in the chest. Radiating.  [Rachel]Yeah. So what about the pain would you be really worried about? Because let’s be honest, the chest is a big area.  [Jaz]Crushing pain.  [Rachel]Yes. Absolutely. So it’s that tight crushing pain that we really are concerned about where one of my patients described it as he felt like an elephant that sat on his chest. And he’s never had an elephant sat on his chest, I think. But it was that description of that such pressure going on on his chest. So yeah, that’s one of them.  [Jaz]It can sometimes radiate to the arm. Jaw.  [Rachel]Yeah. Up into the jaw and down predominantly the left arm. Pins and needles down the left arm. And what else? Anything else? Nausea.  [Jaz]Okay. Yes. Sweat.  [Rachel]Sweaty. Very, very clammy. There’s pools of sweat I mentioned with hypo. You can get exactly the same within MI. Yeah. Nausea, vomiting, sweaty, clammy, impending doom. So again, a bit like anaphylaxis, they say they feel like they’re gonna die. Blood pressure drops usually. Not always-  [Jaz]But here’s the thing where this is happening, right? I’m going back to that very first episode we did. Right? You’re thinking, oh, are they just feeling a bit faint? ‘Cause I’ve given adrenaline and then could it be a faint? Could it be a vasovagal syncope? [Rachel]Panic attack.  [Jaz]Panic attack. Yeah. So there are still a few differentials now. Yes. You’re gonna treat, you’re more likely to treat it as a cardiac issue. If they have a cardiac history. So if they have a cardiac history, I think your safer treat is a cardiac issue than a faint. So you’re treating it as that, but at this point then, okay, get on the ambulance. You call the team and let’s start working on it together at this stage, right?  [Rachel]Yes, exactly. So the other thing slightly with more panic attacks slash faints is that they’re very brief. So they would come along quite quickly, quite suddenly, and then they would go, ’cause of course you can’t keep up a faint forever, can you, we talked about it earlier, but you are, in your experience, it’s 90 seconds to two minutes. Whereas with an MI, it’s gonna go on, it’s not gonna just stop. So I guess the time also makes a difference. The history makes a difference, like medical history in terms of obesity, smoking, that kind of thing, that all adds to a picture, doesn’t it? If you’ve got those classic symptoms. And there has been a lot of studies that have been going on for years now about classic symptoms, but also sometimes women complain of generalized chest pain radiating to the back. Kind of around the bra strap line. So we also just need to be mindful that you’re not always gonna present if you’re having an MI with your classic crushing up into the jaw, down the left arm. So you’re presented with someone that you suspect might be having an MI. You’re gonna call 999, because you definitely don’t want them staying in your dental practice for too long. [Jaz]Someone’s gonna get the drug kit.  [Rachel]Someone’s gonna get the drug kit. What?  [Jaz]And oxygen.  [Rachel]Yeah. From memory, what do you think’s gonna be in your drug kit?  [Jaz]Well, nitrates is what, remember?  [Rachel]Yeah. GTN spray.  [Jaz]So let’s have a look. Let’s get it out. So here we are. Someone’s got a heart attack, suspected, and then here is the zip wallet for heart attack. Again, guys, I’ll make this all available to you guys. And again, it says severe crushing chest pain may radiate to neck. This is so helpful. Yeah. Pale, sweating, nausea. It’s like a little cheat sheet just to give you some reassurance. And then it says, drug, GTN spray, aspirin, if no known allergy, and over 16 years and oxygen. [Rachel]Perfect. So with the aspirin, it’s the 300 milligram dose that you’ve got, which you can see that you’ve got in there. It’s actually a really handy drug to have at home aspirin because it’s cheap. Cheap.  [Jaz]It’s dread for aspirin. Yeah.  [Rachel]And it’s actually just-  [Jaz]So the standard dose, like 75, right? [Rachel]Yeah. People take 75 like headaches and things. But for a heart attack, they advise you have 300. Something that you can buy over the counter, something you can have in your home, but also really easy to have in the dental practice. Then you’ve got your nitrate.  [Jaz]So we’ve got two in here. [Rachel]That’s a lot.  [Jaz]So maybe ’cause one’s out date. Maybe. Let’s see. So one, oh, they both expire Feb 2026. So we’ve got two something.  [Rachel]May be easier to order two.  [Jaz]Buy one, get one free.  [Rachel]Yeah. Obviously be mindful what I said in episode one about the fact that it’s a vasodilator. So your patient’s blood pressure will drop. So one spray at a time. If the pain goes after one spray, that usually does mean it’s cardiac related because it’s helping with the the pain. So-  [Jaz]I mean, your job, if you’ll experiencing something like this, your job is to keep the patient alive and well until the ambulance come basically. [Rachel]Absolutely. Yeah.  [Jaz]We’re not treating anything, we’re just managing it until help comes.  [Rachel]You’re with their pain, you are giving them some aspirin. I would probably wait till the ambulance advises that. Just because it’s very good to have them kind of knowing what you-  [Jaz]So do you think it’s, while the nurse calling the ambulance-  [Rachel]Get it ready.  [Jaz]So don’t you suggest, because now it’s so easy to quick and get the ambulance and dental practice.  [Rachel]Take their advice. [Jaz]Maybe hold off giving anything until we’re through them. Obviously it’s taking, if there’s a delay for any reason, then then go for it.  [Rachel]Yeah, absolutely. Because the only worry is, is like you say, if they don’t know they’re allergic to stuff, but actually this is, you’re kind of trying to weigh up, this is life and sort of death situation, isn’t it? Like what you don’t want to do is not give something and then think further down the line. Or would the aspirin would’ve helped, you know? Anti clotting, antiplatelet drug. That could have made a difference. But-  [Jaz]So realistically, you’re suspecting this. You are gonna call the team. Okay. Someone get the immersive drug here. Someone called the ambulance. Speak to the patient. Yeah, try and think, you know what the ambulance, describe what’s happening. Hopefully the ambulance will get connected soon. They’re like, this is what we suspect, you know their medical history already. And so GTN-  [Rachel]And then give some aspirin, one tablet, 300 milligrams of aspirin. Reassure your patients, because obviously they’re gonna feel really panicky this point and the key treatment which you have- [Jaz]And oxygen as well.  [Rachel]As required. So they did a study a few years ago, which showed that actually you don’t need to give 15 liters of oxygen, somebody having an MI if their SATs are above 94%. So we hold off. So pop the SATs, probe on them ’cause you’ve got it. If their SATs are above 94, you don’t need to give oxygen. If you don’t quite trust the saturations and their peripherally shut down and they’re cold and you think that they look gray and awful, then by all means go for oxygen because it’s better, as I said, to treat. That way around. And then time is muscle. So I dunno if you’ve ever heard that saying, but-  [Jaz]Heart muscle.  [Rachel]Heart muscle. So they need to be within a cath lab within 90 minutes, ideally with a stent. So they need APPCI. So they need to go to, our local one would be reading care. There are 24/7 centers, so they have an on-call cardiologist and they would pop in the stent and try and get the perfusion back to the, they would pop stent in the coronary artery to get perfusion the heart back perfused, essentially. So time is muscle, ie, we don’t want part of that heart muscle dying every sort of minute that we leave it. So the priorities are ambulance, reassurance, get the defib nearby because of course, what we don’t, what’s could happen is the patient could end up in cardiac arrest.  [Jaz]It’s like we did mention that.  [Rachel]Yeah. Yeah. So I would actually, along with your medical box, I would also bring the defib in the room just in case.  [Jaz]I think when something like that happens, you know, God forbid, but like the team would just bring everything. So the emergency drug kit, so you can access to your GTN and your aspirin. The defib in the side, the ambulance on the phone, on speaker, yeah.  [Rachel]Basically in numbers.  [Jaz]Yeah.  [Rachel]So, and everyone’s brain brings something new to it. So, you might have an idea, someone else might remember to bring the defib in. But the key thing is preventing cardiac arrest and trying to reperfuse that heart.  [Jaz]I think one thing we follow is that someone, when someone’s had a recent MI or recent acute episode in a transit ischemic attack. ‘Cause that’s like a mini stroke, isn’t it? Or not? [Rachel]Yes, it is. That’s another term for it. Yeah.  [Jaz]So those kind of patients, we kind of defer anything elective. For a while. Just trying to stay safe, but looking at the medical history and identifying that at risk patient. But again, if it’s their first time having this, yeah, then it could be anyone. [Rachel]Exactly.  [Jaz]And so we gotta be, just have our wits about.  [Rachel]And it would be that day that no one’s got heart cardiac history, and actually no one’s even coming into your surgery for an appointment. But they’ve had chest pain in Costco at Costa and they’ve stumbled in because they knew you’ve got a defib and they’re not feeling well and your access to ’em. And actually a lot of these times that I’ve heard stories. It’s never their patients. It’s always someone came in with chest pain. One of the surgeries told me about a patient that pulled up outside in a car. He’d had pain at home down the road and his friend had driven him to the local surgery and he was in cardiac arrest when he arrived. And they had to try and resuscitate him in the back of a car.  [Jaz]Wow.  [Rachel]Really sad. But I kind of understand why they came. So that’s ’cause they knew that they had a defi and they knew that they had some sort of medical professional. So it’s always like, oh, well hopefully it’ll never happen to us. But you just never know. It’s always good to have the skills.  [Jaz]Well, I think we’ve covered a lot and we’ve covered our one hour each now which is great. I think we made something that is gonna help everyone in the community, but also the more common things that we think about. Any last tips for our dentist listening and watching today? [Rachel]I think just constantly refreshing. I think it’s really important to be a really safe practitioner and making sure that you keep up to date with your yearly reviews and your yearly training. And in between that there are also some really good resources available online, like the resuscitation council. There’s an app called Lifesaver, which you can actually, do a bit of hands-on CPR on your phone. You can answer questions within so many seconds. So there’s lots of resources out there that are free, that you can get hold of. ‘Cause ultimately the idea is to save somebody’s life, or, prevent any further damage to them. So my top of advice really is just make sure that you keep up to date and you’re the safest practitioner you can be. Thank you for having me.  [Jaz]No, thank you. And you do some teaching in dental practice. Please tell us about that. Plug yourself please.  [Rachel]Yeah. So yeah, I tend to, so alongside my main sort of full-time role as a nurse, I also teach emergencies and adult and pediatric basic life support in the community to GPs dentists. I also do, in fact, I’ve also taught just people that have bought a defibrillator for their local community center and they’ve all kind of, got together and said they want a trainer. So yeah, happy to help, but also just happy to be part of this podcast and no, it’s, yeah.  [Jaz]It is been amazing to have you and appreciate you just covering everything so nicely and simply and so clearly, that really helps. I’ll put your details, so if anyone wants to reach out, if any bookings and that kinda stuff. But, thanks so much Rachel. Appreciate.  [Rachel]Thank you very much.  Jaz’s Outro:Well, there we have it guys. Thank you so much for listening all the way to the end. You’ve done it, you’ve listened to two parts of medical emergencies. You can totally claim your CPD certificate. It comes in one part each, so two hours in total, but that is the annual requirement. It is done. You can relax and not have a panic in December. And of course, if your practice is organizing some CPR training, some medical emergencies. Please say yes, do it. The requirements are a minimum and nothing ever beats hands-on, but once and again to do some online learning like this one can be great. This topic is a lifesaving topic, so anytime you can cover it, you should. For those of you watching on Protrusive Guidance, scroll down, answer our CPD quiz. Make sure you get 80%, and the CE Queen Mari will send you this certificate. If you’re not already on Protrusive, why don’t you start a free trial? The free trial’s only available on the website, so if you actually go on your mobile or on your desktop, www.protrusive.app, pick the plan that you think you want. If you want access to everything, you want the ultimate education plan and try one week. I know you’ll love it. You’ll come for the content, but you’ll stay for the community, right? It’s the community of the nicest and geekiest dentist in the world. So all the links as ever are below, and I thank you so much again for watching all the way to the end. I’ll catch you same time, same place next week. Bye for now.

HIGHLY RECOMMENDED CPD for all Dental professionals – without getting bored! Do you know exactly what to do if a patient faints in your chair? Could you spot the early signs of anaphylaxis—before it’s too late? How quickly could you find and deliver adrenaline if it really mattered? https://youtu.be/7b2oG4g12q0 Watch PDP241 on Youtube After six years of podcasting and creating CPD, we’re finally tackling medical emergencies the Protrusive way. In this two-part series, Jaz is joined by lead nurse and medical emergencies educator Rachel King Harris, who breaks down the real-life scenarios every dental team needs to prepare for—without the fluff or generic lecture feel. From vasovagal syncope to adrenaline protocols, you’ll learn how to stay calm, think clearly, and take action when it matters most. By the end of this episode (and the next), you’ll not only tick the box for your GDC-required CPD—you’ll actually feel ready. Because when emergencies happen in the chair, panic isn’t a plan. Let’s get you prepared. Protrusive Dental Pearl: Be emergency-ready! Download a free medical emergencies cheat sheet — a quick guide for symptoms, drugs, and actions during a crisis. You can download this ready-made cheat sheet for free at protrusive.co.uk/me. Print it, laminate it, and pop it into your medical kit. Your whole team will thank you! Need to Read it? Check out the Full Episode Transcript below! Key Takeaways: Medical emergencies in dentistry are rare but high-stakes — being prepared is essential. Guidelines change often — regular refreshers are vital. You don’t need to memorise everything — use validated resources and calm judgment. Vasovagal Syncope is the most common emergency in dental settings. If unconsciousness persists → consider other causes: meds, blood sugar, cardiac issues. Anaphylaxis can occur even without rash — don’t wait for it. Key signs: stridor, lip/tongue swelling, wheeze, “impending doom,” difficulty breathing. Keep emergency drug guides visible and updated (e.g., BDA laminated sheets). Ampules = longer shelf life, more doses than EpiPens, and more cost-effective. Don’t wait for the rash — airway signs matter most in anaphylaxis. Always carry two adrenaline auto-injectors — even for mild allergy patients. Highlights of this episode: 00:00 TEASER 00:53 INTRO 04:50  Protrusive Dental Pearl 06:01 Meet Rachel King Harris: Expert in Medical emergencies 09:42 Practical Tips for Emergencies 12:05 Understanding Vasavagal Syncope 17:01 GTN Spray 20:09 Recognizing and managing Anaphylaxis 30:05 Midroll 33:26 Recognizing and managing Anaphylaxis 34:41 Allergic Reaction to Chlorhexidine Gel 37:27 What’s Inside Emergency Bag? 41:51 Adrenaline Ampules vs Auto-Injectors 52:04 Oxygen Administration In Dental Practices 57:13 Oxygen and Emergency tools 59:05 Oxygen Contraindication 1:06:37 Outro Stay up to date by reviewing the latest guidelines from the Resuscitation Council UK. Check out this Anaphylaxis Summary Document Enjoyed this one? Make sure to check out PDP159 – How to Manage Children in Dental Pain, where we dive into real-life paediatric emergencies in dentistry. ​​This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes C and D. AGD Subject Code: 142 Medical emergency training and CPR Aim:To improve the preparedness and confidence of dental professionals in recognising and managing common medical emergencies in the dental setting, with an emphasis on vasovagal syncope, anaphylaxis, and appropriate use of emergency medications and equipment. Dentists will be able to – Identify early signs and symptoms of vasovagal syncope and anaphylaxis in a dental setting. Apply appropriate first-aid management protocols, including patient positioning, airway support, and oxygen delivery. Understand the updated guidelines for prioritising adrenaline over antihistamines or steroids in anaphylaxis management. #PDPMainEpisodes #BreadandButterDentistry Click below for full episode transcript: Teaser: When you faint, essentially your blood pressure drops. So that quick event that happens, what you need to do is actually try and I know, I don't know whether your dentistry bed's tilt, but tilting is actually the best. Teaser:So you want their head down, if the bed’s not quick enough getting up or it’s not working or whatever, you actually can just manually lift the legs and hold them up or get their relative, if they’ve got a relative in with them or somebody that’s come in and then just keep them like that until they come round. When histamine is released into the patient, they get widespread vasodilation and bronchoconstriction. So those two things combined is a bit of a car crash. Even 0.5 because really you’re going to get an ambulance within five minutes.  It’s true, you’re not though. You need to be carrying two at all times and people don’t. And particularly if you’re teenagers, you know you’ve got a handbag that doesn’t fit it. It’s tricky I actually think that in a medical center am feels better-  Jaz’s Introduction:When you are dealing with a medical emergency in your chair. That stuff can get really scary for dentists. It’s not pleasant to have to deal with it, but we need to be sharp, we need to know exactly what to do because our patient’s life actually depends on this.  This is why it’s a legal requirement in the UK and probably around the world to do medical emergencies training every year, and I’m proud that after six years of podcasting and creating CPD, we can finally now cover this topic in the true protrusive way, and now give you core CPD or CE credits. The GDC recommends 2 hours per year and in a five year cycle, that means 10 hours of medical emergencies training for the dental team, and this is mandatory. Now, most practices arrange some sort of group session where they’re doing simulation and hands-on CPR, which is amazing, but sometimes we’re left to our own devices and we’re watching these little bit slightly boring videos and lectures online. Always scrambling to buddy up with a neighboring practice to actually get this training done on time.  Now, in this episode, I’ve got a Lead nurse, an educator in medical emergencies. Her name is Rachel King Harris, and one of her roles as well as working in acute medicine is to teach dental teams everything they need to know about their medical emergence training every year. So I’m proud to say that after listening to this Part 1 and the next episode, you’ll give a massive tick box for your annual requirement of CPD. But the key thing is that you do it in a true protrusive way. We’re going to make it tangible. I’m hoping that Rachel and I, and mostly Rachel, we’ll present things in a way that it actually sticks. Sometimes when the patient is feeling unwell in your chair, we start to get a bit of panic and confusion. Is this just a Vasovagal Syncope or could there be something going on with the patient’s heart? Is this an anaphylaxis? Should I be giving oxygen? All these questions can come at you a million miles an hour, and you have palpitations and you’re sweating, and medical emergencies are just no fun to deal with.  But after today and the next episode, you’re going to smash your annual requirement of CPD and in a way that you’re going to retain this information because every episode we make some premium notes and we just deliver it in a way that’s a bit easier to listen to, it’s not someone lecturing at you.  You are there by osmosis absorbing these things. And I really told Rachel, I told her I want to create a really compelling piece of content for the dental team. Which makes it tangible and relatable and real world. What I mean by that is the topics we cover in this 2 hour training are actually medical emergencies that you are likely to actually see in your practice and talking about some details that are really important, but no one ever talks about some.  I’m hoping through that, that should you be in that unfortunate scenario that you will face a medical emergency because of this training, you’ll be feeling much more confident, much better prepared, and of course you won’t be panicking in December trying to make sure you’ve done your medical emergencies mandatory CPD, because we got you covered. Now to listen to this episode is free for all. Okay? The podcast is free for you, but to actually get the certification, you have to answer some questions and do some reflections, and that’s possible on the protrusive guidance app.  You can listen via Spotify through the app, all Apple Podcasts, again through the app, or watch the video on the app, and the benefit of that is you just scroll down and answer the questions and our CPD Queen Mari will look after you. And once you start doing more CPD with us, we actually send you quarterly certificates and an annual summary of all your certificates, how many hours you’ve done, and watch this space. There’s some cool stuff regarding PDP coming your way as well. The point of saying that is why don’t you get started?  Come and join one of our paid plans. I guarantee you’ll love it because the nicest and geekiest community of dentists in the world and you get all the CPD, which is not just a tick box for me CPD was like easy, I’d love learning, I have CPD coming out my ears, I probably claim way less hours than I actually do because getting CPD for me was never an issue.  But in this busy world, sometimes getting that mandatory training can be difficult. So why don’t you head to protrusive.co.uk/ultimate, sign up and make this one the first one that you claim CPD on, and then it’ll unlock the over 350 hours of CPD that’s currently on Protrusive to date. Dental PearlNow, every PDP episode, since its inception, I give you a Protrusive Dental Pearl. This one’s going to help you so much, and your practice manager and your principal will absolutely love you because a really good thing that we do in the practice I work in is when you open the medical emergency drug kit, there is just the best cheat sheet ever. Like there’s these laminated pages joined together, and they’re such a great cheat sheet so that when you are kind of in panic mode and you open up this drug kit, it tells you exactly what you need to know in a time of emergency. I’m pretty sure the CQC will also love you when they see you’ve got this already there. It’s a fantastic aid memoir of what symptoms you’re looking for, what drug to do and the management. Should you call the ambulance, should you not? Should you give oxygen? Should you not? It’s all there. So what I’ve done is I’ve prepared it as a download for you. If you’re watching this on the premium part of the app, just scroll down. The zip folder is there, you can download it, laminate it, and put it in your medical emergency drug kit. If you’re not on the app, you can still download this for free. To take advantage of these medical emergencies cheat sheet, head over to protrusive.co.uk/me. That’s M- E, Medical Emergencies. Enter your email and I’ll email it to you directly. Don’t worry. Oncall Jaz always has your back. I promise you, the entire team at your practice will absolutely love this. Anyway, let’s join the main episode and I’ll catch you in the outro.  Main Episode:Rachel King Harris, welcome to the producing of the podcast. How are you?  [Rachel]Jaz, I’m good, thank you. Thank you for having me. I’m excited.  [Jaz]So those of you who don’t know, Rachel, okay, I’ll introduce you. She does our training in practice about once a year, and I’m always there in the front row. Heckling is the best way. And you know what?  [Rachel]He does it well.  [Jaz]And Rachel’s a good banter, right? She’s a good banter. She makes this topic fun.  [Rachel]Thank you.  [Jaz] And of all the sort of mandatory training we have to do, like radiation stuff, right? That can get very dry very quickly. But this is one training which is, lifesaving. This is super important. So what I wanted to achieve with today’s show is to make it tangible. Okay.  Because why is it so often that we forget, right? And we need that annual reminder. And so I’m hoping that the way we’re going to cover it today with some of the stories and analogies, yeah, it’ll help someone down the road. But also it ticks a box.  [Rachel]It does. [Jaz]But it ticks it in a painless way so people can be chopping onions. So you don’t know this, Rachel, but the joke that we have, the running joke in the podcast is people are chopping their onions as they listen to a podcast. Someone wants— two people have told me that they did this early on and I just adopted it. So I always, when I imagine the listeners or Protruserati, I imagine them just chopping onions as they’re listening, right? [Rachel]Hopefully they can chop some more onions while listening to us.  [Jaz]That’s right. I say we’ll continue the onion chopping. And so I wanted to make just a more fun, upbeat piece content around this topic rather than someone just watching like a lecture. And so that’s the idea. But Rachel, just tell us about yourself. [Rachel]So obviously my name is Rachel. I have been a nurse now for 15 years. I qualified at the University of Surrey in Guilford, doing my adult nursing and realized very early on how much I loved emergency medicine.  So kind of the hustle and the bustle and the fast paceness of it all. So I started my career at the Royal Berks in a sort of a acute medical unit, and then realized that actually any emergency department was where I wanted to be. So I moved there and have kind of worked there for about 10 years. But I also had this passion for teaching and education, so I did some— [Jaz]Inspired probably by your parents, right? Because-  [Rachel]Yes, they’re both in education. We talked about this earlier. And then, yeah, I did all of my advanced courses, so adult advanced life support, European pediatric life support, and then just kind of built my profile from there, really.  And then I met you guys, I think you’re one of my first clients, actually through a colleague of mine and have been teaching here for probably my 3rd- 4th year now with you guys, so, I think. My passion is emergency medicine, and I also love education on the side of it. So this is- [Jaz]This is perfect.  [Rachel]Perfect.  [Jaz]This is perfect. So I’m so pleased to have you and your expertise because you know what I’m like most dentists I forget. [Rachel]Yeah.  [Jaz]We forget that this stuff. And so you are our expert who’s going to help us with these things, and help to make it more memorable for us. Yeah. And make it more fun and engaging. [Rachel]And the reason people forget is because if you’re not doing something every day. Then it goes to the back of our brain, doesn’t it? Whereas, because I tend to practice most days, it stays at the forefront.  And I think that’s why yearly updates are great because it refreshes you on those things that you kind of park. It’s great that you are doing this because actually anyone can listen any time, even six months down the line. Oh, I’ve forgotten what she said about X. So it’s always recorded, isn’t it?  [Jaz]That’s true. And I like this. You know, I know a lot of people are watching on YouTube or Protrusive Guidance on the video format, but many people will be listening on a train on an airplane, and then they can answer the questions later and get their CPD.  So call CPD it is, which is great. But what you reminded me here, Rachel, is Dental Trauma. I know you all think of trauma as a medical world, but dental trauma, again, we see it seldom. It comes in really rarely like an evulsion.  So someone’s actually lost their front tooth, the whole thing, bring it in some milk or saliva medium. That’s such a rare thing and whatever happens is that, I end up googling it. So if I know a patient’s coming, I’m like, “Okay, what’s the latest guidelines?” Okay—-  [Rachel]Yeah.  [Jaz]And I’m not saying that’s the wrong thing to do by any— [Rachel]No, no, no.  [Jaz]Because, when I was a teenager, I used to go to the doctors and I noticed that any issue we have, the doctors sometimes used be Googling it. And I used to think to myself, “What kind of doctor is this? because who’s Googling it?”  But actually, why should they be an Oracle all-knowing orbs what they’re doing is they’re checking the latest guidelines, they’re checking information and then using their medical knowledge. To use those guidelines with the patient history and diagnosis to then give a recommendation. [Rachel]Yeah. And that’s, like you’ve just said, guidance publications change all the time. And actually, the correct thing to do is always look up the latest guidance, latest publications, because I can say one thing today, but actually even in a year, it could be effectively out of date when the particularly the recess council update their guidance. So this is why it’s so important to refresh, because things change and you can’t just– [Jaz]So it’s important to refresh because A, it’s just so important anyway. And so it’s like life or death, really.  [Rachel]Yeah.  [Jaz]So that’s why it’s born also because we seldom see it, and though therefore we need that refresher. And of course, like you said, guidance keeps changing. Like in many things in dentistry, medicine, so we stay abreast of it. So three good reasons to listen to the end today and answer a question and get your CPD guys.  [Rachel]And the fourth good reason actually is that it’s a good life skill. So despite using it in dentistry, everything we talk about today can be transferable to just being out and about. And the fact that you are medical professionals, people do expect you to know what to do even though you might not know at the time. So having those transferable skills into the community with friends, family, even strangers is the fourth really good reason to listen.  [Jaz]Excellent. I love it. The direction we’re going to be going in guys, is I want like tackle the most common medical emergencies first because it’s all good and well, learning about the really niche and rare ones.  Like academic, but then that’s what it becomes, it becomes very academic. I want it to be very tangible. Like, I always say, something you can apply on Monday morning. Now hopefully no one will need to apply any of this stuff on Monday morning.  [Rachel]Yeah.  [Jaz]But- [Rachel]It’s there.  [Jaz]The most likely, like 1% chance, would be like a vasovagal syncope. Perhaps we could start with that. And then eventually I definitely want to come at Anaphylaxis. Because I think this is so- especially with the media and stuff and prayer and all these things and how important it is in life or death. It is. And then I want to just talk about hyperglycemia and a few others. Then I want to talk about the drug kit, what should be in it.  [Rachel]Yeah.  [Jaz]And I think that’ll be particularly useful, not just for associates, the practice principles. I’m sure you’ve seen where they kind of make that face like, “Oops, I didn’t know we’re not supposed to have that anymore.” Or, “Yeah, I was supposed to order that in and we can cover.” That kind of stuff. [Rachel]Yeah. [Jaz]That sounds all right?  [Rachel]Sounds perfect.  [Jaz]Alright! [Rachel]Let’s do it.  [Jaz]So in your background in nursing, how often do you actually see a Vasovagal Syncope and explain what that is.  [Rachel]So Vasovagal Syncope is essentially another fancy word for a faint, essentially, and just through the nature of what we do pretty much blood tests is the biggest one to cause fainting, Vasovagal Syncope. So we probably see them more frequently than you’d think.  It tends to be when you draw up the- you get the needle out, it’s coming towards the patient, they’re suddenly looking at the needle, and then it pierces the skin. And then what you find is that patients kind of well faint, essentially. So it’s actually more common than people think. You don’t even need to be needlephobic to not like the look of a needle coming towards you. And I don’t know what it’s like in dentistry, but from the experience of talking to other dentists that I’ve taught. A lot of it is just instruments being around their face. And I must admit, there’s a lot of people that are afraid of dentists isn’t there, and-  [Jaz] Understand- [Rachel]The thought of going in, the thought of sitting there, lying there, and then having them fiddling around with your mouth is enough to make people faint. So I guess it’s good to know– actually, we don’t really need to panic but this is what is really helpful when somebody does faint.  [Jaz]But you should differentiate and diagnose what that is. And thankfully it’s been fairly smooth. So in my experience, Rachel, the most common time I’ve noticed this is straight after LA. So straight after giving the injection.  [Rachel]Yeah.  [Jaz]So I haven’t actually had anyone. Yeah. So for example, sometimes people are so nervous they don’t want to sit in the chair, so we always sit on the sofa first that you see there. And then we have like, you know, calm them down and sound like we’re on your side, we’re very gentle here, etc. So everyone’s fine on that side. But once they’ve had a local anesthetic, that’s classically what I see and so what I see them go pale, lose their color.  [Rachel]Yeah.  [Jaz]Right.  [Rachel]And that’s because all the blood pressure’s dropping, isn’t it? And so therefore they’re losing their fresh face and they’re going pale and gray. [Jaz]My first ever experience of this, I was a fourth year Dental student, we were on outreach, so like clinics around Yorkshire and I remember it was like a 20 something or maybe a 19-year-old male. So I remember maybe reading or coming across something at a time. Is it true that young males are more susceptible to this or–  [Rachel]We hear that? I mean, to be honest, I have to say it tends to be a lot of female teenagers that I’ve come across that have tended to kind of have one of these episodes in the emergency department. And it’s– they hate needles.  And that’s their kind of trigger when you come near in with a needle. But I have heard that boys happen to have these kind of reaction when, particularly in the dentistry world. So I’m not surprised you’ve said it, but I haven’t personally, it has tended to be more the female sector.  [Jaz]And then quite classically, I used to think that okay, it’s because our anesthetic contained adrenaline, and I used to wonder is that- because they often describe “Oh yeah, my heart’s going.”  And then they start to go a bit pale. And so what we do, and then just to make sure we’re doing the right thing, is I was always taught bring their head back, legs up, let the blood, so the reverse of what’s happening, if their blood is drained from their face, if they’re looking pale, you want to do the opposite. You want to get the blood back down.  [Rachel]Absolutely. So when you faint, essentially your blood pressure drops. So that quick event that happens, what you need to do is actually try and I don’t know whether your dentistry beds tilt, but tilting is actually the best. So our medical beds in hospital, we can tilt them like this so that- [Jaz]So like left and right? [Rachel]Up and down. [Jaz]Okay.  [Rachel]So the feet actually come straight up and the head down– [Jaz]It doesn’t tilt, but we can actually do it so that the head goes below the legs. [Rachel]Perfect. That’s exactly what we want. So we want the head down, and then if you can’t, you know, if the bed’s not quick enough getting up or it’s not working or whatever, you actually can just manually lift the legs and hold them up or get their relative, if they’ve got a relative in with them or somebody that’s come in and then just keep them like that until they come round.  We used to talk about throwing water over people and giving them a shake and a tap, but actually it’s a very basic thing. It pulls that blood pressure back up to the central perfusion and they’ll recover a lot quicker.  [Jaz]I remember the first three or four times this happened to me, I was really scared. Which I was like, as a young dentist student. I was like, “Oh my God, like everything angina, heart attack.” It was like trying to think what was the latest guidance? What I do, but just falling back on that advice. Of just doing that and remaining calm. Now I don’t want to say that it’s blasé. I don’t want to be blasé about it. But now if it happens, I’m really calm. Like, “Okay, that’s fine. Let’s bring you back.” I’m just speaking out loud in a nice hypnotic tone almost for a patient.  [Rachel]And they’re scared because they come around but I’ve got a really funny story actually. When I was– I say newly qualified, I probably worked in ED for about, I don’t know, 2-3 weeks. And one of my patients needed some GTN spray. So a nitrate and what a nitrate does, is it vasodilates. So– [Jaz]So why do they need the GTN spray?  [Rachel]Because they had some pain in their chest, which is separate to the Vesovagal Syncope.  [Jaz]So they had angina.  [Rachel]They did okay. Yeah, it was prescribed PRN, which basically means as much as they require as such. So I went along as kind of a new nurse in ED and I didn’t check the blood pressure before I gave the GTN, which in hospital settings is actually really helpful because if they’ve already got a lower blood pressure and then you go and give them a drug that vasodilates the blood pressure drops even more. So he already had a lower blood pressure than normal for him. I went along, gave him two sprays– [Jaz]Because the chest rate, which is the right thing, is away. [Rachel]And he basically fainted on me straight away. Now because I was new and fairly inexperienced at the time, I’d only been qualified for about a year or two. I panicked and I pulled the crash bell. Everyone came rushing in and I stood there and went, I think I’ve killed the patient.  And I burst into tears and I’ll never forget one of the consultants who sat tilting the bed for me. And they’re like, as we just discussed, tilting the bed and saying, “No, you haven’t. Go and pull yourself together and make yourself a cup of tea.”  And I kind of walked off sobbing thinking, “Oh, he is dead and it’s all because of me.” But actually what I’d done was, is given him, I should have given him one spray, reassessed, checked the blood pressure to make sure he was okay and then given him a second if he had needed it or what I did was just go. And then I gave him basically.  [Jaz]At that point, the blood pressure scenario and the syncope wasn’t your number one worry. It was the fact that he was a patient with angina–  [Rachel]Correct.  [Jaz]Or, the associate that with cardiac issues and therefore I could see—  [Rachel]I saw a treat.  [Jaz]Yeah. Yeah. Fine. So that makes sense. [Rachel]It’s a lesson. One spray reassess, second spray, reassess. Don’t just go in gung ho, because actually sometimes you can make it a bit worse for yourself, even though I know you’re treating the angina. But you will cause a Vasovagal Syncope, basically.  [Jaz]Interesting. Now, later we’ll be talking about angina. [Rachel]Yeah.  [Jaz]So if you just jump that a little bit now for our angina patients. GTN spray, classically, I was taught it runs out of date really quickly so always check that it’s in date. Correct. And then I always literally get them to keep it right there, like by that telling, I say keep it there basically. And I’ve never need to use it.  [Rachel]Yeah.  [Jaz]But would just to have It would, yeah. Would, yeah. Exactly. Would you recommend then also doing the same as what you did in terms of what you’re recommending, which is one spray and then reassess?  [Rachel]I always recommend one spray and reassess. Even though they may say, “Oh, you know, I take two or three sprays for this one” I get it. That’s fine if they want to do that at home. But when they’re in your surgery, when they’re in your practice, you’ve got a lot of instruments around, the last thing you need is them standing up and collapsing. So I would always do one spray, check how it works, see how they feel. Has it improved their pain? No it hasn’t. Give it a couple of minutes, give them another spray. Because you are trying to protect them from injuring themselves, hitting their heads, causing themselves more harm than is necessary.  [Jaz]Okay. So that makes sense and we’ll expand more on that. When it comes to the GTN and angina part, back to Vasovagal Syncope, then it sounds fairly straightforward. But the reason I mentioned the fear as a young dentist when you’re facing a medical emergency is, which one could it be? Is it this one? Is it that one? And so what advice would you give to a dentist if something’s happening and they’re seeing that the patient is in some sort of distress. And to just think logically. And to give them a sort of a guide to figure out which one it is.  Obviously common things happen commonly. So maybe assume it could be a Vasovagal Syncope, but by assuming that always, is it that we might be missing something a bit more sinister. And so what advice would you give to a dentist regarding that?  [Rachel]I guess my advice would be checking– because what you worry about with a Vasovagal is that because they have those moments of unconsciousness is this actually a cardiac? And what we have tend to happen in hospitals is that we start shaking the patient and checking their breathing to make sure that we haven’t actually caused it, or the patient hasn’t gone into cardiac arrest. The advice that we kind of give our colleagues in the hospital is you check the breathing and that’s the most simple thing to do. So you lay them flat if they’re not already flat. [Jaz]So let’s assume that you think it is a Vasovagal Syncope. But you’re a little bit unsure and you are a little bit scared so you do the first step anyway: Lay them flat, which flat works for both. [Rachel]Yeah.  [Jaz]And then next step will be check with- [Rachel]Oh, not their airway. So head tilt, chin lift. So really pull that head back, making sure that as long as they’ve not- [Jaz]So we’ve got this little headset here that is handy to bring the head back.  [Rachel]Yeah. And then you look, listen and feel for breathing. And as long as you can see that chest go up and down, that’s breathing. So then you pretty much know then that this is actually faint. And then the next step that I would do is raise those legs straight away and reassure the patient and talk to the patient. And then they should come round very quickly.  Like if it’s a sort of, I say a simple, well, nothing’s ever simple, but if it’s a faint, they should come round quite quickly. But it’s the difference between knowing if this is a serious unconscious event where we need to start thinking of ruling in or ruling out. What it could be is really checking whether they’re breathing or not. And once you can confirm that they’re breathing, you buy yourself some more time because then you can start raising the legs to see if that works and so forth. Obviously if they didn’t come round, you’d start to think about have they taken anything? Has anyone given them anything? You know, why suddenly, is this a blood sugar event?  Those kind of things. But initially, if you’ve done something to the patient or they’re nervous or anxious, you can pretty much say this is probably a Vasovagal Syncope.  [Jaz]Perfect. So the advice here is commonly Vasovagal Syncope is the most common one that we all face. Bring their head back, but then if you’re unsure just first thing, do a check for breathing  [Rachel]Check- [Jaz]And that reassures you. In my experience they usually come around nine seconds to two minutes.  [Rachel]Correct.  [Jaz]Feels like two hours when it happens. Alright. How apart.  [Rachel]And it does for medical professionals too. Yeah. You’re not the only ones that feel like, are we missing something here? But it’s about taking your own deep breath to be honest and thinking they’re safe. They’re on a bed, they’re breathing, almost have a check with yourself and say, “They’re fine. We just need to work out what this is.” Raise the legs.  [Jaz]Everything in our decision making just works way better when our mind is calm. And that takes, it’s very difficult, I mean, it’s easy for me to say.  [Rachel]It’s very- [Jaz]But it’s difficult. But I’m going to give a story which is relevant. It’s similar, but it’s not a medical emergency.. I do a lot of occlusal appliances, splints. It’s my area of interest, TMDs and bruxism and that kind of stuff. So occasionally you get one from the lab, which is really tight. Right? So it goes in the patient’s mouth and they are not able to remove it.  [Rachel]Yeah.  [Jaz]Okay. And so again, in my early days I start panicking thinking, am I not going to be able to remove it?  [Rachel]Yeah. [Jaz]Now it’s like, if they see the panic on my face, that’s game over. [Rachel]Yeah. So true.  [Jaz]Now I am just really relaxed about it. Because wherever it is, I’ll get it out. I’m really just calm about that because compared to a medical emergency, there’s nothing. Right. Let’s face it, right. So if you put things in perspective it’s really no big deal and I’ve always been able to get it out. [Rachel]Yeah.  [Jaz]So it’s one of those things that, it really helps me to just not to stay really calm- [Rachel]Yeah. Stay calm and work through the process in your head. It’s Occam’s razor, isn’t it? If what it’s usually is what it is. In other words, we can word that better, but essentially if it talks like a duck and walks like a duck, it’s usually a duck. So if they’ve just seen a big instrument come towards them and they already don’t like you, and no offense Jaz, but you’re about to do something like a root canal in their mouth. They’re already feeling insecure. They get, some patients are prone to fainting and some more than others. I mean, I’ve never fainted in my life. But my husband has a couple of times and if he sees blood, he gets a bit **, whereas I thrive in that kind of situation, it just depends on your personality.  [Jaz]I mean, one thing we haven’t mentioned though is we, as Dental Professionals, one thing we always do when the patient comes in, even if you’re seeing them third time that week, is just check the medical health- medical history.  [Rachel]Yeah.  [Jaz]And so that again, if they don’t have any cardiac history, the young patient, no cardiac history, then it will again strengthen the cause for Vasovagal Syncope. Whereas the time waking up is a little hairy, a bit confusing for us because they already have a known angina and they have had a stamped place before and that kind of stuff. [Rachel]Awaiting a bypass. [Jaz]Exactly. That’s when it gets a little bit hairy. Yeah. But again, check for breathing is a top tip basically and–  [Rachel]Real top tip because if they’re breathing, you’ve got time.  [Jaz]Yeah.  [Rachel]Yeah. It’s when they’re not breathing, but then we go down a whole different route.  [Jaz]We will explore that. Before we move away from Vasovagal Syncope and then maybe go to anaphylaxis. Is there any other point that you want to make on that?  [Rachel]I don’t think so. I think the main key points are laying them flat and raising their legs. To be honest, it’s actually one of the simplest things that you can treat. So in a way, my advice would be to not overthink it.  [Jaz]Good. Stay calm. Don’t overthink it. And this is, check the breathing. This is the one. Yeah. Check the breathing. And this is the one that we’ll be doing. For your long career, this is the one that will tally up the most, maybe into three figures by the time you come to the end of your career. [Rachel]Correct.  [Jaz]Right. So Rachel, now moving on to anaphylaxis.  [Rachel]Yeah.  [Jaz]This is one which I think is more- would you say is more common than some of the other ones that, if you were to rank in order what a dentist may typically see or- [Rachel]Yeah. I feel like you would end up seeing anaphylaxis more out in the community than you probably would in the dental practice, just because you’ve probably given yourself quite a lot of protection over the years of removing things that could cause it. Like you’re probably a nut free surgery. You’d probably not use latex, am I right?  [Jaz]No, I mean I don’t think anything here is latex.  [Rachel]Yeah, so you probably removed a lot of the things that might trigger.  [Jaz]We talked about it earlier actually. So there was a concern when I was studying at the school about chlorhexidine. Some people had severe anaphylaxis for chlorhexidine. And my Perio tutor, she’s freaked out and then she stopped using it.  Whereas I speak a lot to dentists and actually it has got some good efficacy in reducing something called dry socket. After extraction you can get a dry socket and so people use chlorhexidine gel and a lot of procedures to disinfect the mouth.  We use chlorhexidine mouth rinse. So people have different attitudes and I think it’s one that is still quite rare. At the back of our minds, that’s one that’s always in my mind now from my experience.  [Rachel]And do you use it in surgery?  [Jaz]See, because of my bias now because I’ve been kind of, she put that fear into me. Now I don’t use it so much, but yeah, we have it, for example, wisdom teeth. If I’m irrigating wisdom teeth, sometimes I’ll use that.  [Rachel]Yeah.  [Jaz]And so that’s one I can think of that may be more relevant.  [Rachel]I feel like the big ones are you, and particularly the ones you’re not necessarily going to know about are the bees and the wasps. Obviously there’s all the nut family, strawberries, kiwis, they’re big ones.  But again, these are things that you wouldn’t really expect to have in a dental surgery. But because you are an environment medical practice, there’s nothing stopping somebody being stung out into- [Jaz]You have a story about this? [Rachel] Yes. So one of my other surgeries that dental practices that I taught, the exact same scenario. They were near the dental practice and they got stung by a wasp or bee. And unfortunately they didn’t know which one it was. So they walked into the practice, they went to the reception area and they said, “Oh, I’ve come for my checkup, but actually I’ve just been stung and I’m not feeling great.” Obviously the receptionist kind of went into a bit of a, “What do we do? What do we do?” So she sat her down in the waiting area, got her a cup of water. And then within five minutes this lady had started to develop something called a strider, which is an upper respiratory sound where there’s a narrowing of the airway. You get kind of a higher pitch sound going through it. So it’s like a noise when they take a breath in. She then developed an expiratory wheeze. So when they took a breath out, they had this kind of widespread, wheeze she noticed some sort of tingling in her lips. And when the dentist arrived, come out of seeing another patient at this point, he asked her to sort of stick her tongue out and it was definitely enlarged.  So there was obvious swelling there. She felt terrible, so we talk about something called impending deo. I don’t know if you’ve ever heard of it, but it’s essentially where the patient feels like they’re going to die. And actually, if you left anaphylaxis, unfortunately that is something that could well happen. [Jaz]And that happens through a collapse of the upper airway. Right?  [Rachel]Collapse of the upper airway, blood pressure dropping. Because when histamine is released into the patient, they get widespread vasodilation and bronchoconstriction. So those two things combined are a bit of a car crash.  Because of course your blood pressure’s dropped and your lungs have just gone really tight, so that’s why they get that feeling. And obviously their airways are struggling as well. So she was short of breath, she had obvious swelling, she had a stride or she felt terrible.  [Jaz]Would you have a rash? [Rachel]Yes, you can develop a rash, but you’re not waiting for the rash. And I think that’s what you know is the key message is that a lot of people wait for the rash to develop to diagnose anaphylaxis.  [Jaz]So I’m so glad you mentioned this because I remember DF1, so that’s the first year I’ve attended Dental School. We had this simulation in London Deck and in London by Waterloo. And I failed that station by the way, but it was like, they put you in a simulation.  [Rachel]Yeah.  [Jaz]And this patient’s like, “I don’t feel so well, I don’t feel– and I’m like, oh, is it cardiac? What kind of thing? Is it respiratory? What is it? And then the clue was that had I undone the top few buttons, they’d put these red stickers there. And so that’s always stuck with me now so rush. But you don’t always get one.  [Rachel]But you should. It’s funny you should say that because when I did my advanced life support course, when the first time I ever did it, they did exactly the same. So the patient was short breath, I was like waiting, waiting, waiting, waiting for the rash. And then they didn’t say it was a rash, so I kind of went down the wrong path. So don’t wait for the rash as my kind of top tip.  Because actually if you’ve been stung, you’ve got an upper airway, stride, strider with some swelling, the patient feels terrible, you can pretty much go down the anaphylactic route with this one. So they fortunately recognized it very quickly in the dental surgery and they got their emergency kit out and they administered the correct dose of adrenaline.. I am adrenaline.  [Jaz]And let’s talk about this just a moment, but let’s just make it really tangible for dentists because let’s say there is a patient who is allergic, sorry to use the chlorhexidine, I don’t want to make people bias to think that they should be worried about using chlorhexidine so much, but that’s the only one I can think of right now. So let’s say they’re using chlorine gel and they put it in the mouth, okay? And what do you think a patient would start to– what are the clues, initial onset symptoms?  [Rachel]Initially they start, say that it feel well that’s kind of the classic, like I’m not feeling very well. Sometimes the rash can develop before the airway, so it could happen that way around.  [Jaz]So maybe perioral rash in–  [Rachel]Yeah, it tends to be more of a chest sort of urticaria rash. That can develop over time, or it can develop quite quickly. They’ll probably say they’re not feeling great, and that they may have some pins like tingling feeling around their lips. And that they feel that their throat’s tight. Tight is a real key.  [Jaz]So yes my cousin, who’s got a severe peanut allergy, I’ve been to him twice now. Bless him. Where the tightness. Like, he literally- he’s a fan himself, almost like the way he looks like, like this is not good. Can- [Rachel]It’s so tight. You can’t quite, and you’re trying to swallow. Because you’re so nervous about the fact that you can’t swallow your own saliva because of course there’s a narrowing there.  [Jaz]And it looks sweaty.  [Rachel]They look sweaty, they look very flushed in the face. People talk about blue, blue doesn’t happen. Like it’s, it’s flushed.  [Jaz]Okay.  [Rachel]Blues a very late sign. And they, they kind of tell you they feel dreadful. Fortunately, you are lying them down already, so you are already halfway there. But those are the kind of first key signs in.  [Jaz]And then the voice change. [Rachel]Voice changes, and then if it’s that severe. You will get that stride door. But you are at a very critical point when you hear the stride door, because that’s a real emergency airway issue. Because if you’re hearing such a narrowing that you’ve got that noise, it’s dangerous and we need to do something well. [Jaz]So that’s a little bit later. So hopefully before then we would’ve acted. So we’re looking for just in the impending doom, not feeling well hanging— [Rachel]Doom not feeling well. Maybe tingling. Tingling, shortness of breath. They’ll always be short of breath at the-  [Jaz]Always short breath. Okay.  [Rachel]Anaphylactic. And may or may not develop that as cial rash quite quickly.  [Jaz]I’m glad you said that because I was kind of just from memory, I was  waiting for the rash. I’ve learned something. Let’s not wait for the rash guys.  [Rachel]Yeah.  [Jaz]So, we know articaine.. Sorry, not articaine. Articaine is a little more under anesthetic. Adrenaline. So adrenaline is the answer here. And so our emergency drug kit should have adrenaline. Now, is that usually kept in the fridge or– [Rachel]No, you don’t need to keep adrenaline in the fridge. The ampules can be kept in the bag. A lot of practices actually just have an anaphylactic box and some of them even keep them in each, like in one of the rooms it’s easy.  Because with the bag right, it’s big, it’s clunky, you’ve got to fish through it. The last thing you want to be doing when somebody’s got Anaphylaxis reaction is trying to wrestle your way through an emergency bag to try and find it. So— [Jaz]Well, you’re going to love what we have. What I’ll do now is I’ll just go bring it. And then we can actually talk through it actually.  [Rachel]Perfect. Yeah.  [Jaz]Okay. So I’m back. I have, for those of you who are listening, I’m holding the emergency drug kit labeled exactly so in a lovely green box, but really cool. Next to it was a laminated A four, which I love it’s from the BDA, it’s a Warsaw healthcare emergency drugs in the dental practice, and it’s just got an adrenaline aspirin. The names of the drugs indication, the dose. It’s a lovely little cheat sheet to it’s find. Is it more for practice to have this? Yeah.  [Rachel]No, not every practice has this.  [Jaz]It’s genius, I think. That’s a simple thing.  [Rachel]Sometimes they give practices which any practice can get essentially is download the resuscitation guidelines and they give you access but they definitely don’t give you the rest. So this is perfect.  [Jaz]Yeah, this is good. It’s got all the main ones which will– [Rachel]As long as it’s updated. I think that’s the key thing.  [Jaz]Yes. So we’ll find out today if it’s updated or not.  [Rachel]Yeah, because it’s very easy, and I really want to make this clear that people can often go to a lot of effort in printing these things out, but actually they don’t then update them when new guidance comes out. So if you are going to print and not rely on computers, then please make sure that you’re checking them regularly. [Jaz]So little admission here, Rachel. I’ve never actually opened this box in my life.  [Rachel]That’d be a good thing.  [Jaz]It’s a good thing.  [Rachel]It’s a good thing that you’ve not used it.  [Jaz]Yeah. But now I’m literally like, I’ve opened it and I’m glad I’m doing this exercise because this could happen to me one day. And just to familiarize myself with it. So guys, as I’ve opened this, I’m seeing lots of laminated files and I’m seeing, the first thing I see is an anaphylaxis cheat sheet just a whole one so fainting is second.  So first is anaphylaxis, fainting is second, then hypoglycemia. And it doesn’t say which company this is from or what resource from. So I can only assume it’s from research guidelines maybe, but it’s got like a summary. So rapid onset tells you about drug management, and it tells you airway, swelling, horse voice, breathing, rapid wheezing. It’s difficult breathing. The circulation will be pale, clammy to touch flushing. So it’s a really nice cheat sheet. I quite like this. Yeah. If you’re in doubt. And then it says, okay, management. Okay, so if unconscious lay flat and raise legs, do not place anything in the mouth. It’s all like really? No. If I’m imagining being in that very stressful scenario, then this is exactly what you need.  So what I’ll do, guys, I’ll make this available to everyone. Okay. So, in case your practice is not doing this, you can give this to your practice manager, get them to laminate it just like I have it here. And I think I’m really pleased to see this. As someone who’s imagining myself dealing with a scenario.  [Rachel]Because actually as we talked about earlier, when our own adrenaline is released we forget things. And having these kinds of crib sheets go-to sheets are perfect in an emergency. And even in hospitals, every crash trolley has guidance for our nurses and doctors, because we shouldn’t be remembering things in emergencies.  [Jaz]So I’ve already seen this, but like in our imaginary scenario, we’ve just diagnosed an anaphylaxis. I know what I’m looking for. So now I’ve come across these bags, right? These like massive, zip wallets.  First one in massive writing says seizure. Okay, seizures. And so, I’m going to skip past that one. Then I got one says heart attack. Then I’ve got one says stroke. So already what you said, like the last thing you want to do is rummaging, but this is quite nice and neat and tidy, right? [Rachel]Neat.  [Jaz]I’m looking for low blood sugar. Skip past that one. Severe allergy, I found my zip wallet so I’m going to put the rest of the box away. So that was within about 20 seconds I can find it. I’m going to open it up, let’s see what’s inside another. This is the flow chart, this is the Reese’s Flow chart this is– [Rachel]So we need to update this. So you’ve currently got March, 2008, and actually what you need is the 2021 guidance.  [Jaz]So we’re only 13 years out come on.  [Rachel]So yeah, we do need to update that. So that’s a good thing that we checked.  [Jaz]Okay. But the lovely thing here is we are great. We know about the recess flow chart. We’ll get the up to date one. But now inside here, there are these pre-made packs. Okay. One, two, and three. Okay. So this is one– [Rachel]They’re needles, are they?  [Jaz]I think so. [Rachel]Yes they are, yeah.  [Jaz]Yes, because we use the compute system, so we’ll talk about that in a minute. So there’s one label for with the expiry date on as well. Okay. And is one for preterm small infants. There’s one for all ages and just tells you how much to use.  [Rachel]Yeah. [Jaz]And then large adults. Okay. So we got that as well, basically. So that’s really handy. I know my patient is an adult so I’m going to go for this one for example. Yeah. And so here’s the thing. I had this training from Chris a while ago on how to open the compule. I don’t even know where the compule is.  [Rachel]Oh, it’s there. Ampule you mean?  [Jaz]Oh, the ampule.  [Rachel]Yeah. [Jaz]Ampule. Because I use composites.  [Rachel]Yeah, yeah, yeah. I assume you don’t want me to open that. [Jaz]Don’t open it.  [Rachel]So, yeah.  [Jaz]But see already, right? In an ideal world, let’s be honest guys. An ideal world we’d have let epiPen or the Jext or whatever, right? So let’s talk about that. Because when an emergency like that happens, okay, you want something ASAP. Like I know I’ve been shown how to use it right now. If I had to open that, I would literally be sweating and be like—  [Rachel]And did dentists not draw up drugs?  [Jaz]No. Okay. Here’s the thing. Like everything we have nowadays, it’s prefilled.  [Rachel]It’s prefilled.  [Jaz]So I know Chris, he does Botox and stuff, so I imagine he does that stuff.  [Rachel]Yeah.  [Jaz]I don’t like, the only time I ever would do this is this.  [Rachel]Right. That makes sense.  [Jaz]So let’s talk about that, right?  [Rachel]Yeah.  [Jaz]To make it easy for dentists, the best thing is the pens. So I imagine this is cost effective to do it this way.  [Rachel]So don’t quote me on this, but I believe that one ampule is about 8P might have gone up recently.  [Jaz]Eight pens? [Rachel]Yeah.  [Jaz]An ampule–  [Rachel] About that.  [Jaz]You think that is that, is that with the adrenaline inside? [Rachel]Yes. No, that’s just the glass. But as I say, don’t quote me, that was a long time I got told that. Whereas roughly nowadays, I believe a prefilled auto-injector is about 40 pounds, something like that. So in terms of cost saving. If people are happy drawing up drugs you’re medical professionals, you’re going to clearly go for the ampules. The other thing is, you’ve got 20 doses here because one milligram vial gives you two adult doses because it’s 500 mics. So you get two doses in one vial.  [Jaz]Two doses, but once you’ve used one, once you’ve opened an ampule. [Rachel]You can still use it for your second dose. You just pop the second dose five second.  [Jaz]Okay. But like, it’s like really though, I know you’ve got 20 doses.  [Rachel]Yeah.  [Jaz]But you’ve got 10 people there. Do you see what I mean?  [Rachel]Yeah, you’ve got 10 ampules, but you get two dose–  [Jaz]Two doses. [Rachel]In an ampule. Fine. So you’ve bought yourself a lot of time because we’ll talk about the in a minute, I’m sure you’ll ask about how often you give it?  [Jaz]Yes.  [Rachel]But this is clearly way more cost effective, than having– [Jaz]Let’s check the expiring on that.  [Rachel]Yeah. So you get a lot more on a box of ampules than you do with a– [Jaz]So more time more time before it expire  [Rachel]Yeah. Whereas with an autoinjector you get about a year to 18 months.  [Jaz]So this is two years. From here, basically I can see, so the date of manufacturers December 2023, expiry December 2025.  [Rachel]So you get an extra year, six months to a year on expiry.  [Jaz]So in balance, it’s not something we see often, right. Anaphylaxis as we already discussed. But when you have an ideal world, I’m just being a diva associate and be like, “Hey, why can’t we have EpiPen? Yeah. But really if I push company shelves, I’ll be able to get some G. I’ll break the thing. Yeah, I’ll draw it up. Okay. I might do a sloppy job of it. Okay.  [Rachel]Do you know what a lot of my other dental practices do, is they get those large oranges and then when their adrenaline expires, they all practice, they all go around with a needle and they practice injecting it into the opening ampule and injecting it into the orange. And they find it really helpful because just even opening a glass ampule, people get nervous because they think it’s going to cut. So my top tip for opening an ampule is you need to go on the blue dot of the ampule and I always get a paper towel and then I pop the paper towel with the ampule when I crack it.  Because then if it does split off, it’s not going to go in my thumb because I’ve been there and done that where I’ve had a bit of adrenaline in my thumb where I cracked it. My other top tip is to make sure you get the little fluid out of the top of the ampule. If you just slide it across the workstation, it just takes the fluid out of the top bit.  [Jaz]Explain that one again.  [Rachel]So in every ampule you’ll usually get where it shakes around, you’ll get a bit of a fluid in the actual bit where you are capping it off.  [Jaz]Yes.  [Rachel]So then you’ve got adrenaline everywhere and you’ve lost a little bit of your fluid by just dragging it across the surface, but it just takes the fluid out.  [Jaz]So dragging itself before you open.  [Rachel]Before you open it.  [Jaz]Okay, now I got it.  [Rachel]And then what happens is it drops the bit of fluid back down into the bottle. So when you crack it open, you don’t get adrenaline your thought.  [Jaz]We don’t get a mess and you don’t get wasted. So let’s say let’s open the box, get some tissue paper. Break open the ampule using the blue dot side, basically.  [Rachel]Correct.  [Jaz]And then I will get the needle. So the needle is the one that’s already been labeled? Okay. So I like the system. I’m liking this. And then the dose is already written here on a sicker, so my adult over 12 years has 0.5 mil, 0.5 mil it’s 500 micrograms.  [Rachel]Micrograms of the 1 in 1000.  [Jaz]Yes.  [Rachel]There’s two types of strength of adrenaline. You’ve got the one in 10,000 which is what we use, or what is recommended for cardiac arrest. And then you’ve got the one in 1000, which is used for– [Jaz]So much stronger.  [Rachel]Yeah. So, your practice isn’t going to usually buy the wrong thing and you’re not going to have a cardiac arrest, so you don’t need to get confused about what’s in your bag. But you are going to take 500 micrograms, which essentially is 0.5 mls because in each vial you get one milligrams.  [Jaz]So I would be drawing up half the liquid basically. Yeah. And then I’m going to be giving it to my patient and that this is me. From my memory. Upper outer thigh.  [Rachel]Yep, because you’re going to it’s intramuscular. So the thigh is a very good muscle to inject into. If you’re doing it correctly, you should go in and then pull back to make sure you’re not in a vessel. But a lot of people don’t do that, and they just literally inject straight in.  [Jaz]That’s what you see in the movies like. [Rachel]Yeah.  [Jaz]No one shows it where they just check.  [Rachel]No one does a little fallback, and then you instantly reassess your patient. So once you’ve done something in medical practice, you reassess to make sure that it’s worked. So you—  [Jaz]How quickly, I mean, have you ever had to do this from a patient? [Rachel]Yeah. Loads. Yes.  [Jaz]Tell us how soon- [Rachel]It works very quickly. I mean, within the minute, I’d start to hope to see an improvement within my patients.  [Jaz]So what it isn’t it-  [Rachel]It’s an amazing drug. Yeah, it is lifesaving because what it does is it acts in the reverse of what histamine being released does. So we talked about earlier that histamine causes vasodilation and bronchoconstriction, while adrenaline causes bronchodilation, vasal restriction. So you are basically reversing the effects or hoping to of the anaphylaxis.  [Jaz]But the fact that you’re getting all the symptoms up here and then, and the upper out thigh and how quickly it travels is remarkable.  [Rachel]It is remarkable. I mean, you are hoping that it’s going to show that. It might not patients might need back to back. And we talked about the dose, but actually the time between doses is five minutes. So every five minutes– [Jaz]I mean that five minutes is like five hours. [Rachel]It will be, especially when your patient’s saying I can’t breathe and they’re looking awful. And you know, in hospitals we’ve got them attached to monitoring and we can actually see how awful they are. Whereas in a way, being blind is sometimes helpful because you can’t see the fact that blood pressure’s dropped.  You can’t see the fact that they’re tachycardic. So you’re kind of waiting, you set your stopwatch because you shouldn’t have to try and find a clock and be like, oh, just remember what time we gave it. So set your stopwatch for five minutes and then when the five minutes goes off, you give another dose if there’s– [Jaz]Should you need to. Right? [Rachel]Should you need to. It’s no improvement.  [Jaz]Yeah. So in your experience, how many patients have you jammed who are getting real anaphylaxis?  [Rachel]Gosh, in my whole career?  [Jaz]Yeah. [Rachel]Not as many as you’d probably think, but maybe like 50.  [Jaz]Okay. So of them, how many needed the second dose?  [Rachel]40?  [Jaz]Oh, so we will need it then. Okay– [Rachel]Absolutely.  [Jaz]See, that’s useful. No one talks about that. Yeah. Right. Even you should have told us that last time you were here.  [Rachel]Sorry, I’ll put it in my script for next time, but no, you’re not. Particularly if they’re as severe as we’ve described this, we are describing a very severe case of anaphylaxis, and actually one shot is not going to necessarily get them better. It’ll help, but you may need to give a second dose, a third dose, and just remember that the GPS only actually prescribes patients with two autoinjectors, so they’ve only got 10 minutes. And then they need an ambulance with them to potentially give them the next dose. Obviously you are hoping that it will make a big improvement and it’ll buy time. But there have been some, big cases that we’ve heard about in the news where patients have even had other people’s EpiPens that they kind of volunteered their EpiPen forward or to inject should I say.  And even then, they’ve not been enough. So having the– I always think having ampules is better because we talked about the fact you’ve got 20 doses in there, whereas if you just had one EpiPen, that’s one dose.  [Jaz]I didn’t think about it that way. And actually you’ve actually changed my perception of it. Because I was thinking, ah, this is a cheap way of doing it. Yeah. And it’s annoying for me. But you’re right. But you, if a practice hasn’t an auto-injector to use the correct word, will they only have one?  [Rachel]So usually they only purchase one because they’re so expensive– [Jaz]And therefore is good for two shots, right? Or– [Rachel]And no. So there’s three main ones on the market that I know of. You’ve got epiPen, Jext, and Emerade.  [Jaz]So epiPen’s like the Hollywood one, everyone’s heard of–  [Rachel]Everyone– because everyone calls all of them EpiPen. It’s actually an autoinjector.  Yeah. So you’ve got EpiPen,  Jext, and Emerade.. Now EpiPen and Jext are a 300 micro crown dose. Now if you look up your chart— [Jaz]How do we do that? [Rachel]Exactly. We’ve tried looking this up over years and years about why they are erring on the side of caution by only putting 300 mic, which is actually a child’s between six and 12 dose. But we don’t know why they’ve done it. Whereas Emirate do a full 500 microgram dose. But the trouble with these autoinjectors, is that the shortages the one that every single time.  So if I say, Emirate would be the best one to get. You can guarantee there’ll be a shortage of it. So it is kind of whatever you can get hold of. But when you think about it, most people get given two, but they’re only getting two 300 microliters. And also they usually only ever carry one. Because they leave the other one somewhere else.  [Jaz]So really got like three minutes or four, like if it works- [Rachel]I really need to carry two. That’s my advice for everybody that’s listening– [Jaz]That’s using those brands that have 0.3.  [Rachel]Well, even 0.5 because really you’re going to get an ambulance within five minutes.  [Jaz]It’s true.  [Rachel]You’re not. So you need to be carrying two at all times. And people don’t, and particularly if you’re teenagers, you know, you’ve got a handbag that doesn’t fit it. It’s tricky. And you need to make– so I actually think that in a medical center, Ampules are better.  [Jaz]There we are. There you are.  [Rachel]Plus saving plus you’ve got more doses.  [Jaz]I’ll have to apologize to Chris I hit my hand. Okay, fine, so that’s useful. Now we haven’t talked about this, right? So let’s say I’ve jabbed my patient. They’re starting to feel a bit better. But how much better do I want them to be before I give them five minutes to give them the next dose? And also we haven’t talked about whether I need to give them an auction and at what point do we call the ambulance?  [Rachel]So oxygen is a must because of course they’re short of breath. They’re going to–  [Jaz]So epipen first or oxygen first?  [Rachel]I would go epipen first. If I didn’t have multiple people doing multiple things, obviously in an ideal world, you’d have you and Chris and your Dental nurse and you’d all– [Jaz]Yeah. It’d be teamwork. We do a big shout out every camp.  [Rachel]Yeah. So one of you would be putting oxygen on one of you would be giving the autoinjector or the ampules, and the other one would be raising the legs, because of course, what’s happened with histamine being released, vasodilation. So what you want is to pull that perfusion back, raise the legs. So yeah, oxygen is really important if you’ve got it. And you are in your dental practice. So there’s three parts to a cylinder. Usually you’ve got the little gray cap that you need to flip down. You’ve got the little– [Jaz]Shall I bring it?  [Rachel]Yeah, sounds good.  [Jaz]Okay. So we’ll still make it descriptive for those listening, but anyone who’s watching, we’ll make it visual. I walked in the room with this big green bag. It doesn’t actually say oxygen on it. It says lifeline emergency recess equipment. I actually wanted to say, O2 oxygen’s on it. So this is the first time I’ve ever had to get oxygen.  Ah, I’ve never had to give oxygen either. So for me, that’s a thing I’m learning a lot here in terms of the actual experiential, real world simulation or what could happen in this practice. So there we are, so the green bag, I imagine stop at the top there, we ask, see I don’t know where the zip was guys. So this is definitely new for me.  [Rachel]And then the other one.  [Jaz]And the other one, look at that. So Rachel has been very, very helpful in terms of you’ve- [Rachel]It’s a nice bang.  [Jaz]It’s not, it’s not your first rodeo?  [Rachel]No. And then- [Jaz]Okay. Is a stroke.  [Rachel]Yeah.  [Jaz]And are they all like this? [Rachel]In hospital we just have them on the side of our trolleys, but yes, in the dental world and the GP world, they usually are. Yeah.  [Jaz]And so as soon as I open it again, laminated cards, and it’s a Resus. And this one is August, 2023.  [Rachel]So someone’s obviously put their own little— but yeah, they’re fine. Yeah. Perfect.  [Jaz]And this is for pediatric?- [Rachel]Because it’s the 2021 guidelines, which is exactly what you want.  [Jaz]Okay. Yeah. Perfect. So anyway, I’ve just diagnosed someone with anaphylaxis. I want to go straight for the kilt and we get this tank here.  [Rachel]So yeah, you want to pull the auction out of, its that will holder.  [Jaz]So there we are. It’s got a nice little so it’s got a brick on it guys. It’s got a brick now. Yes. This is what I want. Something that clearly has oxygen on it.  [Rachel]Yes.  [Jaz]Okay. So don’t actually do it because I don’t want to get down back, Chris.  [Rachel]No, I understand. So what you’ve got at the front is obviously how much is in there. So you can see it’s in the green. So you pretty much got a full tank. If it’s in the red, you need to replace that. And then you’ve got the gray part that I was talking about, which is essentially the bit you’re going to flip down.  [Jaz]Ah, that’s easy.  [Rachel]Yep. Really easy. And then that means now you’ve got your port to put the mask connected to. And then the other back part that I was talking about is this part here where it says open. Now they should be always set on clothes because obviously you don’t want any worries about leaking oxygen.  So what you would do is turn it the way it says open, which don’t worry, this isn’t going to do anything. So you turn it really easy and then now you can just turn up your dial. Like so all the way to 15, which is the maximum that you can go and you would give your patient 15 liters of oxygen.  [Jaz]So in dentistry, am I right in saying it’s easy? Because the answer is always 15. [Rachel]To be honest, with a non rebreed mask, which is the one you are going to have in your bag. The answer is always 12 to 15. But I would just go 15 because why like, let’s not confuse matters.  [Jaz]No.  [Rachel]Because that’s the highest amount you can go. If they’re having a severe anaphylaxis, you’d want to give 15 liters anyway. But you can drop down to 12. I don’t want to overcomplicate things, but in hospital we might err on the side of caution if we have patients with long-term respiratory conditions and we wouldn’t want to flood them with oxygen. But in the community you are not thinking like that. You’re thinking I need to treat what’s in front of me. So I’m going to give them 15 liters.  [Jaz]Okay. So 12-15, I think I always remember 15.  [Rachel]Yeah.  [Jaz]So that’s easy to do. I mean, I was in the receiving end of oxygen recently. Actually last month I had a pneumothorax. A spontaneous pneumothorax. My lung collapsed and so I was there in hospital just like on oxygen. And actually, you know what, 15 liters for someone who wasn’t then, you know, yes, it was kind of acute, I guess, but I felt the flow. It was– [Rachel]I mean, piece of pneumothorax is pretty acute.  [Jaz]It was pretty acute, but even then I was like, whoa, this is a nice brush of box suit.  [Rachel]Yeah. So was it on the reservoir bag?  [Jaz]It was in a nasal tubes in my nose.  [Rachel]Okay. Yeah, you probably wouldn’t have as high as that, but– [Jaz]Okay. Admission guys. Here’s me being very honest, I think they said to me as 10 or eight. But then I was like, Hey, I’m a dentist. I’m number 15. So I turned it up myself was 15.  [Rachel]I love your honesty. [Jaz]So maybe it makes sense now.  [Rachel]Maybe that’s why I was so high.  [Jaz]Okay, so I found the oxygen, and I know where it looks now I know where the bag looks like. I know how to open the zip and the velcro now.  [Rachel]And the top tip for giving your patient via your non rebreed, because they’re called a non rebreed mask, is that you must make sure that you fill up the reservoir bag. So you might see a lot of medical programs like Casualty@Holby City , where they leave a flat bag on a patient’s chest. And actually then you’re not getting the proper oxygenation through the reservoir bag. So put your finger over the valve, make sure it fills up with the oxygen before you pop it on their face.  [Jaz]Okay. [Rachel]Because that’s a really key thing with non-rebreather masks.  [Jaz]I think the next time you’re here I think these kind of things that we’d like to see and do.  [Rachel]So click on.  [Jaz]Yeah, exactly. So that makes it very useful. So while we’re on the topic of oxygen, what are the different conditions? So moving, stepping slightly away from anaphylaxis, we’ll come back down to anaphylaxis. But what are all the different medical emergencies that we may see as a dentist that require oxygen?  [Rachel]So probably the most common one would be asthma. So patients could come in you can get patients who manage their asthma really well, or you can get patients that even just a bit of pollen can trigger off their asthma. Or the fact that they’ve walked here or something or ran here. And patients might come in feeling a bit wheezy, short of breath. They might tell you that their asthmatic, you’d hopefully know with an adult, whether they’re asthmatic or not, they should know. And severe asthmatics would need, or a sort of, we call it an asthma attack, but if somebody is suffering with their asthma, they might need oxygen because actually their oxygen saturations will drop. So that’s one of them–  [Jaz]Which actually reminded me should we be– because there’s a lot of people, lot of practice have got those oxygen, sat– [Rachel]I’m sure you did have one. Yeah. But they could be wrong. But yeah–,  [Jaz]I feel like it’s so cheap. [Rachel]They are cheap. COVID made them a lot more accessible, didn’t they? So, yeah, I mean, I think they’re really helpful. Obviously, if your patient is peripherally shut down, the peripheral or cold, or you know, there’s not enough blood going to them, then they’re not, it’s not going to give you an accurate figure. So you just need to be mindful that obviously it’s not the be all and end all, but they give you a good indicator of, and it should be above 94%. [Jaz]Yeah, but if they’ve got anaphylaxis, we know the guidelines are oxygen, so– [Rachel]Correct.  [Jaz]Asthma. [Rachel]Just give it anything.  [Jaz]Oxygen–  [Rachel]Asthma, if they’re their sort of severe life-threatening asthma, you need to give them oxygen, obviously cardiac arrest, but that’s again, a bit of a given. We could continue down the lines of all the respiratory burden and how far you want to go.  But patients with COPD that are really struggling, so chronic obstructive pulmonary disorder, if they’re really severe, they may need oxygen. But we’re also very cautious with those. Yeah. But they can’t have too much oxygen because they retain it or retain the carbon dioxide.  [Jaz]Are there any medical motives that we see as dentists that actually oxygen is contraindicated? Because, you know what, I’ll be, I’ll be honest with you, because I’m thinking like when post comes to serve. I’m like trying to remember everything. I’m like, oxygen probably sounds a good idea. You know, a lot of people might just say, just get the oxygen anyway, kind of thing. Could we be doing more harm?  [Rachel]The only thing really is chronic obstruct pulmonary. [Jaz]Very niche.  [Rachel]Yeah, very niche. And actually the rule is really, is that you always treat hypoxia first before hypocapnia. So you must treat their oxygen levels before anything else. So I can’t really think of a reason not to give it. With heart attacks, myocardial infarctions, they say that as long as the saturations are above 94%, you can hold off oxygen. Whereas they used to say, give everybody oxygen. That was having a—  [Jaz]That was my thought. Yeah. [Rachel]But actually. If in doubt give it because it’s better to give than to make somebody hypoxic essentially. But in hospital we would measure their saturation levels and we would titrate it against making sure they’re above 94%. But no, I can’t think of anything that you are going to really— [Jaz]Because I remember listening to you when you come every and most times you say, grab the oxygen. it makes sense. So it’s good to know that, and it’s reassuring. But back to our anaphylaxis, fake scenario, I’ve given the upper outer. Zoe, my nurse got the oxygen. We put it on, we’ve filled up the reservoir bag. Good. Okay. You’ve shown us or describe it to us exactly the three step process. So the gray thingy, the gray lid– [Rachel]The gray cap, pull that down. Turn the auction, the black controller, turn that to on and then stick the oxygen, you know, tubing onto it turn it on three steps.  [Jaz]And so nice little dial fifteens, the max.  [Rachel]Correct.  [Jaz]Take it there and then put it on the patient.  [Rachel]And how long is it going to last, roughly?  [Jaz]Ooh. Oh, I love this. For some reason 40 minutes came from my head.  [Rachel]So not exactly, but between sort of 15 to 20 minutes on 15 liters. [Jaz]Okay.  [Rachel]So it runs out pretty quick.  [Jaz]Yeah, it does.  [Rachel]And one of the practices that I taught at did run out. They had an asthmatic and this was more GP so don’t freak out. But yeah, as GP practices run out of oxygen and they have to wheel their patient across the road to the care home to plug them into the wall oxygen. So it’s a bit of a lesson that they then bought a massive cylinder, but you guys aren’t using it as much as GP surgeries are, so that’s fine.  [Jaz]Okay, so you get 20 minutes on that. But a patient who’s got oxygen, we’ve given one dose. How do you know– are we looking for complete resolution or if they’re feeling a bit better? Okay, we’re good. And at what point should the ambulance be caught? [Rachel]Straight away because you’ve given adrenaline and actually you can get rebound anaphylaxis. So you could actually feel you could get another rebound in an hour.  [Jaz]So as a team, like one person get the auction, or another person get the adrenaline can reception, please call 999.  [Rachel]Correct.  [Jaz]And say we suspend anaphylaxis. And then, oh, away you go.  [Rachel]Yeah. And I guess. It very much is a clinician decision. If your patient is much better, then no. Do you need to give another one after five minutes? No. But if you are kind of umming and arring and they still look pretty gray and they still say that their breathing doesn’t feel gray– [Jaz]It means pretty good stuff. Right.  [Rachel]It’s good stuff. And also, you know, we’re not going to cause much harm with adrenaline. So if we gave it and they didn’t necessarily need it, they’re going to feel like they’ve got a bit of a fluttery heart rate. But I thought dentists gave adrenaline anyway for–  [Jaz]Yeah. With an anesthetic. And it’s quite often when we go in a vessel, they feel straightened out. I’ve had it by myself before I’ve had an injection in my lower incisor region. And my heart sight racing straight away because it was injected into my vessel and that’s fine.  [Rachel]Just get them to run around the block a few times and they’ll burn it off. The good thing is it’s got such a short half life that if you gave it and you weren’t quite sure, it’s going to wear off very quickly. So I guess it does go back to a little bit of what you’ve got, the picture you’ve got in front of you, IE the patient. And do you think that they could benefit from another dose? Just to keep that breathing going, just to keep their blood pressure steady. If I was in doubt and I thought, actually, I’m not sure, I’d give another dose just to make sure. [Jaz]Do I remember correctly that at some point in the guidelines it had hydrocortisone? [Rachel]Yep. So in the previous [Jaz]Or anti tomine as well?  [Rachel]Yep. There was amine and hydrocortisone. Now it’s a bit of a gray area because they removed it from the initial algorithm in 2021. That doesn’t mean that we don’t give it, it just means that it’s not part of your initial management.  So when you are presented with a patient with anaphylaxis, say you are having one right now, what I don’t want is someone saying, quit, go and get the Piriton because the Piriton isn’t going to vasoconstrict and bronchodilate, it’s going to help with the source of all the helping with the background allergy, but it’s not going to save your life. So by removing it from the initial algorithm and putting it in sort of refractory anaphylaxis, it stops people running for the wrong drug– [Jaz]Wrong priority- [Rachel]And it makes you prioritize the adrenaline a lot more.  [Jaz]So, which in that imagining patient I described, should I also be supplementing it with an antihistamine? [Rachel]Correct. Yeah.  [Jaz]At what point? Which order? So you’ve got I’m high oxygen, adrenaline.  [Rachel]Pull your patient out in terms of an airway point of view, in terms of a perret point of view because obviously if we leave this patient. You know, they could go into cardiac arrest. So try and manage that acute side of things and once you feel like you’ve got time and you’re not trying to draw up drugs and keep the patient calm and raising the legs, then you can reach for the Chlorphenamine and just make sure that their swallows okay.  [Jaz]And Chlorphenamine is that tablet form? Okay.  [Rachel]Yeah, I mean, in hospitals we can give it.  [Jaz]So, I mean, antihistamine, I’ve taken the past the scene, but we’re not talking about that. Right. Or- [Rachel]Yeah. So Chlorphenamine is Piriton, you’ve got cetirizine or loratadine.  [Jaz]So you can give any of those?  [Rachel]Yeah, you can give them. You just need to make sure they’ve got safe swallow. Because what we don’t want to be doing, if they’re swollen, we don’t want them to risk aspirating or anything. So just make sure that their swallow is safe.  [Jaz]Okay. Perfect. Now, when I opened up this kit and it says severe allergy, should there not be some cetirizine or something.  [Rachel]Yeah, it would be helpful to have like a Piriton there, but as long as we remember that the initial algorithm is anaphylaxis fluids or raise the legs, obviously we know that dentists don’t give fluids. And oxygen, so what we worry about is putting something like Piriton in there or is it, you’ll forget about the rest of it and just give, so I guess it’s up to the Dentist– [Jaz]It makes sense that we’ve done the important things. Okay. So I did actually find the pulse ox in there, but no sign of any cetirizine or chlorphenamine. Okay. Chlorphenamine, there’s none of that. But that’s fine because you explained why adrenaline is the most important thing. but I think it’s a good idea perhaps for it to be floating in the bag somewhere just to give– [Rachel]Or even in your practice, like a cupboard or something, that if you don’t have room and whatever bags you have, then you can always put it in the surgery somewhere. Because as I say, it’s not an immediate life sort of saving medication, but it does help with the aftermath of a, alternatively, you know, you should be getting an ambulance fairly quickly. So it is something the hospital can always give.  [Jaz]Okay, great. So that wraps up Vasovagal Syncope and anaphylaxis. We also talked about oxygen and we talked about different modes of delivery of the adrenaline. Was there anything else that we want to talk about in terms of the adrenaline itself in terms of the different, we talked about Emerade having the correct dose, but being difficult to get hold of.  [Rachel]Yeah.  [Jaz]And the EpiPen and the Jext being a smaller dose, and that makes, you know, ideally they should have two, but time is of the essence. Three– [Rachel]Emirate, I believe have a one 50 dose, a 300 dose, and a 500 dose, whereas I believe that Jext and EpiPen just do a 300– but don’t quote me, but I believe. Yeah. Yeah. That’s what I’ve sort of been told.  Jaz’s Outro:Okay, great. Well, there we have it. Guys, thank you so much for listening to our first ever series on medical emergencies, mandatory training, but hope you found the style of listening or watching this wherever you caught the episode, that it was a bit more relatable, more tangible, and more enjoyable than someone just telling you about all the drugs and, and speaking at you. Shout out to Rachel King Harris. She did a wonderful job and is very excited to share part two with you next week. If you’ve got this far, you deserve your CE credit. Head over to protrusive.app to choose a plan that suits you and if you are just ready to actually go for it and make this your best year ever and check out all our mass classes from Verti Preps, from Resin Bonded Bridges, sectioning School and CPD for all the previous episodes. You need our Ultimate Plan.  However, to protrusive.co.uk/ultimate. I do want to thank Team Protrusive as well for this one it would be Gian, Kriselle, Nav, Erica for the publishing, and Mari our CPD Queen who looks after you to make sure you get all your certificates. Thanks again, guys, and catch you same time. Same place next week. Bye for now.

How on earth can a neck injection eliminate teeth sensitivity? Can a patient’s tooth sensitivity really be linked to their occlusion? Is occlusal adjustment ever indicated for sensitivity? And what’s the actual mechanism behind those cases where everything looks fine — no cracks, no significant wear, no exposed dentine — yet the patient still complains their teeth are sensitive? In this episode, Dr. Nick Yiannios shares the concept of Sympathetic Dental Hypersensitivity (SDH), a groundbreaking way of understanding sensitivity that goes beyond the usual suspects like caries, erosion, or leakage. We dive into how the sympathetic nervous system in the pulp can drive unexplained pain, why traditional approaches often fail, and how objective tools like T-Scan and EMG can reveal what articulating paper misses. This could completely change the way you diagnose and manage those “mystery” sensitivity cases that just don’t add up. https://youtu.be/a2Mg72Y_zkw Watch PDP240 on Youtube Protrusive Dental Pearl: When fitting a resin-bonded bridge (RBB), if you’re unsure about the fit and cement gap, use light-bodied PVS on the intaglio surface of the wing. After setting and peeling it away, the thickness of the PVS shows you the expected cement layer. Ideally, it should be thin and even; a thicker area highlights where your gap is excessive. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways: The T-scan technology revolutionizes occlusal analysis. Sensitive teeth can be linked to occlusion and bite adjustments. Frictional dental hypersensitivity (FDH) is a key concept in understanding sensitivity. Sympathetic responses may contribute to dental hypersensitivity. Innovative treatments include laser therapy and ozone application. Addressing root causes is essential for long-term solutions. Dentists should explore literature for new insights and techniques. Critical thinking is vital in dental practice. Advanced technology can enhance patient care and outcomes. Objective data is essential for effective occlusal adjustments. Understanding joint function is crucial for dental health. Differentiating between types of dental hypersensitivity is important. The sympathetic nervous system plays a significant role in dental pain. Educating patients about their conditions fosters better outcomes. The beaker of pain concept helps in understanding patient symptoms. Continuous learning is vital for dental professionals. Objective metrics are necessary for accurate diagnosis and treatment. Highlights of this episode: 00:00 Teaser 00:39 Intro 03:51 Protrusive Dental Pearl 05:42: Dr. Nick Yiannios’ Journey and Innovations 07:46 T-Scan and Digital Occlusal Analysis 08:29 FIRST INTERJECTION 13:46 T-Scan and Digital Occlusal Analysis 14:07 Discovery of Occlusion–Sensitivity Link 20:44 Second interjection 24:25 Student Case – Sensitivity from a Bridge 26:04  Dentine Hypersensitivity 28:39 Cervical Dentine Hypersensitivity 30:44 The Role of Lasers and Ozone in Dental Treatment 35:24 Alternatives for Dentists Without Lasers 43:12 Alternatives for Dentists Without Lasers 44:00 Frictional Dental Hypersensitivity Explained 47:15 The Importance of T-Scan in Dentistry 50:57 Neck Blocks and Sympathetic Responses. 58:24 Third interjection 01:00:01 Neck Block Mechanism 01:12:34 The Beaker of Pain Concept 01:14:38 Fourth interjection 01:16:23 The Beaker of Pain Concept 01:16:59 Community and Collaboration 1:20:57 Outro Curious to dive deeper?You can explore more of Dr. Nick’s work and insights through these resources: Upcoming course: CNO6 – Sympathetics in Dentistry: The Missing Link in General & Specialty Practice AES (American Equilibration Society) – check out their upcoming conference for world-class learning in occlusion and TMD. CNO – Center for Neural Occlusion Facebook community: Neural Occlusion YouTube channel: Dr. Nick DDS – packed with case examples, lectures, and protocols. CNO YouTube playlist Studies & Resources Sympathetic Dental Hypersensitivity – An Alternative Etiology for Dental Cold Hypersensitivity Greater Auricular Nerve Block Reduces Dental Hypersensitivity to Intraoral Cold Water Swish Challenge: A Retrospective Study Dr. Mark Piper Lecturing at the American Academy of Craniofacial Pain: Sympathetics & CRPS1  If this episode helped you, check out PDP199: How to Eliminate Sensitivity During Teeth Whitening #PDPMainEpisodes #OcclusionTMDandSplints #BreadandButterDentistry This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes C. AGD Subject Code: 180 OCCLUSION Aim: To provide dentists with an updated understanding of tooth sensitivity, highlighting the role of sympathetic nervous system involvement, occlusion, and modern treatment approaches beyond traditional desensitizers. Dentists will be able to – Explain the concept of Sympathetic Dental Hypersensitivity (SDH) and its link to occlusion and cervical nerves. 2. Identify diagnostic tools (e.g., T-Scan, JVA, imaging) that provide objective data for managing sensitivity. 3. Evaluate treatment options, including laser-ozone therapy, occlusal adjustments, and neck block techniques. Click below for full episode transcript: Teaser: I want you to think the sideways incursive movements like speed bumps. The more speed bumps, the more likely the nervous system doesn't like all that extra bump, bump, bump, bump. So you want to kind of smooth out the ride when you're going left and right. Imagine you're in a car, you want it to be a little smoother. Teaser:Remember misfolded proteins? If you as a human, which is rare die of prion disease, you are a complete biohazard. They don’t even know what to do with your body. Cremation is not enough, but guess what kills prions? Well, they’re not alive. Guess what destroys prions? Their misfolded proteins. Ozone, trigeminal, cervical,*** and this all ties into sensitive teeth because it’s not just trigeminal. It’s also***- Jaz’s Introduction:Most of us have the same protocol for managing sensitive teeth. We check the patient’s oral hygiene, we check for acid erosion, be it intrinsic or extrinsic. We try and take care of the acid basically. Most of us are heavily recommending some sort of desensitizing toothpaste, like a Sensodine or an Oral B sensor version, or a pro relief from Colgate, whichever it may be. Some of us are scrubbing desensitizing agent into tooth, perhaps even fluoride. And if the sensitivity is coming from like a Class five region, like abrasion a fraction, we might slap a composite in there hoping that the sensitivity will improve. Unfortunately, have those patients who no matter which brand of toothpaste they try, like it all helps, but they forever have sensitive teeth. I already have some patients in my mind that fall into this category. So what’s going on there? Why are these patients’ teeth sensitive? Well, hello there, Protruserati, I’m Jaz Gulati, and welcome back to your favorite Dental podcast. For those of us dental geeks who like to spend a lot of time on YouTube, you probably already know today’s guest: It’s Dr. Nick Yiannios. I remember seeing his videos like, 10 years ago, 12 years ago. And I was like, what on earth is going on? This guy is using a computer to inform him about the bite, and he had all these like EMG leads on the patient and you are thinking, what on earth is going on? I’ve never seen anything like this before. And then you hear about all these patients problems like they’ve got like clicking, popping, muscular pain, headaches, sensitive teeth, and by the end of the video it shows on the computer screen what the new bite is showing. But amazingly, the patience and their response was pretty spectacular. When I look back in my journey into occlusion, and now how I’m diving deeper into digital occlusion, like using the T scan for example, and next month, I myself am getting those EMG leads flying out to America to shadow Dr. Bobby Supple. Who’s a previous guest of this podcast and his podcast was called Occlusion Wars and was just a brilliant summary of the history of occlusion. You have to check it out. Anyway, Bobby’s the current president for the AES and their conference in February in Chicago is one that me and Mahmoud Ibrahim are speaking at. But we are small fish we are tiny tadpoles in this ocean of giants that they have presenting, including Mark Piper and Dr. Nick Yiannios who we’ll be hearing from today. So that’s my plug in there you guys have to check out the AES. If you can come to Chicago in 2026, February, I’ll put the details in the show notes. It’ll be great to see you there. Anyway, I’m digressing I’m just sharing my excitement from learning from all these people and what Dr. Nick has to share is pretty mind blowing. We will answer that question of can a patient’s sensitivity be linked to their occlusion? Is occlusal adjustment indicated for sensitivity? What is the mechanism behind that? And as per the title of this episode, you’ll get to know the real cause of sensitivity. And once you check for caries and exposed dentine and that kind of stuff, that the most common cause of sensitivity, like leakage and stuff like once you’ve accounted for that and you found that, “Hmm, actually this patient has no signs of cracks, there’s not significant amount of wear, there’s not much exposed dentine, why is my patient saying that my teeth are so sensitive?” Then the diagnosis, my friends, is likely sympathetic denting hypersensitivity. And if you want to know what that’s about, wait all the way to the end of the podcast. Honestly, it’s going to blow your mind. I learned a lot from this podcast.  Dental PearlNow, just before we dive in, it’s a PDP episode, so I’m going to give you a Protrusive Dental Pearl. Today’s Pearl’s inspired by a webinar I gave two days ago on Resin Bonded Bridges. I walk through on our platform Protrusive guidance. I do a monthly live, at least one monthly live. And this one, it was a full walkthrough on a Resin Bonded Bridge. I truly believe that for a single missing lower incisor that a cantilever, resin bonded bridge is the standard of care for replacing that incisor. I’m very open-minded, I’m happy to learn and change my views, but it’ll take a lot to convince me that an implant for a lower incisor is better than a Resin Bonded Bridge. So anyway, I was fitting this bridge and I’ve got the whole thing videoed and I’m talking through it. And what I notice is that when I’m checking the bridge on the model, I’m noticing a bit of a gap, then I show you how to manage that, but then I transfer it into mouth and I still see a gap.  So that means it can be an increased cement gap. We don’t want an overly large cement gap, obviously. So one thing you can do if you are unsure about the quality of the fit of your Resin Bonded bridge is you get some light bodied PVS. So usual runny light body stuff, you put it on the intaglio of the bridge, so basically the wing, and then you place it on, you let it set, and then you take the bridge off. And as you peel away the PVS, now you get to see how thick your cement layer or your resin layer is going to be ideally you want cement thin layer everywhere. Now in my case, it confirmed that the wing on the incisal region had a bigger cement gap, but everywhere else it was going to be okay. So I went ahead to use my PANAVIA™ V5 and bond it, and the whole video is there. It’s on the RBB Masterclass, it’s also on the webinar replay section of Protrusive Guidance.  So if you’re not a member already, check it out www.protrusive.app if you love our video walkthroughs. And without further ado, let’s check out this episode. What is this sympathetic dentine hypersensitivity all about?  Main Episode:Dr. Nick Yiannios, welcome to the Protrusive Dental Podcast. Honestly, as I was saying in the preamble earlier, I’ve been a long-term admirer of your work and it’s an absolute honor and privilege to have you in front of me. I’ve got a gazillion questions, but because of time we have to hone on in, on something. And the topic of sensitive teeth, I’m so excited to hear your take on it. But for those few people that haven’t heard about you, like people need to go on YouTube and see your videos over the years are just. Incredible how you’ve served patients with their pain. So please give us a flavor of who you are, where you are from, and how did you get into this strange world that you practiced in. [Nick]You want me to tell you a story then? Okay. I’ll give you a story. So I’m almost six years old, so I’ve been in this a long time. I graduated in ’93, practiced in Dallas for a couple years. I’m in the US. I decided to move, married a girl, moved up to Missouri, which is about, I don’t know, 10 hours north. Practiced in a small town, got divorced, tried to build my practice, tried to get my life back in gear. I’m in the woods, basically, and this is not a wealthy community. Bass fishing is the big thing around there, things like that. Anyhow, long story short, about 2007, I’m probably your age, and I decided, back then Sarah could just become to where you could get things done in a day, like a crown in a day. My most frustrating part of practice was having to deal with crowns that didn’t fit contacts that were off, things like that. Margins weren’t right.  Once it got to the point with Cerec that I realized I could do this in a day, I thought to myself, I’m going to take this on. So I’m pretty obsessive, very kind of a type, A kind of guy. I pulled in Cerec, got really good at it. I saw training by a guy named Rich Masek. Dr. Masek was in San Diego. He was probably the best in the world at the time with Cerec technology. This is like mid two thousand. Got good at that. He pulled me on his board of advisors. He had a teaching center called the Academy of Cadcam Dentistry. I met a guy named Robert Kerstein in one of our meetings.  And Kerstein was the T- scan guy. So digital occlusal analysis, if those aren’t aware of what that is, basically, instead of using articulating paper ribbon, shim stock, things like that, you’re using a Mylar Sensor. USB controlled little handle and you stick in these disposable sensors. They’re about a hundred microns thick and there’s inks and circuits in there and they pick up four screens at a time. So in other words, what hits when is documented and you have a record in a Windows computer. Okay, so basically when I met Kerstein at that meeting, I looked at him in the lecture, shook his hand, got his number, bought a T scan, went home, started applying that with the Cerec technology. Started applying his DTR principles, exclusion, time reduction. [Jaz Interjection]Hello, Protruserati. Let’s start with the first interjection. As you know, some episodes ago, I started these interjections because I feel sometimes you can get so deep in the episode and for our younger colleagues or those who are unfamiliar with some of the terms that we use, it’s really important to make things tangible. That’s always been our mission since 2018. So let’s start with what is the T-Scan and what is DTR? So very simply, let’s start with something that we all know, right? Articulating paper, whether you use something like an inked silk ribbon kind of thing, or some type of paper, red, blue of certain microns. I like to use Parkell. It’s like a 25 micron paper, the red one, it just marks so well. I also like troll foil, which is a 12 one, but I’m digressing.  Okay, so articulating paper, you put it between the teeth and it inks up, right? So you might see lots of ink marks on the teeth, right?So what’s that telling you? It’s telling you where the teeth are hitting or potentially hitting. Because sometimes it marks up, but that’s not really hitting. It’s like a near miss like it’s almost hit there, but it’s still inked, but it’s not a true contact. But anyway, it tells you where the contact is.  Now, the T-Scan is basically a sensor. It’s a sensor that you put in. And what this sensor does is when you bite it, when you get the patient to bite on it, it tells you not only where the contacts are happening on the sensor, but more importantly it gives you so much more information that ink doesn’t. So what the T-Scan does, it tells you about how hard the force is. So when you see two different ink marks, it’s difficult to know which is the heavier one. Okay? You only right 14% of the time based on studies. So when you see you use the T-Scan, they’ll tell you that, oh, actually the upper right first molar is taking 35% of the entire bite force and the upper right lateral is taking 10% of the entire bite force, and the rest are not doing much work, right? So it tells you how much force, but most importantly, it tells you about when it tells you about timing. So for example, when we bite together, did you know that our teeth don’t all meet together at the same time, right? When we bite together, you might find a premolar hits first, then a canine might hit and then a molar might hit and then the next molar might hit, and then so on, so forth until all the teeth are in contact. So that kind of brings in the element of time. And of course, as we know, teeth don’t hit with the same intensity and power. When a patient bites together, a molar might be taking a lot of the bite force, and when you put your finger in that molar, you might feel a lot of freis that’s like that vibration feeling that you can feel. So, you know it’s taking a lot of force. What the T-Scan does is basically technology hooked up to the computer to tell you which teeth hit when and with how much force. So it’s like articulating paper on steroids and for occlusion geeks like me, it’s awesome. It’s nice to be able to measure this data because think about it when we do implants or big cases, we want for there to be as much balance and harmony and distribution of force as possible, right? So that’s the T-Scan. Now we use the T-Scan in a special way to carry out something called DTR. DTR stands for Disclusion Time Reduction. I’m going to explain DTR is, we all kind of know that when we bite together and grind our teeth side to side, in an ideal world, we would get posterior disclusion. I know that occlusion wasn’t taught so well at Dental school, but we all remember something about posterior disclusion, anterior guidance, that kind of stuff. That’s a true philosophy or not, that’s debatable, sometimes group function can work, but some of my colleagues, like the people who teach me DTR, are saying that actually group function can be pathological. Anyway, I’m digressing. So back teeth should be out of the equation. As quick as possible, we should get disclusion. Usually somewhere along the front teeth like the canines for example, they pick up the force and the back teeth are no longer in the picture anymore. Yiannios use is posterior friction, right? Think of it like speed bumps as posterior friction.  So you want to get the back teeth out of the way according to this philosophy of DTR. Now because the T-Scan can measure when someone bites together and starts grinding to the right, the T-Scan can measure how soon are the front teeth doing the work and how soon are the back teeth no longer touching. That essentially is DTR is Disclusion Time Reduction. So the time of them in their normal bite, i.e. their maximum intercuspal position and they grind to the right, how quickly can we get them onto their canines or on their anterior teeth and how quickly can we disclude those posteriors? It takes a couple of seconds to do that, right? You bite together and you grind to the right and it takes a couple of seconds for this patient to eliminate the back teeth rubbing together.  So this actually means that your muscles are working over time and so what Disclusion Time Reduction does is through some adjustments and maybe some additives, like adding some canine rises, you’re essentially refining the guidance and therefore you are shortening the disclusion time. So the patient goes from MIP, you grind to the right and you quickly get onto your front teeth and you’re no longer rubbing the back teeth together. You’re no longer having that posterior friction and that’s Disclusion Time Reduction therapy. I have been seeing some of Nick Yiannios videos on YouTube for over years. And I was always wondering what on earth is this guy doing, some sort of wizard. And over the years I understood and I got the T-Scan now I’m actually being DTR trained actually the day this episode’s going live, you are listening to this right now.  If you’re listening to this day 1, then I’m actually being trained by Robert B. Kerstein right now as we speak on DTR. So now what T-Scan is, and now you know what DTR is. Let’s rejoin the episode. [Nick]In other words, he’d been publishing for over 20 years about how when back teeth hit too long in time, this can become problematic, cause headaches, cause problems like that. TMD world. And I wasn’t necessarily interested in the TMD world, but I was sure as heck interested in getting my crowns right? I’m just a GP trying to do good work for my patients in the woods. So I wind up noticing something that he’d never seen before. I’m starting to adjust bites per his research theory where I’m adjusting discursive movements. In other words, when they bite down and grind off to the right or to the left, on the T-Scan sensor, you’re studying 3000 of a second increments like what hits when. Okay, so it’s almost like if you’re an MIP and you’re chewing your food, grinding around milling and maybe not quite touching, there’s still contact happening. I want you to think of sideways excursive movements like speed bumps. The more speed bumps, the more likely the nervous system doesn’t like all that extra bump, bump, bump, bump. So you want to kind of smooth out the ride when you’re going left and right. Imagine you’re in a car, you want it to be a little smoother, so fewer bumps is a good thing. So based on timing, and he was talking about lactic acid burns, all these things. But long story short, I’m applying his DTR principles in a private practice real world.  And I’m starting to notice that as I’m adjusting bites, maybe they came in, they had a problem with a crown that the guy down the road did, or maybe I did the crown last month, right? And I’m using the sensor and I’m applying its principles and I’m starting to notice they start out really cold, sensitive water and air from the handpiece. And then all of a sudden it drops down to almost nothing. But it doesn’t make sense because some of the time they already had exposed Dentine. And now there was even more exposed dentine. But yet they were less sensitive. So I started handing people ice water. I started handing people- [Jaz]And you were doing this like way back when- [Nick]2008.  [Jaz]It start. But did you perhaps start, like the reason that you were doing DT at that time was not for sensitive teeth? It was for facial pain, right? Is that– [Nick]No, it wasn’t even for or facial pain, it was for me to improve my restorative. I’m like you, I’m a GP trying to serve my- I don’t want root canals afterwards. I don’t want them coming back, for a bite adjustment. I didn’t want things like that, I wanted to be more efficient. I wanted to be a better dentist. Cerec allowed me to cut less teeth. I would like half top a crown I do to this day. I mean, they’re onlays, they’re not crowns you. My margins, the majority of my margins are super gingival. And if you get really good at Cerec, you can’t even see it. And if you know what you’re doing, you can get about a 25 to 50 micron tolerance versus 75 to 100 with lab made stuff. Back in the day we were just starting to get into some of the all ceramic things. But anyhow, I’m digressing.  The point is I started noticing that I’m adjusting bites and the cold sensitivities going away with the water and air from the handpiece. So I started handing people ice water, had them swish, and then checked and all of a sudden I started throwing these up on YouTube. This is back, I don’t know, 2011, 2012, somewhere in there. They were all about the T scan in the beginning. And initially there was no response, no one’s watching. I didn’t care, I was just trying to get it out there. I’m trying to get out to guys like you. And this is the Peaks, yeah.  [Jaz]The birds. But when I watched those videos years ago, Nick, it was like my headaches had gone, my joints were longer clicking, like I missed at that time about the sensitive teeth. I missed it. Completely.  [Nick]Yeah. Well, what got me into this was the sensitive teeth. So in other words, I’m just a GP. I’m not looking to be a TMD guy, I’m not looking to be an orofacial pain guy. So basically, I started applying these principles, and noticed that as I adjusted the occlusion, their cold sensitivity would go away much of the time. Not all, but probably most of the time. I called up Kerstein and I’m like, “Hey, what’s up with this? You ever seen this?” “No, I haven’t seen this.” Well, he’s a researcher. I’m a real world guy. Robert, I’m seeing this. It’s real. Anyhow, long story short, a year or so later, maybe two, the YouTube videos are going up. I’m starting to get some, a few people looking, and it’s mostly guys like you and me bashing me.  How dare you touch that version of enamel. You’re going to get sued. You’re going to perforate that crown that they did. You’re going to all this kind of crazy ****, and then it went kind of quiet for a while. Then all of a sudden the phone started ringing. And here’s someone coming in from Malta. Here’s a guy coming in from Australia. Here’s a guy coming in from Canada. Here’s a guy coming in from Mexico. And I’m like, what the hell’s going on here?  [Jaz]Did you feel a lot of pressure?  [Nick]Yeah.  [Jaz]Did that create a lot of pressure? because when I have someone, I’m like in London, right? And I get patients from like Birmingham, Newcastle. I feel the pressure. I’m like, okay, everything you need to do with your book, extra time, everything needs to go well. It’s a big thing. So for you to get these international patients that, I mean, that must have been a whole new level of pressure.  [Nick]It is. Because you don’t know, you’ve never met them before. Never treated a stranger, right? So anyhow, I started applying the DTR stuff. I started becoming more and more, I didn’t, not because I wanted to, but I’m starting to see all these TMD patients. Because most of them will have sensitive teeth. Then I would notice that there were many times that they would have their headaches would resolve too. So Kerstein was right in a way. There were times where it was applicable. But then, over the years it got to where I’m starting to see people from literally everywhere and it’s starting to almost interfere with my practice because I’ve got locals I have to take care of.  And to your point, it’s very, very hard to make time for those travelers. And you can’t predict and you’ve got an overhead, you’ve got to pay, you’ve got staff, you’ve got to pay, you’ve got a life you need to have, right? So I didn’t really sign up for that. It’s not what I was looking for. So once story-  [Jaz]Can I just stop you there? Because I’m really enjoying this, but I’m just kind of like, I’m relating a lot to what you’re saying earlier in my journey to where you are. But like, very relatable what you’re saying because at that time, when someone’s coming so far to you. What many people may not appreciate, but I know you will appreciate and you’ll be able to teach me on, is the level of communication.  Like my TMD patients and I are emailing a lot. There’s long essays, there’s emails, there’s a lot of reading, there’s a lot of communication that goes into, there’s a lot of emotional trauma, there’s stories and whatnot. So did you feel that that was also like, wait, how do I fit all this in with your regular practice as well? Did you find that as well?  [Nick]Well, what I did was I put up a wall. I made it to where they couldn’t send me that, and it sounds uncaring. It was the opposite. I started getting into the BioPack. In other words, the bio pack, there’s an engineer named John Radke. John and I are good friends and back then, I didn’t even know him.  Nowadays, we lecture together and we’ve published papers together. He’s the editor of Advanced Dental Technologies and Techniques. We just published last week. Mark Piper, Radke, myself, and a guy named Thomas Coleman out of Vermont. A new reason for sensitive teeth. We call it sympathetic Dental Hypersensitivity, SDH. We can go there a little bit too if you want.  [Jaz]We definitely will.  [Nick]My point is the biopack, there’s something called joint vibration where you can accelerometers, it is almost like a headset over the joints. The patient opens and closes multiple times and the sensors pick up vibrations, eminating from the joint. [Jaz’s Interjection]Hey guys, Jaz here with the second interjection. That’s a really quick one, right? What is JVA? It’s Joint Vibration Analysis. Essentially, it tells you how healthy or unhealthy the jaw joint sounds when it moves. So essentially when we open and close, and if you feel your TMJ area, it should be nice and smooth and it should be like a quiet car engine.  But if you’ve got a clicking, popping crepitus, that kind of stuff, then it really rattles and knocks. And basically what the JVA captures is those rattles and it gives you like a little graph form so you can actually convert that to an objective data. You get these vibrations that can indicate an unhealthy joint. It’s a way of tracking joint health. This is some technology that I’m not using at the moment, so it’s good to get some insight into let’s rejoin the episode.  [Nick]Point and it gives you an idea of what’s going on with the cartilage because I started realizing a couple years into it that I need to have objective data here. They’re coming to me with all these subjective things, like to your point, they’ve got this long list of problems and this communication. I started realizing, “No, I need to start having– I’m not going to talk to them until they come. I don’t want to even hear why they’re here when they show up. I want to put together a protocol whereby I can objectively measure them.” Okay? So this is about 2013- ish i’m starting to realize I have to put in place a protocol. About that time I got in my head, this stuff needs to get out there. I also got in my head that Hey, I need to stop applying DTR on everybody because I’d done it hundreds of times at that point and started realizing it doesn’t always work, right?  So it doesn’t always take care of their headaches because there could be many things that are wrong with them. So Kerstein and I kind of split ways we were very tied for many years and I still love the man and I’m not ragging him. And I started going, I started chasing a guy named, Mark Piper, like TMJ Surgeon, like probably Yoda. The crowd here probably have never heard of Mark Piper. But Mark Piper is a badass, excuse the language–  [Jaz]Best mustache you’ve ever seen in your life. Like the best.  [Nick]Yeah, he’s got a heck of a handlebar. One of those old Western ones but unbelievably smart man. He was at the end of the Dawson curriculum for years. In other words, if he went through the Dawson curriculum back in the 70s, 80s, 90s, and he started with Dawson in the early 80s, he’s since retired about two years ago. He’s an Md dMD, Harvard Vanderbilt. So Physician, Dentist, General Surgeon, Oral Surgeon, ER Doctor I mean, brilliant guy. And probably my biggest mentor of all time. And I’ve had 4 or 5. But he’s number one. So I reached out to Piper and he had a little course going on. I went to it and he’d heard of me, pulled me aside. Because at the time, Kerstein had asked me to be a co-author in the textbook. They’d asked him to write on the T scan, and I came up with the name Frictional Dental Hypersensitivity, FDH. That was the occlusion, the speed bumps, all that caused the cold. And I spent about a year in the literature trying to find out the reasons why, and there was no good reason as to why little speed bumps in the excursive movement would cause the teeth to be cold sensitive.  He and I are talking about it and I’m giving you my theories as we’re walking to lunch the first day, and he is like, “Did you ever think about the sympathetics?” And I said, “Yeah, I did, but there’s nothing in the literature.” He goes, “It’s the sympathetics.” So that was about 2013. So here we are, what, 13 years later. It’s the sympathetics.  [Jaz]And so we got to figure out what that actually means in terms of making that tangible. Right. And, but what you’ve set there is you give some context of your history, your mentors I love learning about everyone’s journeys and mentors, is a regular theme that comes up and everyone who I admire and it’s so nice to hear who everyone’s their mentors were. I’m going to just bring it back to a basic experience I experienced when I was a Dental student, right? So this was probably 15 years ago. I fit a bridge, it was a cantilever from a canine to a lateral, replacing a lateral. The patient comes back with extreme sensitivity on the canine. Now, this was a resin barn bridge. I know in the states they’re not very popular Maryland bridges, right? They’re not very popular in the States, but here, they’re super popular, right?  And so that’s when I learned that by adjusting the pontics, which were way too high in excursion pontics, these kinds of bridges should not be an excursion at all. And that was a student rookie era. And I took it away, and then that was the first time I experienced it. When he came back a few weeks later, his sensitivity was completely gone at a macro level, something that we’ve all done at one time or another. And then we’ve all experienced that, oh, the sensitivity’s gone. But then the problem we face, well, not the problem, but like when we go to the lectures, when we read the books, sensitive teeth. From my understanding, based on what we’re taught is down to having thin enamel, having an erosive diet, it’s a diet issue, it’s a reflux issue. It’s an exposed dentine exposed tubules issue, which is rectified by let’s say, if the abrasion and fraction is big enough with a composite or by rubbing Colgate Pro relief or Oral B the latest version or Sensodine whatever. Right? And that’s really what we offer our patients unanimously, 99% of dentists will send their patients off with this. And for some patients it works. For many, it doesn’t. I’d love to know from you, from studying sensitivity and looking at this kind of link so deeply, so thoroughly with occlusion, with frictional, dental hypersensitivity and also now the sympathetics. Can you give us dentists an understanding of the etiology and say pathophysiology of sensitive teeth? [Nick]Alright. Yeah, let’s do it as quickly as I can. So everyone’s heard of Dentinal hypersensitivity? So I want you to think about the occlusal portion of the molar, and typically you’re worried about exposed dentinal tubules, you’ve got maybe some wear of enamel to where there’s some dentine exposed, right?  [Jaz]It’s like cupping. Would you say cupping, like erosive cupping?  [Nick]Yes that’ll apply. And yes, it could be chemical in nature, it could be gastric, regurge, things like that, it could be an acidic diet. It could be wear emanating from the joints, your orthopedic joints. Now don’t get me into my orthopedic realm, but two thirds of the human bites right here, 1, 2, 3 thirds, right? So biomechanically, the mandibles-  [Jaz]So those listing on Spotify and Apple Nick’s pointing as TMJ. So two thirds of the occlusion is the TMJs guys.  [Nick]Yeah. So basically, I want you to think of the mandible, like a door. And the TMJ is like a hinge to the door. The door has teeth connected. Right? And on top of the condylar, head of the mandible, you’ve got cartilage attached by ligaments on the lateral and medial pole. When you displace that soft tissue, that cartilage, you will very readily alter the occlusion. Okay. So it’s almost like taking a crowbar to the hinge of one of the doors, one of your TMJs bending it a little bit. Does the mandible, the door, hit the jam? The maxilla a little bit differently? Of course it does. So the cupping, one of the possibilities, again, I’m digressed, but it could be biomechanical, it could be orthopedic, it could be the– look, the bottom line is sensitive teeth, it’s all a process of exclusion. In other words, you have to exclude fractures, faulty fillings, things like that. When you go through all these checks and everything pans out, there’s not a leaky crown. There’s what it is you got-  [Jaz]Caries free, obviously carry that’s the basic thing. Do the basics first.  [Nick]Yeah. Caries free. Dental hypersensitivity: the occlusal surface of a tooth, cupping to your point, exposed dentine. You’re activating C fibers via dental tubule flow. So these open tunnels that are pissing the nerve off they’re like popping the nerve, just irritating the hell out of it. There’s fluid flow. The neck of the tooth, which is the majority of the time- [Jaz]Can we talk about the dentine hypersensitivity just a little bit more? Right. So in this scenario, if that’s your diagnosis with no other source of sensitivity, what should you generally be doing? Is it a matter of restorative or is this the time where you say, okay, diet advice and use this sense of toothpaste? [Nick]Well, it’s the same reason on the cervical, that’s why I’m going down there that I was going to tell you. So you can have exposed dentine on the occlusal surface, open tubules. Remember, you’ve ruled out other possibilities. And then the most frequently you’ll find cervical dentinal where you’ve got it, where enamel at CEJ right open dentinal tubules. That’s going to be different, more sharp. It’s a delta myelinated A delta fibers, basically that’s firing, that’s ding in the nerve pissing it off. But the treatment for both is the same, what I do and it works. I’m not going to say a hundred percent of the time because that’s not fair. But if I say 95 plus, that is fair. I’ve been doing this forever.  [Jaz]Before you reveal, because we had a little chat, and then what you do is very interesting, right? But Joe blogs, your doctor blogs, the average dentist is going to stick a resin in there your GIC or composite. Okay. And give some centers, toothpaste. And for a lot of patients that might work. Let’s face it for some patients that will work. Right. But your protocol I hadn’t heard of before so please tell us, where did you- was this like, where did you learn this protocol from? How did it develop and share?  [Nick]I spent years in literature. I still spend time in literature all the time. I’m reading things, I’m learning things, and I trust my eyes. I trust my hands and my eyes. And remember, I’m not an academian. I’m not looking for fame, I’m not looking for any of that. I’m looking to help the people that I serve.  When you spend that much time in the literature and you’re looking for something you’re reading hundreds and hundreds of papers and you’re seeing different angles. You’re learning to identify that half the time, what they’re talking about is biased and BS. A lot of times it’s funded by no disclosures. Well, if you look deeply Google that name and this guy’s working for GlaxoSmithKline, it’s like, “Oh, okay. There we go.” Yeah. You’ll see this. You got to look. You can’t just trust what they say in the paper. Authors declare no conflict of interest. Okay. But anyhow, my point is, so how I ran into these things was that way. So the typical doc is going to want to drop desensitizing agents, oxalates, ides, things like that. Don’t waste your time. In my world there’s a company called Fotana. They make a laser. It’s a dual wavelength laser called the Light Walker.  In US dollars they’re about a hundred grand, they’re not cheap. But there’s about 80 things I do with that. Okay? And I have three of them. All right? And I use them constantly. It’s not just for sensitive teeth, it’s for surgeries, it’s for healing, it’s for biostimulation, it’s for root canals, it’s for extractions, it’s for laser-assisted periodontal therapy. I don’t want to get off topic, but the point is basically on Dentinal or Cervical Dentinal Hypersensitivity, what you do is you spend about 30 seconds illuminating the cervical aspect or the occlusal aspect of the tooth with neo dium energy. It basically kind of, what’s the word? Discombobulated the pulp. And it also theoretically starts denaturing proteins that are sitting around in the tubules that you can’t see microscopic, because a lot of people you’ll find over time in the practical sense, you’ll see them for a checkup and they are cold sensitive.  Then six months later they weren’t, even if they did nothing. Because a lot of times we’ll have deposits from salivary proteins going in there and clogging up the tunnels on its own. That’ll happen a majority of the time. Probably.  [Jaz]But isn’t that how also toothpaste market themselves work and they use the chemicals  [Nick]Yes. [Jaz]To clog it up and– [Nick]Yeah.  [Jaz]Block the pause if you like.  [Nick]Right? Yeah. So think of them like little tunnels that are open, you want to clog them. So that’s what they’re trying to do. And that’s what happens naturally out of your salivary, the stuff floating around your saliva.  Well, in the times that it doesn’t happen, what I do is I hit it with neodymium energy, about 30 seconds off the surface. Let’s say you have an fracted area on a number, or I’m not going to say numbers because you’re probably international. Upper right first premolar. A very common area. Yes. The typical spots are going to be like upper and lower premolars. Okay. By the way, occlusally related. But anyhow, my point is let’s say there’s an infraction on that. Upper right first premolar I will take the neodymium handpiece and I will spend about 20 to 30 seconds illuminating it. There’s certain settings that are not hard to find. They come with the laser. And then I pull out the Erbium, which is a different wave link. It’s 29, 40. Whereas the neodymium was 10 64 nanometers– [Jaz]They’re both on the light walker. They’re both in the same unit.  [Nick]It’s dual wavelength. So you buy that one dual machine, you got two lasers, right? Two tools. So basically then I hit it with Erbium and I spend about 10 or 15 seconds per area. Then that tooth, it would take me about 15 seconds. And then I take med grade ozone gas, which you’re taking from med grade oxygen through a converter. And all three are coming out at 50 gamma, which is a concentration and essentially kind of varnishing that shut. And 95 plus percent of the time that will cure them of either DH on the occlusal or CDH on the cervical almost always. Until such time however, they may wear out more of the occlusal and expose new tubules or more of the cervical may recess and they may expose more tubules. So you always tell the patient, “Hey, this is lasting. It will be permanent until such time that happens.” Which it is.  [Jaz]But then as you alluded to just a few moments ago, actually, the root cause of that, it could be dietary, it could be occlusal in origin as well. So you’ve got to then address the root cause as well. [Nick]Yeah, the dietary, for example, we talked about proteins precipitating in and clogging the tunnel, right? In the natural sense, what if an acidic environment just allows that? So my point is, I know from experience for many years of doing this that it will almost always work if it’s true DH or CDH if I hit it with the laser and the ozone. So there’s your cure.  Trust me when I tell you that if you’re like me and you’re deep into your technology, I know it sounds like a lot of money, and I’m not trying to sell Fontana, that’s not my point. I don’t care what brand it is. If you can get a hold of that kind of tech, you can do this now. You can do about 80 or 90 other things that you can’t do otherwise too. It’s amazing tech. I’m a laser dentist too. I like big time into it, hard tissue and soft tissue lasers, basically. Erbium is hard tissue. Basically neodymium is more soft tissue. Okay? So 70% of the fillings I do in my office, no shot, no drill with the Erbium laser. And I’m not exaggerating. I will pop my ears and ceramic crowns off with my laser. The less friction, the less trauma that I induce in the pulp of a tooth, the less likely I’m to have an necrotic problem, a root canal problem, an extraction, what have you. And again, I’m starting to tip into the sympathetic realm again because now we’re starting getting into sympathetics. Now I’ll get there. So I’ll take it from here if you don’t mind. So, DH, CDH. Right? So another possibility is FDH. FDH would be–  [Jaz]Can I please Nick before we get to friction because I think it’s really important to just touch on this point because what can we say? What can you say based on experience to the dentist who is not going to get access to lasers and maybe in their country they’re practicing in that it is just not going to happen in the foreseeable, right? Yeah. How can they serve that patient who has Dentinal hypersensitivity or sensitivity or Cervical Dental hypersensitivity, are the traditional restorative routes of composite or varnish that a useful or an acceptable alternative?  [Nick]It’s not worthless, but it’s not definitive generally. There are times, a example, I had one this week where she had cupping like a class six lesion on the top of a lower molar, and the first thing I did was I laced it and then I used my erbium angle after I desensitized with the lasers and ozone and I laced it to bond it. So I gave her an extra layer. I kind of sealed off the cupping, after I desensitized it. And by the way, when I initially hit her with water and air on that cupping area, it was uber sensitive. By the time I was done desensitizing with laser and ozone, it was gone. But I wanted to close off the cupping to where it wouldn’t get bigger. So I dropped a composite in there. Now, had I done a composite only, maybe it would’ve worked, maybe it wouldn’t have. So I hate to say it, but I don’t have a great answer for you. If I was without that kind of tech, I would probably hit it with bonding. I would close off, I’d probably etch and bond and I might get some longevity out of it. HEMA, things like that. Look, I use those for 20 years, the last 10 years I’ve been using lasers and ozone. I don’t even have desensitizer in my office. I’m not kidding you. I have a very big, large practice, seven operatories, very state of the art. There is no GLUMA , there is no anything in this practice. We do not tell people to go get Sensodyne, we do not use fluoride, we do not use fluoride. We’ll never use fluoride. That’s us personally, we’re more holistic.  [Jaz]Okay.  [Nick]I don’t want to get too deep into that, but–  [Jaz]No. That’s great to know. And I feel as though we just closed off that chapter for the dentist. It’s like, okay, but that’s great for Nick, but what do I do in my clinic? It just gives them something to think about. But we’ve opened their mind because the vast majority I’ve heard of ozone being used in root canals before. I haven’t heard of it in, used in this way. This is new information for me.  [Nick]Ozone machines are not expensive. You’re spending about $3,000 if I want people to learn, in my opinion, okay, I’m not that old, but I am old. Learn to open your minds and be a critical thinker. Learn to go into the literature, learn to spend time, spend maybe an hour or two a week when you run into something confounding in your office. Go jump in the literature and try to figure it out. Learn to identify the incorrect from truthful learning. Maybe brush up on your stats a little bit. We all took it in school. Learn what a P value is, learn what a good N is. So things like that, maybe what I’m trying to say is open the mind to other possibilities. For example, ozone, if you jump into PubMed or Google Scholar, everyone in this audience guaranteed can get to Google Scholar scholar.google.com on your cell phone or your laptop, whatever. Type it in. And I want you to type in Ozone in Dentistry. And you will see about 10,000 papers. And I want you to spend a little bit of time bouncing around example ozone, which is supposed to be this bugaboo and it’s dangerous. And I inject people with ozone gas all the time in abscesses.  What am I doing? It’s antibacterial, antivirus, cidal, and anti-inflammatory. It also kills what are called Prions. Remember misfolded proteins? If you are a human, which is rare die of prion disease, you are a complete biohazard. They don’t even know what to do with your body. Cremation is not enough, but guess what? Kills prions. Well, they’re not alive. Guess what? Destroys prions. They’re misfolded proteins. Ozone in your life’s experience so use your critical thinking forget the politics. After a big thunderstorm, you walk outside, you smell what? Ozone. What’s nature doing? It’s scrubbing stuff. Getting rid of the dead stuff.  What else? When the sun’s out UV. What’s that doing? Destroying bacteria and viruses, right? Right. So my point is ozone, there’s massive applications. Now, if I didn’t have a laser, I could grab an ozone machine for about 3000 US. Will it work definitively? Not as well as the combination, but it’ll probably work pretty well. And if you start chasing the Ozone World. You start realizing you’re going to start realizing you can start using the heck out of that thing. And it can actually make a little bit of money off of that thing. It’s a very inexpensive piece of equipment and the only disposable is you need to be able to replace refill the the oxygen tank med, great oxygen. So that would be my advice.  My advice would be, look at the literature, get yourself an ozone machine you can use it for all kinds of Perio, Endo, Hypersensitivity things. That would be my advice, that’s a cheap in. And I don’t care where in the world you are, you can probably get med grade oxygen if you’re a health professional. And that would Well– [Jaz]That’s great. I think it’s good. You mentioned the fact that everyone should do their, carry out their due diligence and look at the literature. And I think that’s it is very clear that, we even before we hit record that you have been deep into literature in many ways and takes us nicely into the next bit, which is frictional. I think that you were talk about Frictional Dental Hypersensitivity, which is the speed bumps and how the occlusion has a link. And I just want to love to hear about that now.  [Nick]So basically back in the day, around 2008. 2009, 2010,, Kerstein and I were on the phone and I’m like, “Man, I’m adjusting bites in the water, in the air. After I adjust the occlusion, it gets less and less sensitive, even though they’re exposing more of the dentine.” I am doing so sometimes right. Depending on the wear patterns. Anyhow, so that I called that FDH, and I put that in the literature. So Frictional Dental Hypersensitivity, basically the speed bumps, the excursive speed bumps. So initially, the initial thought, the best I could do in the literature at the time was there’s something called an A beta fiber in the pulp of a tooth, A beta if you have a mosquito or a fly land on you and you smack like your neck or wherever he is at, you feel it, right? Those are proprioceptive, A beta fibers, they’re all over the epidermis. We have them everywhere. We even have them in the pulp of teeth. Okay. So when I went to school back in the 90s they told us that we had C fiber, A delta, and that was pretty much it. Okay. Innovation wise. And so the C fiber was the unmyelinated slow, dull pain. The A delta was the fast myelinated pain. Well, come to find out, probably around 2000 ish, they started discovering histologically that they had A beta fibers, a few of them in the dental pulp, and they were responsible for proprioception. And they were also linked up to the sensory homunculus.  The sensory homunculus is that part of the brain that has that really weird, we all saw it in school. Weird representation of a hemisphere of the brain and this is the arm, this is the leg, this is the this is that. So the A beta allowed them to add the dental pulp to the sensory humunculus. I don’t want to get too deep. This is geeky stuff. Long story short, I don’t believe it is A beta. I used to think it was the teeth being flexed excessively and the A beta intra pulpal.  [Jaz]Because the theory I’ve had as well. Yeah.  [Nick]Yeah. That was the theory. Right? Well, it’s not that. In my experience, I can tell you with almost a hundred percent certainty, it’s not based on what we’ve been doing the last few years with the research. Okay, so that’s FDH. So theoretically, I walked into with Piper at that lunch and we were talking about A beta. And that’s when he looked at me, he said, “Do you think about Sympathetics?” I said, “Yes, but it’s not the literature.”, He goes, it’s the sympathetics. And I think he’s a hundred percent right. Okay, so that’s FDH. So basically, if you eliminate Incursive movements in the, say the crown that you just placed on tooth number 19, they come back a week later and they’re exquisitely, not exquisitely. Let’s say they’re, yeah, I drink something cold and it’s a six out of 10 and it goes away pretty quick that’s likely FDH. Okay. If they’ve got the margin sealed, if everything’s decent, you’re not too close to the pulp. You pull out your T-Scan, if you have one and you track for in time, now your next question’s going to be what about for the guy that doesn’t have a T-Scan? Well, it’s kind of like if you don’t have the laser it, it might work, it might not. Articulating ribbon, this is important.  Articulating ribbon, depending on the study, is about 12 to 33% accurate. Relative to force in time. All the big stiletto heel things that we learned about in school and all this stuff, and the 99.999% of us, all we ever use is that if you start going to digital and you start seeing force in time and 3000 of a second increments, it will change your world. [Jaz]Absolutely.  [Nick]The T-Scan will change your world and I’m not trying to sell T-Scan either. Just like I’m not trying to–  [Jaz]It’s changed my world. It’s been Yeah.  [Nick]Well it’s huge. I use it on– this is important too. I use the T-Scan on every patient that walks in my office that it gets restorative. Every patient that gets aligner therapy, I’m getting ready to do oral. [Jaz]Same.  [Nick]Yeah. I always have a record of before and after. Let’s say you walked in, you’re my patient and I’m doing two fillings. Let’s do something real basic two occlusals on eight on lower- let’s say lower left first and second molar. The first thing my girls do is they have you clench and grind on the T-Scan sensor. So all of a sudden I walk in and I’m looking at the proper reading and I’ve got a record of their bite.  Now they’re probably 70% of the time when I’m doing that filling for you, I’m just using the Erbium laser. No shot, no drill. And then I’m having you bite and grind, checking and comparing before and after. I’m using ribbon two to mark, but I don’t trust ribbon. I trust the data, the T-Scan, the literature is about 95% accurate relative to force in time across the board, 12 to 33 95. Which one would I rather use? Most are completely unaware.  [Jaz]Well, it’s the objective data for me Nick, I was always worried about equilibration.Whether, whichever definition you use, whether you’re doing it to CR or just getting a bite bouncing, adjustment. Occlusal adjustment.  [Nick]Occlusal Adjustment.  [Jaz]Absolutely. And so I was worried about occlusal adjustment because in my notes occlusal adjustment and then I was missing that objective data. Now that I have objective data that I had pre-op, this was the actual force in time data and post-op, I have objectively improved the occlusion. Right?  [Nick]Yes.  [Jaz]And then no one can argue with that. And for me, that really was the license to, okay, now I can do it in a way that I mean control. [Nick]Well, let me give you another hierarchy. Remember the door analogy with the hinges? You’ve got to be able to get a read on what’s going on with the joint, if you really want to know. Every single patient that we ever see, even their periodic exams, when they come in for their six month cleaning, we slap the joint vibration on them and we’re comparing it to past JVA readings. Joint vibration remembers listening for tears and cartilage. You can cross reference the data with Flowsheets and get an idea of the Piper classification. There’s Piper’s name, how deranged the joints might be, and that matters, like we alluded to that earlier. If you bend the hinge of a door, the way the door, the lower jaw with teeth connected is the jam, upper jaw with teeth connected. And that in itself can be problematic. And also another thing you can track with T-scan, let back, jump back to digital occlusal. If, let’s say I did those two fillings on you, I numbed you, or I didn’t numb you, I checked the after. And let’s say you’re Cooley didn’t come back, or let’s say you come back a week later, you’ve got a little bit of sensitivity problem to cold.  The whole topic of this podcast, I’ll pull out my T scan again and I’ll check again. Maybe I missed something for about 3 or 6 or 9,000 of a second. Maybe there’s a little excursive rub, a little speed bump and I’ll hit it with the bur, that one little spot. Then all of a sudden I’ll have you swish ice water as you walk in. You were a seven, you swished a minute later, you’re a one. I do this all the time. I’ve done this for—  [Jaz]That’s so fascinating because a minute later the upper teeth don’t know what’s happened to the lower teeth just yet. because they haven’t had enough time to even meet. So do you see what I mean? Like, they haven’t had the time to like trial it, to see to, to, for the weather it’s flexor or sympathetics, which we’re going to come to.  [Nick]Now let me leave FDH for just a second and let me take you guys to SDH now.  [Jaz]Okay.  [Nick]So you either have DH occlusal of the tooth where you have CDH, the cervical aspect, maybe recession exposed, Dental Tubules, like just like you would on a DH, right? Remember, laser ozone is the cure most of the time, almost always. Or you could have FDH, which is the bite. The little speed bumps in the incursive movements. [Jaz]Okay. I’m really sorry to interject, but I really need to know this, Nick. Okay. Yeah, because one of the questions I need to understand, and for sake of everyone, is when you are not sure— Okay? So I think what you’re saying is to follow as a hierarchy. Look for the DH first and deal with that. Look for the CDH first to deal with that before you jump to the frictional, because there’s no point then doing like adjustments and whatnot until you’ve actually taken care of the previous two, right? [Nick] Yes. But here’s the point. You need to have the objective metrics. I’m sorry, there’s no cheap way into this. You’re not going to be able to do what I’m doing with your ribbon. It’s not going to happen. You might get lucky. You’ve got about a one in four chance of hitting it. Okay? This stuff gets really deep and I don’t want to get too deep, but the bottom line is, the reason I’m trying to take you to SDH is because SDH is why FDH happens. [Jaz]Yeah. Yep. Let’s hear about it.  [Nick]So over the years, as I’m seeing people from all over the place I have a large database. So I decided to jump into the database. I had my head assistant look and she spent about a month there. And we were looking for things. We were — because we’re starting to give neck blocks. We started doing that years ago. Maybe Piper taught me this net block, basically that’s a lecture in itself. But their nerves– [Jaz]What are you injecting?  [Nick]We’re injecting anesthetic. Typically Marcaine 1:200,000. Basically the upper C spine, their cervical sensory nerves that make their way from the neck, they cross over the sternal cloud of mastoid, that big bulging muscle. When we turn right below the skin, it comes very superficial. It’s called the great auricular nerve. That nerve in particular is one of the ways that’s a cervical sensory nerve from C2, C3 ventral. That comes very superficially right by the SCM, where you can drop anesthetic about two millimeters below the skin. The anesthetic will essentially throw up a roadblock, not because you’re trying to block the greater auricular nerve, but because that cervical sensory nerve is a way that sympathetic nerve fibers make their way to the lateral face and teeth from the neck autonomic sympathetic. So what’s the point? Well, if I have a sympathetic response, I want you to just remember this one thing: Sympathetics Vasoconstrict, parasympathetic dilates blood.  Okay. So if I have ramped up sympathetic tone, I’m constricting blood vessels. If it’s always on, they’re always constricted. If I don’t have enough blood flow, might I kill tissues? I wonder why that crown prep I did last week that was nowhere near close to the nerve, needed a root canal this week because you stimulated sympathetic flow. [Jaz]So this is why some good or endodontists, they advocate when you’re doing a deep restoration or crack to you to dissect a crack, for example, to use an anesthetic without epinephrine or artane. So without adrenaline, sorry.  [Nick]That’s fair. Yeah. The only reason I use the 1 to 200 is because I want to last a while and it’s not, and honestly, the only time in my practice that I use any epi at all is when I give a neck block. Or if I’m doing say, eight or 10 veneers up front or something like that. Because we do, when we do veneers, we’re using Cadcam Tech.  We’re doing Cerec same day. Like they walk out finished. We call that CAD Smiles. We do that about every three months, I ship in a lab tech, he works the lab side of it, and I do the preps. And we do two patients a day like 16 to 20. I’ll use Marcaine there, I’ll use Marcaine up on the neck block. And honestly, I can use Prilocaine, I can use Citanest plain, whatever. I can use Procaine. If I want to get really holistic and no epi, I’ll drop Procaine in there.  Okay. And if you understand the holistic realm in dentistry, a lot of the patients and dentists that are in that realm, they’re using Procaine, which is the old fashioned Novocaine, which is supposed to have an allergic reaction. Every 20,000 people. I know a lot of holistic dentists, and I’ve never even heard of one. So we’re getting into that money thing again, in other words, corporations pushing certain things that are more profitable.  But the bottom line is , whatever. Here’s the point. The sympathetics, if they’re ramped up, and why might they be ramped up? Well, too many tap, tap taps, too many speed bumps. Now we’re pulling back to FDH, but I introduced the sympathetic idea if I have excessive sympathetic tone. Here’s another thing to know. The dental pulp, if you look histologically, 10% of the nerve fibers are sympathetic, originating from superior cervical plexus, which is neck. Anyone who took dental, anatomy, histology, whatever in Dental School, look it up online look it up right now on Google Scholar, whatever. It’s, I’ll say that one more time. It’s very important of the innovation of the dental. Pulp is sympathetic in origin. The other 90% is trigeminal.  [Jaz]Okay.  [Nick]Now, of that 10%, that’s sympathetic in origin. Some of it’s sensory and some of it’s motor. What’s the difference? Well, afferent, efferent, right? Sensory brain feels something. Motor brain’s telling something to do something. Gland, muscle, whatever, right? So if you have sympathetic nerve fibers in the pulp of a tooth, what the hell are they doing there? And why are they coming from the neck? It’s not the trigeminal this is very important. In other words, we all think trigeminal, our realm is trigeminal it’s V2, V3. Well, the reality is this is a big deal. It’s going to be a very big deal probably after I die. But who knows? It takes time for these things, right? But this is important. This is the topic of our most recent paper we published about a week ago. So Sympathetic Dental hypersensitivity was the name of the paper. Look it up in Google Scholar, SDH novel Etiology.  [Jaz]I can share it with this in the—  [Nick]Please do  [Jaz]–show notes.  [Nick]Please do. And I’m dead serious. It’s worth reading. The authors are myself, Piper, Radke,, the guy who created BioPack and another dentist who’s a kind of an expert in the old school of sensitive teeth. But the bottom line is the sympathetic efferent fibers, the motor fibers coming from the neck. The reason they’re there is to constrict the arterials in the dental pulp. Now here’s the kicker. Most every other part of the body, we have sympathetic and parasympathetic nerves to counter them. And the dental pulp, guess what? They can’t find histologically. Parasympathetic, five parasympathetic. So when you or I prep that crown, it was an easy one nowhere near the nerve, no cracks, no problems, just a broken cusp, no big deal. They weren’t symptomatic, they needed a crown. And then a week later, they are really in pain. When your bur hit that tooth, you ramped up a sympathetic tone. You caused excessive constriction. There’s no parasympathetic way to counter it. The constriction got so bad, it choked off blood flow. You get hypoxia, ischemia, potential necrosis distal to that point. So if you guys have ever wondered why it is that. Good guy that was a routine filling a routine crown. The caries was nowhere near, there’s no crack, no nothing. And now I’ve got a root canal problem. I’m telling you what.  [Jaz’s Interjection]Okay, interjection number three, guys. Okay. I know it was a lot to take in. So a quick little summary. That’s all this injection is, right? Remember Dentinal hypersensitivity, I think we can all understand this type of hypersensitivity. Typically occlusal surfaces expose tubules, right? You blow your 3 in 1, your air on it and it’s, ooh, that’s sensitive. Okay? So we can all understand and visualize that. Now, CDH, just Cervical Dentine Hypersensitivity, think of those abrasions, abfractions, where the CEJ is, and again, loads of our patients get that. The ones that you may not have heard of are Frictional Dentine Hypersensitivity. Those are the occlusal speed bumps that he described so like posterior friction, it’s the back teeth rubbing, getting in the way, stimulating this nerve response, causing this hypersensitivity. So essentially it is hypersensitivity due to occlusal cause. And now lastly, something that was new to me was a sympathetic dental hypersensitivity, which say nerve driven response. Now we’re going to delve deeper into that, but remember that when you find someone, a patient who’s got sensitivity, obviously, check for cracks, carries the usual stuff first. And then once you rule that out, then you check, okay, is there some exposed dentine occlusally? So that’s your dentine hypersensitivity. And if not, you check for abrasions and a fraction. So your Cervical Dentine Hypersensitivity, do you see any of those lesions that when you’re blowing air near the neck of the teeth and they’re super sensitive and you see those abrasion areas. Now, if they don’t have that. Then maybe think, could it be frictional? Could there be too many occlusal speed bumps? And if it’s not that, then it’s just fascinating what Nick’s saying with the Sympathetic Dentinal Hypersensitivity.  [Nick]So when you do a neck block at the greater occipital nerve, the sympathetic fibers, that’s one of the main highways by which the sympathetics make it up to the lateral face. And ear the oracle is the ear great auricular nerve. It runs to the angle of the mandible, innervates parts of the parotid, parts of the ear lobe and the mastoid area. Look it up online. Look it up in Google Scholar you’ll find the only thing you’ll see on Google Scholar relative to the dental world is stuff about wisdom, teeth extractions. Helping people get numbers on V3. And I’m telling you why, because the sympathetic nerve stuff is still active even though you’ve given a block.  Remember, 10% of the dental pulp is sympathetic and mostly efferent fibers, which can constrict blood vessels. So why we’re giving the nerve block is because we’re trying to reduce the amount of sympathetic flow. All right? This is how the sympathetic guys, let’s call them the bad guys. This is how the bad guys make it into the lateral face and the teeth themselves, it’s a big deal. So here’s the point. So our end was 194 in the paper and we basically, I’d injected all 194 of those peoples, and I had a ice water swish before and after, and we’re looking at their responses and basically there was like quartiles, I don’t want to get too deep into it, but about 124 of them it affected. And there was about of the 190, I think it was a hundred ninety four, a hundred twenty, yeah. So there’s about 70 people where it didn’t do anything. In other words– [Jaz]And just to clarify now for people following along in this study, it was a, the nerve block into the neck and it was just before and after ice water, just from that one intervention, right? [Nick]Yes.  [Jaz]Okay.  [Nick]Yes. So in other words, 124 of the 194 thereabouts had a complete change matter of degrees. Some of them, it went down to almost zero from say an 8 or 9 out of 10.  [Jaz]So statistically significant change.  [Nick]Huge. The P was less than 0.0000000000.  [Jaz]Perfect. [Nick]Anything less, if you know anything about P values 0.05 or less is statistically significant, right? Our numbers were like unbelievably significant depending on which quartile you’re looking at. So the bottom line was, here we are injecting in the neck, which has nothing to do with trigeminal, and their two sensitivity went away on a very large subset of those 194 people.  Okay, so what does that prove? Well, that, does it prove anything? Well, we need controlled studies we need people in a university setting, taking this on. We need them doing like saline injections instead of anesthetics, seeing if there’s a change. Right. This is a clinical retrospective study, so it’s the poorest. It’s not a randomized controlled study. I’m sorry, I’m a GP I don’t have time for that. I’m giving the best I got. But the bottom line is, I can tell you, because I’ve been doing this for years, and I, there are many times where they’ll come in for screening, like the TMD patient that’s traveled a long distance to see me. Remember we were talking about this about 20 minutes ago, what you do or what I’ve done over the years, and I integrated and put that into my teaching center the cno doctors.com thing centered for neural occlusion.  I created the neural occlusion screening protocols, which mean they come in, they don’t even tell me why they’re here. We run them through a normal thorough dental exam. Then we send them off for MRI and CT. Then we start doing electromyography readings of various iterations. Then we do jaw track and kinesiology, heart rate variability monitors, things like that. All this kind of stuff very objective data. I run them for two to three hours through all that data, the MRI, the CT, the EMG reading is a T scan, the this, that, the other. And then I look at them about three hours into it and I’m like, so tell me why you’re here. By then, they’ve spent three hours looking at the data. As I explain as we go, they already have, and now all of a sudden, for the first time, they’ve seen where their discs are. They’ve seen if the bone is alive or dead. About every six patient, by the way, has an AVN Avascular necrosis on average over the years to stuff, I’ve seen that. Now if you travel to see me from where you live and you’ve been to 30 different doctors, there’s a pretty good chance you’ve got something really bad going on, right?  [Jaz]Yeah. True. [Nick]The patient pool that I’ve seen some stuff you would not believe. Okay. So the vascular necrosis, I literally see probably, I don’t know, four to five a year. Now, can an occlusal adjustment fix that? No. Not even close. Okay. So my point is you have to make them own their problems.  And how you make them own their problems is you give them objective data and you educate them. And then all of a sudden that big, long communication problem that you’ve had over the years, when you’re dealing with people that live a long ways away, you shut it down. And I started throwing that out in my videos about seven or eight years ago, saying, Dr. Nick doesn’t want to know why you’re here. And people initially were kind of taken aback by that. Like, oh, he doesn’t give a damn. He’s just out for my money. No, I’m not. There’s a reason for it. because we don’t have time to go through all the subjective BS. They all told me it was in my head. And I’m like, yeah, it’s probably in your head, your neck. It could be the autonomics, it could be the trigeminal or the cervical that’s messing with you. . So, bottom line, this cold stuff led to TMD world, which I did not expect nor plan or want. I don’t want any piece of that. [Jaz]See, I thought it was a TMD that led to the cold stuff, but now I’m learning your journey. There we are.  [Nick]My journey was the opposite. The cold stuff, trying to be a better dentist led to craziness where I’m starting to see people that couldn’t get help. They could. Here’s the bottom line. If you can just help them diagnose themselves, you’ve done them a massive service.  If you can objectively help them understand you have an AVN on your left joint, you have a fusions bilaterally in the joint itself. Your sympathetic tone’s ramped up. You might have complex regional pain syndrome type one. Your hypotonic on this muscle, you’re hypertonic on that one, your occlusion times are terrible here. So what, what happened after I initiated a neural occlusion screening protocols over 10 years ago, only about 40% of the time maximum did I apply occlusal adjustments because the other 60% of the time it was not indicated. What was indicated was, you need to go see Mark Piper. You’ve got an AVN, or you need to go see the chiropractor.  Your C-spine is jacked, or you need to understand your neurologist is a little misinformed when he says complex regional pain syndrome or RSD, old school Reflex Sympathetic Dystrophy, which means ramped up sympathetic tone to the point where you want to put a bullet in your head. They call crips type one, the suicide disease. And probably every third, I’d say every third or fourth patient I see has Crips. And I knew nothing about Crips until I learned about it from Piper. So, bottom line, trigeminal, cervical, sympathetic, and this all ties into sensitive teeth because it’s not just trigeminal, it’s also sympathetic.  So when I make occlusal adjustments, and this is what I want Robert Kerstein to hear, I want Batman to understand what I’ve learned over the last decade when you have fewer speed bumps, as you’re making those adjustments, those discursive adjustments. Every tap, tap, tap, every bump, every bump in a bump in a bump, ramps up sympathetic tone causing hypoxia inside the pulp of a tooth. Hypoxia causes ischemia, not necessarily a necrosis, but ischemia to the point where it’s kind of hyperpolarized. And all of a sudden that coal insult is just like unbelievably bad when you get rid of some of those speed bumps and you decrease the tap, tap, tap, which ramped up sympathetic tone before and now there’s fewer taps. It’s not about timing, because in my opinion, you cannot reproducibly do that. On the T-Scan, there’s a center of force icon.  It’s like a little kite, when you bite down, you see this little graphical deputation, and when they clench, you’ll see that kites hold real still, and then you’ll have make a right excursion movement and the kit will start floating off and zinging around straight in that line. When they’re going right, make it go towards the upper right nice and straight all you got to do. The timing will be different, patients if they have dystonia, if they have problems like that, they’re going to be slower, faster, this, that, and the other.  I love Robert and I love his research and the Disclusion time and all this, but in my experience, I’m far better chasing the center of force icon. I want to straighten that line. If I straighten that line, which is the path of breadcrumbs, whereby the all the average force percentages at that given moment on the graph, when I straighten that out, that’s when the magic happens. In my world, I don’t even look at timing.  [Jaz]Okay. Interesting.  [Nick]Okay. I’m getting too deep because most of the audience has probably never even seen a tcam. [Jaz]But this just gives us a flavor of how much there is to learn and how much there is. No, you’ve already spoken about the fact that if you’re relying on articulating paper, you are relying on what is largely false data or rather missing data. Right? We think the big mark or the small or the bullseye is indicative of force, but it isn’t. And a very low percentage of time. And we know that, we’ve discussed it. In fact, Rob Kerstein was on this podcast. So we titled that podcast episode articulating paper lying to us. And that was a good one. But what you are building on here with relation to two sensitivities for me is very new. All these protocols are suggesting, but also this input and involvement of a sympathetic let’s talk about, because final bit now I’ve only got a few minutes left, but in terms of narrative, right there, there are different narratives. Nick, like for example, some academics or some theories of TMD is, it’s very much emotional, it’s stress related. The occlusion is irrelevant, anatomy is so irrelevant. So the Bio-psychosocial with the emphasis on the psychosocial.  [Nick]Yep.  [Jaz]Then there’s our friend Rob Kerstein, who has taught me that, A lot of these, if you do the imaging and the joints are okay, then a lot of these issues are occlusal. Okay. And if you’ve fixed occlusion, you get that Disclusion Time Reduction you get that time below 0.3, 0.2, whatever it was for that individual then, with the correct EMG data. And then you’ll cure that patient. What would you say is your narrative and your legacy? [Nick]My narrative? My legacy? The bios– [Jaz]Today, because things are always developing, as you’ve said that, and I wrote, I really respect about you, is you said that at once upon in time, you thought this about the flexing of the tooth. And now you think different. And I admire that about was open—  [Nick]My mind, I could be dead wrong. But the data, look, you’ve got to chase the data. And you got to trust your eyes. So if I read something and I try to vet it as best I can, make sure there’s no conflicts and I try to apply, said research or results or what have you in my practice, if I’m not seeing that either I suck or I’ve done something wrong. Now the bio-psychosocial thing, you know what that is? The autonomic sympathetics. This is deep. Now we’re getting into deeper neurology. I want your audience open up that Google scholar and I want you to see how the autonomic sympathetics affect the pene gland melatonin. I want you guys to look into that.  So the next time you start hearing this bio-psychosocial stress thing I want you to think sympathetics, I want you to think hypoxia. I want you to think melatonin levels. I want you to look for yourself, and then I want you to maybe learn how to do the neck blocks. Come to the center for neural occlusion. This is not a sales pitch. This is my passion this is not a money maker. Trust me. We’re lucky if we break even.  [Jaz]Yeah. [Nick]My wife always reminds me, I need to quit this. But I’m not going to. My point is, I’m sorry. I love it. I’m passionate about it and let me tell you why I’m passionate about it 2 reasons. It makes me a better dentist. And if you’ve seen the kind of patients that I’ve seen with the kind of problems they’ve got, and you’re able to at least help them figure out what the heck’s wrong with them, that’s when you get your endorphins rushing.  That’s when it doesn’t matter. That’s when you’re really there for the right reason, that you’ve actually accomplished something. So what’s my legacy? My legacy would be to pass what I’ve learned onto others and hope they will take it up and prove me wrong. Prove me right. Learn, spend some time.  A lot of doctors will go out and they will and I think it’s great. They’ll go volunteer their time in Africa. They’ll go on a mission trip. How I give back is this, the videos, the research, the publications, it’s all thankless there’s no money. I get paid when patients come to see me, but it’s the least profitable thing we do. My wife reminds me of that all the time too. Love her for it. But I’m not quitting because I’m passionate about it. Because when you can literally change people’s lives, which I’ve done innumerable times,  [Jaz]I’ve seen it, it’s been brilliant to see your videos over the years.  [Nick]Then there’s times where you can’t, but at least they understand why, based on my limited understanding of their set of problems because it’s never one thing. All right, last thing that I should get into real fast. There’s a concept called The Beaker of Pain. I call The Beaker of Pain this like you or I sitting here right now, our masticatory system, our stomatognathic system is not problematic. You and I aren’t hurting we’re not thinking about our pain in our jaw or our headaches, right? So our beakers likely not empty. The point is when the beaker, the number of problems, when the beaker fills up and it overflows, that’s when we’re seeking help. But there’s lots of things filling the beaker. It could be a neck problem, it could be a bite problem, it could be a tooth problem, it could be a muscle problem. It could be a sympathetic problem, it could be a psychological problem, pineal gland. It could be a whatever. So the goal, my goal when I screen people is to try to understand what the hell’s in their beaker. They’re in my chair, they’re obviously overflowing. I have to try to diagnose as much as I can. There’s going to be 10, 20, 30 things in that beaker. I need to objectively identify as many of those possibly that I possibly can. I need to take whatever I can do treatment wise as a dentist, Turkey based, or suck that up to where it doesn’t overflow anymore. There are times where the occlusion is enough of that beaker, when you suck it out, you’re not thinking about it anymore. They’re walking around like you and I.  [Jaz]I work with a TMJ physio, her name’s Krina. Give her a shout out and she talks about it in the form of a bucket. So say the same thing as, see there’s so much in their bucket. It’s about how can we help reduce the bucket. And so, it is great that you mentioned that. It’s a great point because it’s never just one thing. Absolutely.  [Nick]The bottom line is understand there’s a beaker of pain, a bucket of pain, whatever you want to call it. Understand they always have multiple problems. Understand the top three are trigeminal, cervical sympathetic. Learn these guys. We already have a pretty good handle on trigeminal. We suck at necks and we know absolutely nothing about the sympathetics, the average dentist  [Jaz]Until now.  [Nick]And by the way, the sympathetic stuff brings us big time into medicine. This is our realm and I’m ready for the day. My medical board in my state may say, why are you sticking people in the neck? I’m totally ready. Put me in front of whoever you want, the neurosurgeon. I don’t care. I’m ready. Yeah.  [Jaz’s Interjection]Hello. Geeks it’s the fourth and final interject, and I use that word geek intentionally because if you’ve made it this far, this episode, oh my goodness, you are a geek. This is one of the geekiest episodes we have ever done and wow. Just well done for making it this far. Right? So I actually forgot to ask him a question and I emailed him, I said, one thing I didn’t get to ask is the greater auricular nerve block, if it reduces the sensitivity, thus it kind of points to a sympathetic etiology, right? So it’s a Sympathetic Dentine Hypersensitivity, right? So if you give those neck injections and they’re, they swish ice water and they’re completely fine, that points to the etiology, right? But once the block wears away, the sensitivity returns.  So I asked, what’s the long-term fix for these patients? So what he told me is the dentine hypersensitivity, the cervical Dentine Hypersensitivity, to remember the occlusal and the cervical and the Frictional Dentine Hypersensitivity, they usually have a definitive fixes, okay? But you can’t always cure the sympathetic endotype. So sometimes a cure is occlusal corrections. He says even for the Sympathetic Dentine Hypersensitivity. And for those ones you have to vet the orthopedic. So you have to make sure that the joints are healthy or adapted and they need bilateral stable or adapted joints for you do any occlusal corrections. So like MRIs and CT’s and sometimes the etiology actually arises from the C spine and sometimes etiology is further down the spine because sympathetics can arise from T1 to L2.  So sometimes the damage and injury is somewhere along the sympathetic pathway, and that can be the cause. And sometimes the etiology is just a ramped up sympathetic tone, and it’s a combination of the above. And therefore this sympathetic dentine hypersensitivity is the least predictable to fix. Now, isn’t that just absolutely fascinating?  [Nick]And by the way, there’s precedence in the literature by yours truly about the neck block. Multiple papers now, chapters and textbooks, and we’re going to be publishing more and more and more and more. And it’s a huge deal, and if you jump onto the YouTube channel, type in Dr. Nick DDS on YouTube, you can start seeing, especially the last year or two, you’ll start seeing some really strange stuff the cold stuff, the this. If you look back five years ago, it’s big MRI stuff. You look nowadays as big sympathetic stuff. And by the way, last thing, you joined yesterday, Facebook. I am not promoting Facebook. Don’t really like Facebook, but we’ve had a forum on Facebook for over 10 years now. Center for Neural Occlusion it’s a private one. There’s also a public one don’t join that. You can if you want. The private one is for doctors only. Highly recommend that we all come together and ask each other questions.  And one of these days, if the CNO ever grows in my retirement, I might spend time on it to make it grow. I’m planning on having my own dedicated website, my own forums where people like you and me can like interact and ask questions, try to learn from one another. So that’s–  [Jaz]I’ll put the link to that. I’ve been on it for a short while. I’m just, maybe there’s some hidden video stuff on there, if you like. And it’s incredible honestly, what you’ve done with patients and what I’m seeing has been great. It’s been great to learn from you and what I’m looking forward to.  Next paper they’re going to write as well, and I’ll be able to share the paper that you have and what you mentioned towards the end is about. Integration to medicine, how this unlocks that. Well, it greatly brings together the AES conference in February where you’ll be speaking, as well, the oral physician. And I just really want to plug that really hard because it’s thanks to the AES who’s connected me with you and Dania Tamimi and all these great guests I’ve had on. And so—  [Nick]I know Dania’s mentor, Hatcher, he’s part of the CNO.  [Jaz]Yeah. She talk about– [Nick]He’s like a badass, Oral Maxillofacial Radiologist. One of the best in the world. At least he used to be he’s not active anymore. But when I formed a CNO we formed a board of advisors, not directors, and we’ve got like TMJ Surgeons, Med Radiologists, Maxillofacial Radiologists, Periodontists Orthodontists, GPS researchers, Blood guy, Rick Myron, if you’ve ever heard of him, the PRF guy, you need to interview him. He’s the guru. PRF plate Rich fiber.  [Jaz]Yeah.  [Nick]Amazing.  [Jaz]I’ve heard of PF in surgery and wound healing and that kind of stuff in implant world, but don’t know much more about it.  [Nick]This guys’ published 10 textbooks and 350 plus publications on that topic.  [Jaz]Amazing.  [Nick]Yeah. Rick Myron. Okay. Yeah. So watch out guys. [Jaz]Yeah. Yeah. I’m always, I’m guess, like I said, I’m a sponge, right. I’m here to share so just final things. I’ll look forward to meeting you in February in Chicago. And I want to encourage as many colleagues to, to come to that as well. And obviously the websites c and know everything I’ll put in the show links and the Facebook group is probably the best way for someone to connect with you and show some love or debate and discuss.  [Nick]Totally easy. And do you have to wait for me to let you in? We ask are you a medical or dental professional just to answer the questions. because a lot of times we’ll have patients trying to sneak in and Nope, nope. This is just for us. Yeah. [Jaz]I can imagine. I can imagine. [Nick]And by the way on AES the way I understand it. Mark Piper says this is his last time to lecture, so you better show up. And here’s another quick tip on Mark Piper. I want you guys to jump on YouTube and I want you to type in Dr. Mark Piper, AACP, American Academy Craniofacial Pain. I want you to learn from the best in the world, in my opinion, on this stuff, on the sympathetic angle. I’m his student. He taught me, and I still have a thousand times more to learn before I can get to his level. I filmed that when he and I spoke at the American Academy of CranioFacial Pain back seven years ago. He hit them with the Sympathetics and Crips Complex regional Pain syndrome. And then I followed with practical stuff and Occlusion World to dental World, specialty GP stuff. But that one lecture, I’ve listened to it probably at least 10 times over the years.  [Jaz]Amazing. I’m going to stick that on. I’m going to, I can’t wait to, can’t wait to watch it and stick it on. A hundred percent. [Nick]That’s worth your time.  [Jaz]It’ll be made available to all what we call the Protruserati. Nick, absolutely a pleasure to host you and speak with you. Learn so much, with our short time together today. I can’t wait to learn more from you over the years. Keep doing what you’re doing, please. Right. Keep doing what you’re doing. Keep, I’ll see you in Chicago. Next year, my friend. [Nick]Thanks, man.  Jaz’s Outro:Well, there we have it guys. How fascinating was that? I really appreciate you listening all the way to the end. Big shout out to Dr. Yanos. It was a complex topic and like this guy knows so much and I always noticed that with my guests who just know so much, it’s often difficult to get the right bits across, so hopefully together I was able to interject at the right times. I love him for his storytelling and the admission of the fact that you know what? He changed his views and theories and he’s amenable to changing your mind and how something works and he thinks very critically. I think we can all learn from that and appreciate that anything that was promised in this episode, the team try their very best to put it in the show notes. If you are watching this on protrusive Guidance App on iOS, Android, or on the web, scroll down, answer the quiz, get 80% and we will send you a CE certificate. We are a PACE approved education provider. I’m going to thank my team for the hard work they do. And one more request.  Protruserati, have you hit the subscribe button yet. If you haven’t, it really does help us to get more reach, to attract more guests in the future and to keep doing what we’re doing. So don’t forget wherever you’re listening or watching from, hit that subscribe button. Thanks again. I’ll catch you same time, same place next week. Bye for now.

Join Dr. Ashish Soneji, a dentist and photography mentor from Southwest England, as he discusses the evolving world of dental photography. Discover why mirrorless cameras are taking over from DSLRs and when you should consider making the switch. Soneji shares tips on which lenses to invest in, the significance of lighting, and even introduces a 21-day photography challenge for beginners to improve their skills. Whether you're upgrading your gear or sticking with what you have, this conversation is packed with valuable insights!

Should we be doing more to save questionable teeth? What if you could buy more time — without compromising patient care? Dr. Omar Ikram returns for a powerful episode diving into the real-world decision-making between endodontics and implants. Together with Jaz, they explore tough scenarios — like teeth with nasty cracks or minimal remaining structure — and ask the critical question: when is it truly time to extract? They break down concepts like retained roots, root burial, amputation, and a new term Jaz introduces — palliative endodontics. Because sometimes the best outcome isn’t immediate replacement, but smart, strategic delay. https://youtu.be/5msP908JvuI Watch PDP238 on Youtube Protrusive Dental Pearl: When discussing treatment longevity with older patients, tailor your language to be more relatable. Instead of saying, “I plan my dentistry to age 100,” say, “I want this to last well into your eighties or nineties.” This makes the conversation more personal and realistic, helping patients better connect with the concept of long-term outcomes. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Understanding the limitations of implants compared to natural teeth is vital. Medical history significantly impacts dental treatment decisions. Managing patient expectations is crucial for satisfaction. Palliative endodontics can provide temporary relief and management. Reading and interpreting CBCT scans requires skill and experience. If it’s not that five millimeter defect, it’s up to you. The second molar is a good one because often second molars can’t be replaced with an implant. Retaining roots is definitely a good way to go. You need to risk assess the patient before extraction. Palliative endo is technically always an option. Success in endo can be often difficult to achieve. Asymptomatic and functional is a good criteria. If endo is on the table, it’s feasible. Highlights of this episode: 00:00 Teaser 00:35 Introduction 01:48 Protrusive Dental Pearl 04:15 Interview with Dr. Omar Ikram: Philosophy and Growth 10:17 Endodontics vs. Implants: Treatment Planning 16:35 Antidepressants and Dental Implant Failure 19:37 Managing External Cervical Resorption (ECR) 22:30 Patient Communication 24:16 Cracks and Complications in Endodontics 29:12 Endodontic Protocol 30:50 Challenges with CBCT and Cracks 32:07 Second Molars: Retain or Extract? 35:05 Retaining Roots for Future Implants 36:21 Root Burial and Special Cases 40:08 Root Amputation: A Niche Solution 40:57 Key Signs to Rethink Root Canal Treatment 43:17 Cracked Teeth: Poor Prognosis 47:08 Stained Crack Tooth 50:19 Success vs. Survival in Endodontics 56:02 Final Thoughts and Upcoming Events Want to sharpen your endo game even further? Watch Stop Being Slow at Root Canals! Efficient RCTs with Dr Omar Ikram – PDP163 Check out Specialist Endo Crows Nest — led by Dr. Omar Ikram, offering expert care, hands-on courses, and practical tips for real-world endodontics. This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A and C. AGD Subject Code: 070 ENDODONTICS (Endodontic diagnosis) Aim: To help clinicians develop a deeper understanding of when to preserve a tooth through endodontic treatment versus when to consider extraction and implant placement. Dentists will be able to – Identify key red flags that may contraindicate definitive root canal treatment. Understand the concept of palliative endodontics and how it can be used to delay or defer implant placement responsibly. Recognize the value of retained roots in maintaining alveolar bone, particularly in medically compromised or high-risk patients. #PDPMainEpisodes #EndoRestorative #BreadandButterDentistry Click below for full episode transcript: Teaser: Biggest difference between implants and retaining the tooth through root canal treatment is that implants, that's the big difference. Sometimes when you say to patients, you'll be dealing with an implant failure in your lifetime. Teaser:They look at you like, really? I thought implant would last till I was a hundred. How long anyone’s gonna last on this planet? But in my planning, I plan to age 100. So I see everyone as living to age 100. And so my planning, I don’t think this will make it, therefore– Your health is within your own control. Also, it might be only 50%, 25%, but some of it’s within your own control. I want the patient to go on holiday and not be sitting there worrying about whether their tooth might be bothering and they have to go to a dentist and take antibiotics– Jaz’s Introduction:Endodontics versus Implants: is this even a worthy battle? Let’s be honest, right. Any implant dentist worth their salt would agree that for themselves or their family member where an Endo is feasible and you have a good prognosis, that that is the obvious choice first before having an implant, because an implant will still be an option for the future. And that’s pretty much easy and unanimous in dentistry. Unless of course your patient suffers from titanium deficiency disease. Now where this becomes more pertinent is those dubious scenarios, lack of tooth structure, those nasty cracks we’ve particularly discussed these two scenarios. Whereby perhaps we should be considering implants. But wait, Dr. Omar Ikram may have a few things to say about that and why we should be considering perhaps root filling, retained roots, root burials, amputation, and a term I introduced called Palliative Endodontics. Why that might have a growing role so that we can defer implants because we know implants do not last forever, Endo doesn’t last forever, nothing lasts forever. So important about seeing the bigger picture when it comes to longevity. Dental PearlHello, Protruserati I’m Jaz Gulati. Welcome back to your favorite Dental podcast. Every PDP episode, I’ll give you a Protrusive Dental Pearl. Now, there is a theme in this podcast where we discuss about the age of the patient. We all know it’s better to have an implant when you are 60 or 70, than when you’re 40. And one thing I always did is when I communicate to patients, I was inspired by a consultant in Restorative Dentistry Dr Chander used a line to a patient.  He said, “Look, I don’t know how long anyone’s going to live for, but I always plan my dentistry to age 100.” And I’ve been using this line to my patients, and yeah, it’s okay it works well, they get to see the bigger picture. But a lot of patients can’t relate to that. A lot of my patients, their 60’s, 70’s, and 80’s they just can’t relate to that. They immediately start thinking off topic and thinking, oh, I probably won’t make it. So one of the changes I’ve made in communication based on what Omar discussed with me today, and really the pearl I want to pass on to you is instead of saying to age 100 for everyone, look at your patient. Let’s say they’re in their 70’s and then you wanted to say, “Look, I want this to last well into your 80’s maybe into your 90’s.  Now, they may still think, “Oh, I probably won’t make it.” But it’s just a bit more relatable than putting a number age 100, because chances are most people don’t know a 100-year-old, but they might have friends in their 80’s and 90’s. Do you see what I mean? Obviously, it’s a very niche scenario. But me personally, I have a very age population that I look after my patients on average are 60. And so this change in terminology in the way I communicate to patients in terms of longevity of treatment. I think’s gonna really help me to get the point across well into your 70’s well into your 80’s. And you’ll hear this again in this episode being a big part of today in this episode with specialist ended on Dr. Omar Ikram.  Before we join the main episode, have you downloaded the app yet? The best way to do it, if you haven’t already, is visit the website www.protrusive.app. Once you’re there, make your account. Then once you’ve made your account, you could download the iOS or Android app and log in to find the nicest and geekiest community of dentists in the world. What I’ve found is that dentists join the app for the content. The premium notes, the transcripts, the Protrusive Vault, our Mini Master Classes and Courses, just a better overall listening and watching experience. But what they stay for is the community. What they find is that they fall in love with dentistry all over again because dentistry can feel so lonely and isolated.  And on some of these social media groups, you get shot down when you ask for opinions. But really, we’ve brewed a culture very hard to brew, a culture of kindness, being considerate and selflessly sharing information. So remember, the website is protrusive.app. The app is called Protrusive Guidance, I would love to see you on there. Let’s join the main episode with Dr. Omar Aram and at the end, of course, you can answer the quiz to get your CE credits on the app. Main Episode:Omar, welcome back to the show. I just saw you post on Instagram, so you are on the bike doing a marathon. Tell me more about that. [Omar]Oh no, it was just one of those big days at work and I was doing an extra bit of punishment for exercise. I tend to do this to myself when things get tough, I think what’s something I can do for 20 more minutes? You’ve had that big day, you think I can’t do it anymore. And it’s like, you can, and by doing that, what you’re doing is you’re just pushing yourself that extra bit and saying, “You know what? Even those hard days in clinic, I can still do a bit more. “ [Jaz]I love that. It reminds me of a book. The David Goggins book? Can’t Hurt me.  [Omar]Yes, yes, yes. Have  [Jaz]You read that one?  [Omar]Yep. That’s a favorite of mine. That’s a good one.  [Jaz]I mean, exactly what you’re saying. It reminds me so much of that. So I like your life philosophy. [Omar]Yeah, and it’s a good one. I mean, basically he talks about callousing the mind, doesn’t he? That’s it. Making yourself more [inaudible] and thinking you can push yourself a little bit further all the time. And what you do is then you grow. Because if you just sit back and take things easy, you basically don’t grow. You just stay static, and we all know many people who have done this in our lives. There are people I know who are still working, like when the day that they graduated from dental school, and that might be fine for those people. I’m not saying anything wrong, but they haven’t grown. And sometimes those people aren’t enjoying dentistry as well. And I think to myself, but you haven’t given it a chance. And it’s just little incremental growth. I’ve been graduated now for 27 years as a dentist and it feels like forever, but if you do those 5% growth in 27 years, there’s a lot of growth.  [Jaz]Well said. It’s a theme I cover a lot on this podcast. How do we figure out those very engaged bunch in dentistry who say that, “Yeah, they absolutely love dentistry.” And then those who are disengaged and not enjoying it, and I think of the several factors. One is your mindset, but in a way that you have that growth mindset. You have that abundance mindset, okay, you want to keep giving back to profession. There’s more to learn. I think if you see it in that way, then you don’t stay stagnant.  [Omar]That’s right. I think that you have to think to yourself sometimes dentistry is a long haul. Like it’s a long game. Yeah, we all graduate, we all want to get busy. I see it a lot with younger dentists. “I want to do what Omar’s doing.” It’s like that’s took 27 years. Just be enjoying where you are and you will get there if you keep enjoying, you will do far more than me. But you will do lots more than anyone. But you do have to keep doing those, you know, 5% growth per year, six or 7% growth. You’ll have to be committed to that. And I know life will get in the way. I sometimes talk to my friends and I say, life will get in the way of your dentistry. And this is where your team around you, the people around you who are supportive, maybe your parents, maybe your partners, maybe your children are part of that progress. Because if they hold you back, then you won’t progress.  There are a lot of people I know again, who have seriously big commitments with their family and things like that, and that will just stop them progressing as dentists. I’m not to say that they won’t be great parents or great partners or whatever, but it will hold them back in their dentistry and that’s something we have to all be thankful for.  I mean, sometimes I think to myself, you and I are in the place we are because of not only what we do, but what our partners and kids and family will allow us to do. And fortune, we caring for people as sick, we will be less involved in dentistry. And also the generations that went before us, that didn’t muck it up for us. You know, they laid a platform for me to go to university. If I didn’t have that platform, I wouldn’t have been able to do it, and I wouldn’t have been able to do what I’m doing now. And you have to be really, really thankful for that. People that you even met decades, I’m talking 50, 60, 70 years ago, people will have been doing things the right way to enable you to have the platform and the start that enabled you then to go to university. Also they set almost from the grave or from the past, they set you a benchmark, like for example, I have a grandfather who is heavily involved in partition India and Pakistan. And for me, I never met him. And I look at his picture with one of the people who came up with the concept of Pakistan and I think, “Wow, this guy was right there when they created Pakistan.  And he was involved with the people who doing all that.” And I think to myself, I never met him, but I would’ve liked to have made him proud. And that is something quite amazing when you look at past generations, even though you never met them and think, and they laid the platform for me to be able to do it. And then you should pay that forward as well for other people. It might be your kids and your partner, of course it might be your patients, of course it’s your patients. But sometimes, I think to myself “And what else? And what about colleagues? What about that dentist who came to me on the course on Wednesday and said, I’ve got serious depression.” I’m like in a really bad place. And I said, “Look, if you can get the grades to get into dentistry now, and you can battle with that and you can enjoy dentistry, you will actually be able to do anything you like.  It’s just a matter of you being able to see that. You might not be able to see it now, but if you keep going, you will be better, and then the sky’s the limit.” You’ll get to a point where the obstacles that we all come up against the costs of living, making your practice, you can list a hundred barriers will all come up against the ones that you able to break through a leap are the ones that many others won’t. And every time you come up against the barrier, if you can leap it in style or gracefully leap it or whatever, then you will become better for it. And many others won’t be able to do that. And then you’ll get to a place where you’ll realize that the sky’s the limit. Like after that, you are definitely there with this podcast, I’m sure.  But I’m just getting to the stage where I’m thinking to myself what I want to last, what is it? 20 years or so of my career I don’t know how many years I’ve got working in dentistry, but I’d love to keep going as long as possible. But there was a time where I wanted to retire early because I thought dentistry was really hard. But now I don’t have that thought at all. I think to myself, let’s keep going with this positivity and fun it’s a massive part of my life now.  [Jaz]Like I said, it’s a mindset like the philosophical start that we’ve had, Omar to his podcast, I mean, 3 little reflections of based on what we said is the book Outliers argues exactly what he said that actually it’s not just ranks to riches in terms of hard work and determination.  You need so much more to go in your favor. There’s a reason why both Steve Jobs and Bill Gates were born in 1955. There’s a reason for that because when they were 17, 18, they weren’t old enough to be like married commitments. They were young enough, enthused enough, and they both were early adopters of having being lucky to be in a home that had a computer kind of thing. And then you paid homage to your grandfather. So that’s great. So Outliers, that book then reminds me of Mark Twain quote, “It took me 20 years to become an overnight success.” And then the last one to point out is “Everyone’s got a plan until they get punched in the face.” And if you get punched in the face, you may need an Endo.  And therefore we’re talking about Endo or an Implant. Because we’re talking Endo versus Implant, right? So this is like a big debate . On one side of the ring, we have orthodontics on the other side we have implants. And quite commonly in conferences, I see this as a very popular lecture title. And it’s great, and I think there’s space to discuss more about it. And I guess the elephant in the room, Omar, first excuse this little monologue is there is a bias, right? You are an endodontist. Okay? So we kind of know what the ding, ding, ding, when there will be at the end. However, I don’t know a single implantologist worth their salt. If Endo is on the table as a viable option, A single end is worth their salt. Who would opt for the implant when the tooth is still a viable option on themselves, on their patients, on their daughter. And I think some of the themes I wanna discuss with you is feasibility. Why endo for an implant, but then what makes it unfeasible? What are the red flags that we should be thinking?  Actually this Endo will not be predictable and we should be then going for an implant. So I guess where I want to start is what are the complications of extractions and implant that we want to veer away for? And we’ll build on, “Okay, well how can we do more endo and when is endo appropriate?” [Omar]That’s a really great start. Because I had this down and I think the biggest thing we have to think about with regards, I’m gonna start with what I say to patients now. I used to say like we all did. You’ve got an infection in your root canals, you could take the tooth out or you could replace it. That’s not the right thing to do at all.  That’s what they teach you at dental school is totally not the right way because every patient is different, and every tooth is different, and every scenario is different. The smart clinician will actually be able to work out what’s right for that patient because of certain factors. So what I say to patients is, our teeth are supposed to last for about 24, and everyone says, what are you talking about?  Teeth are supposed to last for 80 and 90 years, but this first molar comes through when you’re six years old, the second molar comes through around 12 years old, and the third molar comes through around 18 years of age. So you add six years that’s 24, 24 is also the years where we look at implants as maybe an option because the patient’s stopping growth. And 24 is probably about the life expectancy of a human being. In a world where we don’t have tribes and we don’t have farming and we don’t have roads and all those things we have now. So in order to keep your teeth going way longer than 24, because people live in the developed world to about 85 in Australia. 83, 85, depending on gender, women last longer.  They live a longer life apparently. And basically, if we are going to keep people’s teeth going instead of just 24 or so to 85, we are going to have to create something that’s not normal. And we’ve done that with longevity, with heart bypass surgery and valve replacement and brain surgery. And you can list all the medical advances which aren’t supposed to be done to people that’s kept them alive. We have to do the same in dentistry. We are keeping a tooth around longer. So that’s gonna involve things like root canal treatment possibly. And that’s gonna extend the life, not keep it till you’re 95 years old necessarily. So to get back to your question is to say implants, the biggest difference between implants and retaining the tooth through root canal treatment is that implants don’t have a periodontal ligament.  That’s the big difference. And then patients, someone look at me like, “Why is that an issue?” And I say, Look, when you bite on a tooth, the ligament moves like it does in any ligament of any muscle when you are lifting weights or whatever to tell you that the bone has to remain there. You don’t have a ligament, you don’t have that connection with the body, you don’t have bone retention.  The tension and the ligament keeps the alveolar bone present. If you have a denture on the ridge pushing down, after you take the tooth out, then the denture will actually resorb bone because it’s like your wetting ring on your finger. It compression will resorb bone. The implant won’t prevent food pressing on the ridge, so that will prevent the bone resorption being fast, but the bone resorption will happen because there is no ligament. And so sometimes I’m saying to patients, “Look, implants last between 15 to 25 years, that’s a really good implant.” Obviously they can fail straight away and all those things that, something that can happen. But if the patients say under 60, I say to them, you’ll generally be dealing with an implant failure in your lifetime if you take the tooth out and replace it. If the patient’s 65 or 70, sometimes I’m saying to them, “Look, an implant will last you into your sort of mid to late 70’s 80’s it’s a possibility.  You might replace it sometimes, like depending on the tooth, of course, as you said before, if a tooth is restorable, it would have a root canal treatment. But then what is restorable is what’s possible, and it’s based on your skill of not only endo, but restoring teeth. And the problem is many, many endodontists aren’t amazing restorative dentists necessarily, although I think you’ve got some really great ones there in the UK for sure. And also many general dentists don’t wanna do the Endo. So it’s that kind of new kind of situation where we have restorative endodontists who do good Endo, and then they do good core and restoration of the tooth because restoration of the tooth has the most impact on survival of the tooth and longevity. So if you do a great Endo and chuck a temp, and it’s going to be way worse than if you can restore the tooth and then set the crown up for the general practitioner or whoever’s doing the crown or the cuspal coverage. So what we’re saying here is really the periodontal ligament is really the main factor. And so I’m talking to patients now more and more about this. But also other things that you’ve got to bear in mind with implants, so just to get you started on a few of these. So the obvious ones, the ligament’s gonna be lost and it won’t last forever. It’ll probably last between 15 and 25 years, and that’s good enough for some patients.  Some patients, as I said, if they’re 70 and the tooth’s really in a bad state, well it’ll probably last 85 or 90 with the implant. Maybe if the other thing just mention is that I never, ever now say take the tooth out and replace it with an implant. I go to someone for an opinion. Unless the tooth’s like cracked down the middle. There’s a few probably get to this red flags, but there are a few situations where you really cannot do endodonic because the tooth is structure is totally destroyed and that’s red flag.  But if the tooth is half viable for anything, I often say, “Look, I wouldn’t opt for root canal treatment as the first option here. The tooth structure is bad or you’re in that age group where an implant may last your entire life into your late 80’s 90’s etc. depending on the patient. I mean, if the patient’s well and healthier, they’ve got a good family history.  Sometimes I’m talking about family history of longevity and they’re saying, “Oh, but my mother lived to a hundred,” and I go, “Well, maybe we keep the tooth, maybe it won’t last your whole life. Things like that, you have to be a clinician. You have to talk about these things. Doctors talk about it and why not dentists?  Then the other thing we’re looking at here is medical history. Again, some of the antidepressants have like four times the failure rate. You’d be surprised about four times failure rate with implants.  [Jaz]Do we know the mechanism of antidepressants and implant failure? Do you understand the mechanisms of that yet?  [Omar]Well, there is some theory on this. It’s got to do with basically the bone interactions with the medication. It’s not really well understood but basically there’s this research showing that it’s the SSRI or the Serotonin– [Jaz]Selectively uptake Inhibitors. [Omar]Correct. Those ones. They’re basically the worst ones. So if a patient’s taking that, talk to them about not having an implant because there’s problems with that. You know the obvious ones come up– [Jaz]Bisphosphonates. [Omar]Yep correct, bisphosphonates. And also not only bisphosphonates, but are you in that category of patient who may need to take  bisphosphonates? Have you got osteoporosis that’s early and things like this– [Jaz] Or in the family?  [Omar] Yep, in the family, are they female patient who get osteoporosis maybe a bit more than males because of the physiology. Smoking, obviously diabetes, the obvious ones, oral hygiene, those sort of factors. So things like bisphosphonates, again, very important to say. And if you’re about to start bisphosphonates, well we need to start maybe doing the implant or not. Again, an opinion before we do anything. I’m doing that a lot nowadays go for an opinion. If he says, or she says, what you want the specialist or the dentist to say regarding longevity and it’s going to be wonderful, then do that. But I can do something for you but I’m not saying it’s the first option all the time. So I almost never say, just take the tooth out it’d be rare.  [Jaz]But this is the conversation that the general dentist has, right? You’re putting yourself in the shoes of the general dentist and the message you’re giving to listeners is try and get an opinion just in that middle category, and you’re unsure from the person who’s going to be doing the more complex job, the implant, or be the Endo. [Omar]Yeah. So what happens is the patients often come to me from a general practitioner, you know, the classic one is external cervical resorption, central incisor, can you save it? And the answer is, well, I can sometimes and sometimes I can’t. And again, we’ll talk about that maybe in a few minutes about the red flags for endo.  But I’m often going, well if you are under 60, we need to keep this tooth going until you are into your 60’s. That’s often say, well into your 60’s and beyond will be wonderful, but into your 60’s is where we want this tooth to last till then an implant lasts 15 or 20 years and you’re sort of nearing 80’s and then you have the fixed bridge option. The bridge option should be the last option because they use the teeth either side to hold it in. You’re going to damage those teeth and maybe if you’re 90, that’s not an issue. Certainly it is an issue if you’re in your 40’s having a bridge because we know that’s going to fail the abutment teeth will fail. You’ll have root canal treatment on teeth just because they were there prepped to hold the teeth in to pontic again, all that sort of stuff.  So you do not want bridges in young patients, but in an older patient maybe it’s fine. So this is the sort of way I go is like implant that fails if you were in sort of late 80’s and that failed then a bridge and that should keep you going well into your late 90’s. And then we’ve done the things that I was talking about that extend the life of having a fixed tooth there.  And I think that’s the key is like, look for that fixed option to last forever. Sometimes when you say to patients, you’ll be dealing with an implant failure in your lifetime, they look at you like, really? I thought implant would last like till I was a hundred. And it’s like, no– [Jaz]Everyone thinks that, right? Spend that money and they expect it to last forever. And so we need to give them that dose of reality and expectation management. But you’re saying that specific case of let’s say the Cervical resorption and you could save it, but then who else’s opinion would you seek? [Omar]Yeah, so if the external cervical resorption is really severe, then I’ll often get the patient to go for an implant consult or opinion. And again, I say, look, if you are in a situation with a person who is going to do the implant, so this is going to be a great result and it’s going to last for 20 years, maybe you’ll take that one because what I can offer you sometimes isn’t 20 years.  What I can offer you might be like five to 10 years maybe. It depends on the severity. External cervical resorption is one of those really difficult ones where it’s like could be just a restoration and it could be like completely gone. By the time the patient gets to us, often it is completely gone.  They’ve had external cervical resorption for many months or years, and the tooth is asymptomatic because as I explained to patients, your immune system is removing your tooth and we have no inflammatory reaction against our own immune system. And basically the immune system is bowing into your tooth and actually protecting your tooth from the bacteria in your mouth. So the immune systems in the cavity predicting your tooth from the bugs so you don’t get bugs using the hole in your tooth as we do with caries or cracks because the immune system’s removing the tooth but protecting it at the same time. But you get to that point where it’s symptomatic and it’s like the hole is so big now the bacteria can gain access and that’s when you have the problems. And it’s like, so now the tooth’s like really in a bad state, I have to say. If I have a tooth with external cervical resorption, with pulp necrosis, it’s usually not looking too good. That’s how I generally would judge cases like that. If it has a vital pulp, even if the structure is quite compromised, I’m usually more keen on saving those teeth.  But it’s a sliding scale with external resorption and thankfully we have CBCT, which is such a good tool for showing the patient “Look, half your tooth’s gone.” It’s not, there’s a 2D radiograph. So I’ve been doing a few cases like this recently, but holding onto teeth with externals cervical resorption is very difficult. Quite often they need crown lengthening and surgical treatment of the resorption as well as root canal treatment.  And it just kind of adds to the cost. And again, you need to justify the cost for the patient because if you’re spending the same or more than an implant in private practice in England, I’m sure, and the implant is the same as a crown and root canal treatment, and if you chuck a surgery for the external cervical resorption, then it’s possibly more. But if you can say to the patient, and the reason why we want to keep this tooth is the implant will fail in your lifetime, then they’re all more on board with what you are doing. I found this a change, my messaging from when I was a new grad going.  Yeah, it’ll last like, 15 years and you have no experience to tell the patient that, because that’s what some of the papers say. They say it last eight, 15 years, 10 year survival’s very good, even 20 years survival. The Eckerbom paper is like in the sort of 74%. You’ll be using these kind of stats, but actually what you need to do is work out if that patient doesn’t need the tooth for that long, then you’re looking at the patient.  An 85-year-old doesn’t need the tooth for 15 to 20 years. That’s generally how it goes. And as patients age, different things come up like. You know, maybe they can function with just premolars and there’s a whole heap of things that come up as you get older that totally change how– [Jaz]Do deliver that message gracefully, Omar? Usually if I say to an 80-year-old patient that, Hey, I’m going to do this, and I’m usually the first one to say, “Okay, I think this has a really good success rate, 15, 20 years I can expect from this intervention. And I usually wait for them say they laugh at opposite I probably won’t be here at that point, I’ll take that option kind of thing. So rather than me saying, you probably won’t be here at that point, therefore is a graceful way to communicate that.  [Omar]Yes, I totally learn the hard way as everyone does. I never say you won’t be needing it. You say. It’ll last you well into your nineties, and as you said, the patient usually says, but I’m not gonna probably live till I’m 90. And I go, well, that’ll last you a long time then. But conversely, what you’re often doing, I find nowadays is I’m taking patients who are under 60 and they say, you’re 55 years old in my books that’s a young patient. And they look at me and go, “What do you mean?” I go, ” Because most people live till 85, 83, whatever it is.” You’ve got many years chewing ahead of you. I mean, I know you don’t think that way, but, but realistic, you do. That’s the way the average life expectancy works in this country. And so by retaining–  [Jaz]One thing I learned, Omar is, sorry, if you don’t mind saying, is one of the consultants I work with, Satinder Chander, he said to patients, I can’t predict how long anyone’s going to last on this planet, but in my planning I plan to age 100. So I see everyone as living to age 100. And so my planning, I don’t think this will make it, therefore, to get you to age 100, here’s my plan, plan A, plan B. And I just feel like that’s a really nice way. Look, you can’t predict anything, but I’m going to plan to age 100.  [Omar]That’s a tough one. Being an ended on to supply to the age a hundred because a lot of the time we are dealing with such broken down teeth, cracks and things like that. It can be difficult. I usually say around, 80, 85, I don’t actually say that. I sort of say if we can get the tooth to last well into your 60’s and beyond, that’s what we’re aiming for in an implant would then last year.  [Jaz]I think that’s more realistic. A lot of time when I said that a hundred line patients raise their eyebrow, I was like, well I can’t relate to that. Do you see what I mean? So I quite like your way more like depending on the age of patient into your 60’s into your 70’s into your age. I think that just has a bit more realism. So I actually like that more. So let’s talk about the red flags, right? So for example, one question I had is. Let’s say you have a lower molar, let’s say a lower second molar, classically split tooth or a crack tooth going from the mesial marginal ridge all the way to distal marginal ridge. You start exploring the crack let’s say it has an MOD amalgam, you remove the amalgam, and then before you access into the pulp chamber, you already have a crack that you can see running from mesial to distal, but it’s above the pulp chamber. You haven’t actually gone to the pulp chamber yet at this point are you committing to tooth?  Actually, no. I can see this crack here. At this stage, is it, oh, this tooth is not saveable, or do we need to do our due diligence and explore into the pulp chamber and confirm there as well?  [Omar]That’s a really great question. So I’ve got a couple of really useful comments on that. If we’ve decided to go ahead with saving the tooth and you’ve had this conversation with the patient about age and what we want to do, we are saving the tooth because we want the tooth to last well into their 60’s or whatever the reason is, we’ve got the patient on board and I think this is been a really important thing with me.  And the way I communicate with patients in the last few years is that the patient is on board to save this tooth. Firstly, as an endodontist, they’re in my chair so they wanted to save the tooth, if they didn’t want to, they maybe went for the implant straight away or the extraction or whatever with the general dentist or come to the surgery, didn’t go for the consult. But when you start exploring that crack, there’s a couple of things. First of all, CBCT will show you that if there’s any periodontal defects, if the periodontal defects deeper than inter proximity and you can’t probe it, very easy. If it’s deeper than five millimeters, it’s pretty much game over because they’re going to have a periodontal disease there even when you do the root canal treatment because that’s essentially impossible to clean region and all that stuff. But if there’s no defect deeper than five millimeters-  [Jaz]This is a clinical measurement or a CBCT measurement. What you’re saying here?  [Omar]I measure on the CBCT because often you can’t probe between the two. Yeah. So assume that if it’s three or four millimeters, let’s say, but you can’t probe it because interproximal. [Jaz]And just again, just so for clarity for the younger audience, are you measuring from the CJ to the bone crest? Where is this measurement being taken from?  [Omar]Yeah. CEJ.  [Jaz]CEJ to the bone level. [Omar]The depth of the pocket. Yeah, you measure on the CBCT because a lot of the times you cannot get the probe into proximal and probe it and measure it. And sometimes even with those 4, 3, 4, it seems like less it’s not that deep. I mean, obviously you’ve got the deep pocket all the way to the apex, then it’s gone.  It’s obvious, but what I’m saying here is you see these defects and you go, there’s gonna be a crack involving the bone. Next question is, how deep is it? If it’s five millimeters or more, then they’re not going to be able to clean that. And they’re going to do the best endo in the world, and this is going to be gone because of periodontal abscesses and they’re still going to get pain. They’re going to get that swelling of the ginger and all that stuff. They can’t get their toothbrush out and clean down that defect. The next thing you go is on vitality. If the pulps vital, that’s a good thing because vitality is actually something that means that the crack is not causing necrosis. So if the crack is not deep enough to cause necrosis, then the pulp will have warned the patient of pain and the crack is early.  The pulps, like an early warning signal. If we have that intact, we have an early crack. If we don’t, then the crack could be anywhere and it could be like a hay line down past the route. And even though there’s no pocketing now, there might be in three or four months time and maybe it’s not worth it. So vitality is the big one for me.  [Jaz]Vitality is good. It makes sense there because if it’s necrosed, it’s too far down. But what about that middle ground of irreversible pulpitis? Something that I understand that as GDPs, we might see more than new endodontists. We see the irreversible pulpitis come in at that stage and we can see that it’s clearly a crack. That was the etiology behind this. At that stage, are we in a crossroads or is that again, we’re putting that in we’re still probably Okay. because it’s still technically vitality.  [Omar]Okay. This is a really interesting one because if you get to that sort of stage and you’re looking at irreversible pulpitis, well firstly irreversible pulpitis is actually vitality as well, so that’s good. But like that’s a positive. But the other thing is that don’t forget that you need to then start looking at the patient’s occlusion and why they have a crack as well. So you start bringing that.  But sometimes I’m seeing patients I’m, look, you don’t have any molars on your left side. The right hand lower right first molar is cracked now because you don’t have any lower left molars and we need to hold onto this tooth. We need to hold onto the lower right first molar because you want to maintain it because you’ve cracked it and you’ll crack other teeth. If I recommend extraction, I mean there is a limit, as I said, with periodontal pocketing and necrosis and things like that will sway me to extraction. But generally you are trying to now justify why you are keeping the tooth if there’s a crack.  You’re basically justifying the exploration, I would say is the best way because sometimes you don’t need to explore much more than that and go look, it’s just not going to be worth it. I mean, if it’s necrotic and there’s a crack there, I’m starting to look at, having said that, I often clean out the root canals, obviously, to get rid of the infection and then seal it up and say, look, sometimes with those necrotic cases, maybe just keep managing it.  It’s not worth finishing, but maybe just keep monitoring it and then when it starts to bother, you have the tooth out. But plan to get the opinion now and then again, see if you want to do it soon, or whether you want to do it later or it fits in with your job. But I’ve got into, into a stable state where the tooth is now cleaned out and sealed. The crack will obviously open up at some point, but it might take a few weeks or months. Then you have a bit more time  [Jaz]In this scenario, to what extent of your endodontic protocol are you carrying out for disinfection? Obviously you’re not obturating with GP, you are just hyper chloride, are you doing any shaping and any long-term predicament? [Omar]Yep. I’m shaping with rotary or reciprocating files I like for shaping something smallish but not too small. I like 20/06, 20/07 as I suppose 20/07 wave, one gold sizes. Something that’s quickly gonna get down there but produces shape that you can kind of clean out. You don’t want to go for like a small file that’s kind of like, then you have to use another file when you’re going to tell the patient that tooth’s not going to be completed.  You want to quickly clean it out to a certain size. Like, as I said, 2007 wave one gold is kind of something that resonates with me. Clean it up, fill it up with calcium hydroxide, seal it with IRM. That’s my favorite seal because of the antibacterial activity and it’s got that sealing effect. IRM is a wonderful material, I think in Australasia it’s not as popular as it is in say the Uk. And since I’ve trained in New Zealand and in England, I have both sides of the coin. And I have to say IRM was loved over in the Uk. It’s such a good material. It is used for apical surgery. It was in the past before we had MTA.  So that’s how good it seals. It can be used as a retrograde filling and it works. And so basically seal it up with IRM and then put a little GIC on the top or something that’s gonna last a bit longer. And then say the patient, look, I’ve stabilized it for your trip or whatever. And then you’ll lean to have the tooth out because it’s cracked really badly.  And often I show them pictures and that’s quite handy. Just go look how badly tooth. because the patient will often go away and go, but it doesn’t hurt anymore. And there must be no problem. It’s like, no there is a problem because structurally this tooth isn’t good.  [Jaz]In Singapore, Omar, I came across this term from an endodontist and I loved it because essentially what you’ve described, and I say this to my patients now, is Palliative Endodontics. This is a palliative, patients get it. In that very niche scenario, I appreciate it’s a very niche scenario, and I’m sorry if I distracted from the lovely point we were exploring about that scenario with the crack duty.  You mentioned the CBCT, you mentioned a great guideline about looking at the CBCT. Now, one thing worth mentioning is even with the best resolution CBCTs we still can’t see the cracks, right? They’re still not good enough to see the cracks. Am I right in saying that right?  [Omar]That’s pretty much correct. The problem is, a lot of the time what we’re dealing with is we’re dealing with a lot of scatter and we’re dealing with a lot of beam hardening and everything looks like a crack. And then you can sort of mistake the real crack for the actual beam hardening or the scatter. There’s a lot of that going on. So reading CBCTs is actually quite a skill, but what we are looking for is the bone defect. We’re looking for that little, I call it a Pacman bite or a little bite out of the bone in one area. If you’ve got Periodontal disease, the area’s broad. If you’ve got a wisdom tooth that was removed, say it’s a distal of a lower seven, it’s broad that somebody’s taken the bone away. The pericarditis has caused a periodontal defect. Essentially, it’s broad. If you’ve got one little tiny bite out of the bone in one area, and you can see that on the axial.  So the axial scroll down, it’s like a little dark area, just goes down the route, but it’s like a semicircle. Then you are pretty sure, and often I will correlate that with the GDPs pictures they’ve sent me. So the nice referrers that I have here, send me a picture and go, this is where the crack was. Check it and then you go, well, that correlates with the crack that they’re showing in their picture when they open the tooth up with the CBCT and this will be gone. Having said that, as I mentioned. If it’s a lower seven or something, there’s no tooth behind. There’s no food trapping. If the patient’s quite elderly, do you want to joggle the tooth along for a few more years? If it’s not that five millimeter defect, I’m often saying it’s up to you. You can try and save the tooth, it won’t last forever. Again, what I was about to say before I got onto this subject is that second molars are such a big talking point as far as retaining versus extraction. So this is where we’re going with this scenario.  They’re also the most cracked teeth around, so you’re often saying to the patient, look, again, if you’re a third of an 80-year-old patient or whatever, maybe take the tooth out, it’s cracked. You could function with the first molar, there’s no problem. Or sometimes just saying, look, you are under 60. The tooth in front, which is first molar, it’s going to get a lot of wear and tear. If you take the seven out, if they take the second molar tooth out, it’s going to be solely the, it’s going to be the terminal tooth in your arch for the next 30 years or so. That will mean that you lose that tooth before it should be lost if you have this tooth out. The other thing I’m commonly saying to patients now is, if you think about a first molar that’s heavily restored, because it’s been there since the patient was six years old, maybe it’s had a crown, maybe it’s had a endo.  Ask the patient, even though you’re looking at the second molar, ask the patient how long they’ve had that six or the first molar root filled for, they’ll say 15 to 20 years. And you go look, that life expectancy for the tooth is coming up and you need a bridge option. Sometimes if they’re an older patient, you may need a bridge option when you’re older, you may go for an implant, but you may need a bridge leader.  So you have to preserve the second molar tooth because the bridge option won’t be an option if it’s not there because you took it out on the whim. If you took the second molar out one day, because you were feeling it was painful and you weren’t sleeping and you just felt angry, you will lose the option of a bridge later in life. Even if it’s like when you’re 75 or 80, you won’t even have it there. So I’m talking a lot about this with patients like, you know, look at the first molar, see what the restorative plan is into their life, and then work from there. The second molar is a good one because often second molars can’t be replaced with an implant or dentists don’t want to replace that tooth with an implant because they don’t see value. Obviously oral hygiene’s difficult in that region. All those things bone-  [Jaz]Higher forces. [Omar]High forces maxillary sinus close to ID nerve. If you’re talking about people with high ID nerves and things like that, there are problems. So I often say to patients, there won’t be many dentists who will placed an implant in this position. If you have it out, then that’s the end of that tooth forever in that position. I’m not saying it’s necessarily the main tooth because that’s your first molar and that’s what you really need, but you’ll lose that option of a bridge forever when that’s gone. That’s, that’s really important.  [Jaz]I like this idea of looking at the adjacent teeth and trying to talk sense and this logic that we’re talking about them, they can really apply it to themselves much better personalized care. And that’s at the crux of it. So can we just do a little quick summary of the red flags where you put your hand up and say, you know what, Palliative Endo is technically always an option in a way. Right?  As long as you can get some sort of seal. So putting palliative endocyte in that we can actually deem this endo palliative because we can’t get you a reasonable result because, okay, well lack of two structure is one, but that doesn’t mean you can’t do palliative. You can still clear out the infection and put some sort of material there. And there’s benefit in preserving the periodontal ligament for even for the future implant. Right.  So tell us about that retained roots actually maintain, because that was one of the questions I sent you in advance. What do you feel about retaining roots that are root filled so that in the future it’s more a timely to have a procedure or an implant in the future?  [Omar]Yeah, that’s a really good thing to do. I mean, if you can maintain alveolar bone, that’s going to be a good thing. It maintains the width and the height that’s important to mention is that with implants you need width. You don’t want a knife edge ridge to put an implant into. It’s just not going to happen without bone grafting. And bone grafting is another procedure, as I say to many of the patients. They know sinus lift is another procedure, bone graft, these are all procedures they’re going to make the implant more costly. And I think most people who place implants want to place implants in the bone of the patient, not grafted bone. It’s much better, it’s better to place it in the patient’s bone. So I think retaining roots is definitely a good way to go. If you can, root burial is what some people do for those pediatric patients where it’s like you’ve got an unrestorable central, it’s been smashed by an accident or trauma or even resorption cases where you’re like, oh well it’s so resorbed, it’s not gonna be able to be restored. Then maybe root burial is something that you can do with endo or without the endo means sometimes if it’s vital you can just bury the root.  [Jaz]And when you’re doing that, is that something that you’ve done much of either in your training or than if it’s commonly done in private practice? One of those things, isn’t it? [Omar]I have done it for patients who are on bisphosphonates and not in the sense that they’re going to get an implant, but that they’re going to retain the tooth and not require an extraction. And what was really interesting about those cases was that these patients actually end up with you risk assess the patient before you recommend for extraction. And so when I was working at the dental hospital, many patients were coming in and they’d been, previously, they had bisphosphonates, they had previous episodes of BRONJ, or Osteonecrosis. MRONJ, and the other thing is spontaneous episodes of osteonecrosis. So they might hit their lingular of the mandible with a toothbrush or even the alveolar ridge at behind the tooth retromolar region, and then all of a sudden come to you and say, I’ve got this spine of ulcer that isn’t healing.  And you look at it and go, that’s not just an ulcer, that’s spontaneous osteonecrosis due to bisphosphonates. Those patients you need to prioritize keeping root stumps and things like that because they’re high risk of getting a osteonecrosis from removal of the tooth and complications, I would say. But if they’re taking lower level bisphosphonates, taking them for less time, haven’t had all these things, then you can sort of risk assess and say, look, if they follow the various protocols that we have for extraction, you’ll probably be okay. So I always risk assess the patients like that when I’m talking to them. So maintaining the root stump sometimes is necessary. The other ones that come up with obviously previous radiation therapy patients, where I remember there was a patient from overseas who came and my oral surgery said, this woman needs her teeth retained. She’s got literal radiation burns from the radiation treatment that they’ve done for her.  Head and neck will be very susceptible to damage you’re going to have to do it. So I ended up retaining those roots, it’s very hard. You end up clamping the gingiva with the rubber dam. Then you end up getting some coronal seal, which you hope is another of the seal because we all know that’s so important. But yeah, they go from there. I used to do that more, I’d say in in hospital dentistry.  [Jaz]That’s what I would’ve thought. Now I’ve got a similar scenario, lovely gentleman who been seeing for five years now. When I first met him, you know, he did have a oral cancer in the past. He had a radiotherapy on the side of his face and we decided together with an endodontist that, okay, it’s really important we avoid the extraction. And so essentially he did a palliative endodontic. Okay. He managed to disinfect and a couple of canals. He managed to put some GP and the other one he put some calcium hydroxide. And what we’ve done over time, I believe he just either put some IRM or GIC. And so now it’s like a retained route with like a millimeter or two of restorative material as the seal. Now I’m just thinking about this scenario again.  Would it be better in that stage just actually drill that coronal tooth structure until, let’s say the bone level or maybe even deeper than the bone level? Because I’ve never done a root burial myself, so I don’t know what the guidelines are to allow the blood clot and then the gingiva and everything to remodel over it. Is that how it works? Would that actually be better than actually leaving a restorative material out exposed?  [Omar]Well in theory it would be better to bury the root because of course if you have restorative material, then it’s very difficult to keep that clean. It’s like food impaction. We all know those cases where you’ve got root caries and things like that. And often these patients, they do have root caries. That’s why you’re doing the palliative endodonic. I mean, if it’s restorable, it’s not palliative. So what happens is you end up doing a root burial. It makes sense because by doing a root burial, then they don’t have to worry about keeping it the dentine. [Jaz]And so what are the guidelines? How much do you remove the tooth structure when you’re doing a root burial? Like are you going like sub crestal? I’ve never done it before, sir.  [Omar]You just need to go at the elbow crest and you need to be able to stretch over the gingiva, over the root fragment. I mean, this isn’t something I do, obviously being an endo, but it’s a max facts kind of oral surgery. They incised the periosteum because the periosteum keeps the gingiva stiff can’t drag it over. People who do this are very skillful at their incising, the periosteum and it’s a bit like an oral antral fistula repair kind of scenario. The same kind of idea. The gingiva comes all stretchy if you inci the periosteum. [Jaz]That’s what I thought, but I’m just glad you’ve done that and it’s important we mentioned that as an option for very niche patients that we can’t cover all the scenarios, but in some patients like that patient I described who’s had the history of radiotherapy, that makes a lot of sense.  [Omar]Here’s another one root amputation. Don’t forget about that as an option. Some patients with resorption on the mesial root of a lower six. If they need to keep that tooth for a few more years, let’s do the root canal treatment on the distal root and get the root amputated on the mesial. Like as long as it’s not if you’ve got that crack going into the distal root, then you probably it’s game over. But what I’m saying here is, again, you have to justify the need to retain the tooth. If the patient’s that age, you don’t want them to have an implant failure, you want to juggle the tooth along. So I am recommending root amputation in a few cases, again, niche patients.  [Jaz]I do about one a year of root amputation. It’s very satisfying and totally has a place, and going in line with everything we’ve said quite often it’s a, yeah, a molar or even a second molar is the most recent one I did. Access can be tricky, but it’s very rewarding to do that kind of a longevity based treatment. Right.  We were just summarizing the different causes of concern whereby you think, okay, we definitely need to go down have that consultation with the implant let’s plan that. What are the things that would make it a palliative endo rather than, okay, let’s give this a really good shot.  [Omar]Okay. So the obvious one is the root fracture of the split tooth, where you can basically not, you can’t restore it, the structure’s gone. The other one is I look at pericervical dentine. So pericervical dentine is what determines longevity. Again, that’s a call for the prognosis of the patient. Like if they needed to for two years, maybe that’s enough. If they need it for 25 years, then probably it’s more of a problem.  So pericervical dentine I always encourage all dentists that I’m teaching to write a note in their radiographic report about the pericervical dentine state, as in like tooth looks, restorable, pericervical dentin is adequate, or tooth looks very heavily accessed or heavily treated. Pericervical dentine is inadequate for longevity. Sometimes you’re saying that to patients. So percervical, dentine to me, plays a role in whether I, again, it depends on the patient’s prognosis and how long they need, but quite a lot of the time I’m going, look, it’s not really worth it because it’s so hacked up and treated previously that we’d better get on with something else.  Again, an opinion to look at something else, but if you really want to save that tooth, I know that it’s not got a good longevity. But if you come and that gives them the opportunity from dental legal perspective, they haven’t signed up on the day they’ve gone, got your quote, got the ideas, you’ve given them an exit strategy to go on and get the implant or the replacement. They’ve gone and done that and gone. That’s not what, not for me. I want to go back and get this tooth saved. Even though he said the longevity was not as good and dento-legally you have that in your notes it’s the consult. They went away, they got another opinion and came back and then you are all good to go, even if it’s only a short term option. And it’s important to explain that’s why I love consults now for every patient, I rarely start treatment on the day because basically it just gives them that calling off period of going, look, I don’t want to do it, I do wanted to do it. If they’re in there on the day that the tendency is just to get there, sign up on, get going because they took the day off work, or they, you know, rearrange all their meetings or whatever they’re doing and then they go, I should have done something else. So it gives them that cool off period just to think about it so that’s the one. So Pericervical, dentine and basically longevity and things like that? Yes. There’s not actually that many cases where I straight up recommend extraction.  [Jaz]The nasty crack and the lack of tooth structure is pretty much summarizes the worst from even in the resorption. It’s a lack of tooth structure problem. And we have a crack problem where you have, it looks like you have ample tooth structure, but the crack is so nasty that you know that the prognosis is not gonna be so good. And I think some of the main questions I get is, oh, can we do more podcasts about cracks and stuff?  So can you give us some guidelines? Okay. What kind of cracks? What visual features or tactile features? You mentioned a imaging feature, which is fantastic about seeing that Pacman bite. I love that. Any other features of cracks that you can describe either clinically tactile or imaging that point towards a poor prognosis? [Omar]We talked about depth of the crack on the CBCT. The other one I look for is the occlusion of the patient. So they’re totally biting on this tooth all the time. The chances are this tooth is very cracked. Things like that, their habits. Because even if the tooth is cracked but not severely now if they crack it in four months, that’s not ideal because you’re looking at the occlusion history of cracks, previous restorations and what they look like. So are the composites all smashed up and ditched? And also, which teeth?  So a great example of this, I had this really lovely youngish, she must have been like 30, maybe 32, 33 lawyer in the chair. And I looked at her teeth and they were all cracked. And I just said, you’re a stressed out lawyer lady, aren’t you? I mean, it’s just so sad. You’re young and your teeth are all cracked. Like I was treating all her cracked teeth, but she had premolars that were cracked restorations that were absolutely smashed up. And she wasn’t an old patient. So you have to look at the previous restorations whether they’re cast and they’re really smashed up.  Because that’s a really bad sign, whether they’re direct restorations and the age of those restorations. So how long ago did you get the restoration done? Oh, like five years ago. It looks terrible. It’s like they are smashing their teeth. So again, if you are looking at cracked teeth history and prognosis, you want to consider their history of their general dental condition.  [Jaz]On the dental condition. Tell me if you agree or disagree with me here. When I look around, we do a scan, we get an, an image of the patient, like an overview, right? And if I see that this patient may be older in their 60s and they’ve got like lots of MOD amalgams, which like with mostly like stained cracks, which look to be in enamel, that is a better scenario than the patient who’s got tiny restorations or unrestored and got virgin cracks that for me is the more dangerous patient than the one that’s got heavily restored but smaller cracks.  [Omar]Correct. Yeah, that’s it. Because the restoration, I know it sounds a bit strange, but it acts like a little stress breaker in the sense that you might get a mesial or distal cracked, but you may not get an MOT crack. It’s kind of like the crack has to actually go through the entire restoration and the rest of the teeth, whereas if you have those cracks in virgin teeth, it tends to make you think the patient’s really clenching.  You’ve cracked a virgin tooth, that’s actually quite bad. Also, the fissure pattern of the say the second molar is a problem. It’s a W shape, the cracked as fast, right through the whole tooth, and it’s closer to the TMJ. So you basically end up with that loading of the joint. But again, you look at the patient’s wear and tear on the teeth and say, look, I really think you’re smashing your teeth up. You really need to do it have a splint. And sometimes I’m even offering them, stress therapy, like, go and read a self-help book and that person at work is annoying you and making you do this, don’t let them annoy you. Honestly, I actually talk to them about stress and say, look, I know you’re caring for someone who’s sick sometimes, and that’s going to be really hard.  But don’t let that affect your own teeth. It’s already hard enough what you are doing to look after this ill person. But that’s not gonna help. If you have damaged your tooth and you can’t help them because you are a dentist or something like that, it’s not going to help them if you are in pain from toothache, you won’t be able to care for that person. So really just separate the two things and work on that stress as well, because there’s always a reason why patients have pathological wear on their teeth. It’s essentially pathological wear from mental health issues to clenching, to grinding, to stress and all of those kind of things. So really, that’s a really important point, but trying to manage that stress because people say, oh, get Botox, it’s like, yeah, but that’s just putting a bandaid over the thing.  The actual problem is the stress that from whatever the stress is try to manage that. I mean, you can’t eliminate it sometimes, but manage that stress as much as you can. And also maybe do the splint or the Botox or whatever you want to do, but like you can do something. Your health is within your own control also. It might be only 50%, 25%, but some of it’s within your own control.  [Jaz]Omar I’ve just popped up a nice image of a crack for us. So I’m gonna describe it for those Spotify listeners who removed the amalgam and it was like MODish, lovely, nasty stained cracks. So again, stained means bacteria is able to get inside. There’s worse a prognosis, but in terms of like there are cracks that are a bit more delicate in terms of appearance and then those that are nasty. This is very much in my books, a nasty one. Would you agree with that?  [Omar]Yes, I totally agree. Probably necrotic as well, isn’t it?  [Jaz]Yes. And so is this one, without even accessing the pulp chamber, are you thinking, okay, this is the either palliative or have that consultation and plan for implant future or you know, are you surprised sometimes by accessing into the pulp chamber and seeing actually it comes to not necessarily a halt, but it becomes not stained anymore, for example, or it kind of stops a few millimeters? Subgingival, what are you thinking there?  [Omar]I would say, actually in my experience, generally the crack ends up a bit worse than I was hoping. And with these kind of cases, even if it’s necrotic and it’s stained like that, if you see a crack and it’s kind of going down the route and you cannot see the absolute end of it, it’s going to be way worse than what you thought. Now that’s the problem again, you would take a CBCT and go, look, there isn’t a defect right now, or there is a defect if there is, obviously probably taking the tooth out or recommend an opinion. But if the tooth doesn’t have a defect in the bone, then you might consider something. Because I guess the best way of visualizing a crack really is use of CBCT in the bone defect. Because you can’t see beyond the orifices. You’re not going to drill all the way down that route to find out where the crack finishes.  And if you do, it’s just removing structure, which we all know is so important for survival. So this is where CBCT is absolutely important because you know you’ve got your clinical, it goes into the pulp. Yes, I can see the crack, but does it go into the pulp and then kind of stop? Or does it just go down all the route? I tend to find that in these cases exactly like the one you’re showing. I would be hoping for it to save it and I would be, my heart would start sinking away and I’d be like, this is going to be gone. [Jaz]I know I’m putting you on the spot here, but as a percentage, what percentage do you think that look like? This obviously ignoring the patient inclusion roaring patient age, just appearance of the stained crack going mesial to distal. Would you say that actually we end up doing the root canal and it’s a job well done versus I go in and I’m bringing the patient back up and saying, look, I’ve addressed it, but you’re gonna have to have it. [Omar]I would say it probably getting towards the 20% range, not many. And again, you have had that discussion. We’ve all got this in our mind of like, how badly does this patient really need to hold this tooth? And sometimes it’s like, ah, they’d do okay with an implant. Oh, they wouldn’t do then you start going, well, I really need to hold onto this tooth. And it provided all the other red flags on with the periodontal defect and stuff.  You would try and save that tooth and you’d justify it in your notes and say, look, the patient is not going to be a good candidate for implants or maybe has had implants that have failed it’s another one. It’s a first molar, we really need to hold that tooth that’s so important for this person and they’ve had implant failure, so I’m going for it.  You can do that, you can say like, that’s the reason why I’m gonna totally go and do this. And, and as long as they’re on board with that, I can’t see anything wrong with trying to do that, as I said. But you do have to have the not split down the middle and the periodontal defect there because then it’s going to work against you.  [Jaz]I picked a nasty one for you, so those who are listening maybe want to catch the visuals on the app to see the image and almost talking points there. I guess, I mean, I had so many questions, but in the interest of time, I’m gonna just say, I think something that’s really important to mention here is the whole thing about success versus survival. Can you explain to dentists, remind us about success versus survival and then what is the data implants versus and onto treatments when we look at those characteristics of success and survival?  [Omar]Well, it’s an interesting point and my colleague that I work with in Crows Nest now, she’s done a few talks and I liked her talk, so she went through it with me and she brought up some interesting points that I didn’t bring up before. So success and survival. So successes very much endodonic healing of the apical lesion. But it has been in the research modified with a whole lot of few ways. Like some people even don’t quite classify them the same way. So some of those people call retaining the tooth success, but that’s not success. Success in how I understand it and Endodonic is essentially healing of the apical disease radiographically or on a CBCT imaging success.  And that’s the traditional way of looking at it. Survival is just the tooth is there, and so the implants are assessed on survival generally, there is a success criteria with implants, but it’s quite loose compared to the success of root canal treatments. Because root canal treatment success is actually pretty reasonably hard to get. I mean, especially if you use CBCT, first of all, we need a patient who’s gonna heal. Second of all, we obviously need to do the endo really well. And third of all, we need the time to elapse for the patient to heal, whatever that time is. Many studies say within five years, but there is research showing that it takes 20 years for the root canal lesion or the endodonic lesion to heal Molven’s study. So there are those cases, and so what I’m trying to say here really is that success and endo can be often difficult to achieve. So as I’ve got more experience as a clinician, I’ve more got away from worrying about the little dark area, although I’m trying to heal that. It’s one of those things I want to do both, of course, I want to do both. I want the patient to have the tooth that’s their benchmark of success, it’s survival in my book.  But I also want the lesion to heal because we wanna show pretty cases in their lectures now. We want to just make sure that the patient’s happy and everything’s going planned. It’s beautiful and that makes us feel good for the day. Because at the end of the day, it’s all about patients feeling good and ourselves as well. But like basically aiming for success as the first point is often a difficult one to satisfy because of the time it takes to heal or the difficulties of the treatment. So then I default back to like survival. A lot of the times say, look, all the criteria that came up a number of years ago was called asymptomatic and functional. And I liked that kind of terminology because it gives us a nice way to segue and we’re keeping the tooth there. Because of this, we need to keep the tooth there. It doesn’t matter if the lesion takes 3-4 years to heal. It’s going to heal it might heal.  It might take a long time to heal we know that from research, but what I’m trying to say here really is that it’s really important to start with the focus of keeping the tooth. And if the patient’s not in pain and you’ve kept the tooth, then that is a good, you’ve accomplished something quite good for the patient. Asymptomatic and functional, I like that because if you talk about survival, you’re saying, well they could have a draining sinus tract surviving. It’s like, yeah, it sort of isn’t what we’re going for here. Or they could be every now and again, I have to take antibiotics because it swells up that’s survival but that’s not what we’re looking for. Yeah. We want the patient to go on holiday and not be worried about the tooth. That’s the way I look at it. We want them to go.  [Jaz]That’s very real world metric.  [Omar]Yeah. I want the patient to go on holiday and not be sitting there worrying about whether their tooth might be bothering them and they have to go to a dentist and take antibiotics because that’s what they’re doing. If they’re having to– [Jaz]Always on holiday Omar, always on holiday.  [Omar]If they’re having to do something in their life to keep themselves out of pain or stop the swelling, or that’s not asymptomatic and functional. because survival criteria would say asymptomatic and functional says the tooth is still there and the tooth is not bothering them at all, so I like that criteria.  [Jaz]I love that as well. I love, I’m going to write that down. Asymptomatic and functional, I think is a really real world way of looking at it.  [Omar]Yeah. Yeah. I like that. And so implants, again, when I was just talking to you about implant implants, a lot of the research is done on survival of implants. And the problem with that is, first of all, implants are placed often by experts in the field. Whereas endodonic often done by dental students, dentists anyone who’s in the study. Then the other thing is, implants just aren’t placed in people who are gonna be high risk for losing the implant. If you’ve had five implant failures, they’re not going to use you in a study for the sixth implant. Whereas root canal treatment is a go-to whenever there’s a problem. I mean, like in institute split, all those things we talked about. So you’re going to get a bias towards implants looking better. Because first of all, the criteria of survival is basically the only criteria. I mean, there’s a successful criteria, but it changes. With endo, it is harder to get, say, success than asymptomatic and functional.  And then survival again with endo is easier because it could be a sinus tract and all that stuff. So basically if you look at them head to head, they have a very similar survival rate. I think the last time I looked at this was quite a while ago, and it was a King’s college study, Shannon Patel, he was doing single visit endo with a one year follow up.  I believe there’s been more research on that paper. And he was showing that his success rates for root canal treatment on an incisor teeth was high, like in the sort of a hundred percent sort of level. But as you got towards the back of the mouth, it was dropping to around 75%. And then implants, if you look at them, they’re the same. We were looking at obviously success of Endo and a CBCT one year later. A small sample size, it’s is practice cases for a year. And then if you look at survival of implants, that’s in the sort of similar kind of level.  [Jaz]They’re both similar, then it just makes sense that it goes back to the very first point you made, right? If endo is on the table, it’s feasible because it’s got enough tooth structure and the crack is not so nasty. And even if it’s looking a bit dubious, then there is still so much to be gained by getting some survival and allowing the patient to have an implant later on in life.  Then first up, and one thing that we actually didn’t elaborate on, but the whole thing about using retained roots and doing endos on them to keep them in the mouth, we sometimes forget because what we think is, oh, let’s take out this retained root, then do a socket graft, but actually just work with that retained root ’cause.If they’re basically going to walk around with nothing there anyway, then you might as well do a retained root and then keep that PDL, keep everything, keep the bone preserved there rather than putting artificial bone or whatever for the future. But again, I’m the implant dentist, i’m not the person for that. But Omar, thanks for the brilliant overview today. We covered a lot of ground, a lot of different topics, from root burial to successful versus survival to different characteristics, red flags. Is there anything else that you would like to leave us with before I ask how we can follow you? How we can learn more from.  [Omar]So I’ve got Instagram and Facebook @specialistendo on Instagram and Facebook’s Specialist Endo Crows Nest clinical hacks. I’ve been doing this teaching online for, wow, it’s been over like 12, 13 years now and it’s been so fun. We are running courses in Sydney this year. I’ve got one in Melbourne. I’m hoping to come to the UK soon and at what some point, and we are looking at doing a bit of lecturing maybe in Taiwan later in the year. So that’s going to be super exciting.  So we’ve got lots of things planned for this year. The other thing is just new breaking news for me, is that I’m now opening my own educational based dental practice with the kind of concept of creating a facility where specialists work there like me and my colleagues, and we provide opportunities for people to come and observe cases. With a set up with screens. And also there’s a facility for educational courses within that same practice. So that’s something really exciting that I’ve just come up with in the last amazing few months. And like the idea is to create like a dental hub where people come learn and even if you’ve had a bad day at work. Come in and talk to me about your bad day at work and we’ll have a coffee and discuss why it was a bad day and ’cause that’s what I would’ve wanted when I graduated. I would’ve wanted someone that would, would take me aside and go, look, it gets better.  And all those discussions that you can have with your younger dentists or even older dentists who are having a bad day, it doesn’t matter. So basically, that’s the exciting news for me. And so thanks so much for having me. It’s been really great to talk to you again. Our previous discussion about, I believe it was files and all those interesting things–  [Jaz]Being more efficient in Endo. Thank you so much for your time Omar, I’m honestly an absolute superstar in everything you do, and you’re a Mr. Motivator man. You literally are a Mr. Motivator. I think, I love talking to people like you who, we talk about the clinical, we geek out, but you bring the world and life experience and philosophy into it, which I’m always a big fan of that. I’ll put all the links for Omar programs and his Instagram account and his Facebook page as well.  And as soon as you have something they can give me about any UK visit or any other links I can put on. People always ask me, where’s the link for this? And I’d love to put it all in the show notes. So please do send me that, Omar. And I’d love to distribute to all the producer from us. Thank you so much for covering these varied themes. I had a lot of fun.  [Omar]Thanks Jaz for having me and have a good day.  Jaz’s Outro:Well there we have it. Guys, thanks so much for listening all the way to the end. I wonder if it means now I need to record the same episode with an implant dentist. Do you think that would be necessary? You know, I don’t know because. All the implant dentists I respect, would probably agree with 80 to 90% of what me and Omar were saying in this episode. And to get a dentist to agree 80 to 90% with another dentist, that’s a pretty good thing right. Of course in this episode, there was some bias because it’s an endodontist we’re talking to. They live and breathe endo and saving teeth. But the message is a good one. As restorative dentists, first and foremost, we preserve vitality. And if that’s not possible, we preserve the tooth and the PDL for as long as possible. And if that’s not possible, we want good survival and success of our implants, and ultimately we want the patient to win. And that is at the crux of healthcare, my friends.  Now, if you’re listening on Spotify, apple, etc, please do hit that subscribe button and share it to your WhatsApp group, share it to your colleagues. If you found it interesting, we’ve got hundreds of episodes in the backlog. If you’re just discovering protrusive, where the hell have you been, welcome. And of course, join the Protrusive app, www.protrusive.app.  The Protrusive Guidance app is the home of the nicest and geekiest dentist in the world get 80% of the quiz. So scroll down if you watch on the app, answer the quiz and claim your CE credits, our CPD Queen Mari will send you the certificate and every quarter she’ll send you an update of how much, see you’ve completed protrusive. And then annually she sends you like a big annual summary as well. And yes, it’s all tax deductible because it’s dental education at its finest. Thank you to thousands of dentists who have joined us on protrusive guidance. It is so beautiful, the community you’ve created. And with that, I’m going to say goodbye. I’ll catch you same time, same place next week. Bye for now.

Is Practice Ownership worth the stress?  What’s the most difficult thing you have to do as a practice owner?  Thinking about starting your own squat practice? How long does it really take before you see profit, and what sacrifices do you need to make along the way? In this episode, Jaz is joined by Dr. Shabnam Zai to unpack the real highs and lows of running a dental practice. From the loss of control as an associate, to the resilience needed during COVID, to the challenges of leadership and managing a team—nothing is sugar-coated here. They also tackle the big money question: when does a squat practice finally become profitable, and is it worth the grind in those first few years? If you’ve ever wondered whether practice ownership is for you—or why it might not be—this episode will give you the clarity (and reality check) you need. https://youtu.be/Tf1bgOWMA2A Watch PDP237 on Youtube Protrusive Dental Pearl: “DO NOT COMPARE YOUR WORK TO WHAT YOU SEE ON SOCIAL MEDIA” Most cases shown online are the very best results, done under perfect conditions by clinicians with thousands of hours of experience.  Instead of letting that trigger self-doubt or imposter syndrome, use it as inspiration: respect it, aspire toward it, and occasionally achieve it — but remember that real-world dentistry is different. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Engagement in work is crucial for job satisfaction. Time management is essential for balancing work and family. Marketing and patient relationships are vital for practice growth. Quality time with family is more important than quantity. Coaching can help surface potential and provide accountability. Delegation is essential for effective practice management. Vulnerability can arise unexpectedly in practice ownership. Managing people requires empathy and clear communication. Being an associate can be fulfilling and offers flexibility. It’s important to have projects outside of dentistry. Balancing family life with practice ownership is challenging but possible. Financial planning is crucial before starting a practice. Understanding your priorities helps in making career decisions. Documenting staff performance is key to effective management. Continuous learning and self-improvement are vital for success. Highlights of this episode: 0000 Teaser 00:25 Intro 06:10: Guest Introduction – Dr. Shabnam Zai 08:38 Journey into Dentistry and Practice Ownership 15:08 Practice Philosophy and Security 16:33 Decision Making and Growth 19:10 Hardest Part of Being a Practice Owner 24:30 Balancing Parenthood and Dentistry 26:10 Coaching and Supporting Others 30:44 Compliance and Personality Types 34:15 Compliance and Personality Types 35:55 Navigating Career Vulnerability During COVID-19 37:06 The Importance of Self-Awareness and Managing People 40:07 The Forever Associate Trend 43:01 Projects vs Goals 48:33 Balancing Parenthood and Professional Growth 50:47 Financial Considerations for Starting a Practice 59:05 Final Thoughts and Mentorship Opportunities 59:42 Outro Enjoyed this episode? You might also like Treatment Co-Ordinators – Are They Right For Your Practice? – IC043 #PDPMainEpisodes #CareerDevelopment #BeyondDentistry Connect with Dr. Shabnam:Website → shabnamzai.comInstagram → @drshabnamzai This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes: B: Effective management of self and working with others in the dental team. AGD Subject Code: 550 PRACTICE MANAGEMENT AND HUMAN RELATIONS Aim: To provide dentists with an honest, practical insight into practice ownership—particularly squat practices—covering the challenges, rewards, financial realities, and mindset shifts needed for success. Dentists will be able to – Explain the main motivations for becoming a practice owner versus remaining an associate. 2. Describe the key challenges of practice ownership, including compliance, leadership, and financial planning. 3. Outline the realistic financial commitments involved in setting up a squat practice. Click below for full episode transcript: Teaser: Sometimes when you take a step back, you can actually take a bigger step forward. When people say, how much does it cost to set up a spot, I laugh because it's completely the wrong question to be asking. Teaser:The reason I say that is, is because how much your practice is gonna cost depends on, but I did it by reducing clinical day, but I cut down from five to four. What was interesting, my income didn’t change. You know, you have to be honest. Sometimes practices don’t work out. You know, and that’s okay, but– Jaz’s Introduction:Practice ownership, it makes a lot of sense. In fact, in a lot of countries that is the culture. You qualify, you buy a practice, you do your own brand of dentistry. You are never truly fulfilled until you are a practice owner. In fact, in some countries, the associates are rare. Now, here in the UK, US, Australia, there is a big associate culture, if you like. There are many associates out there. And you know what? As an associate, myself, there are so many good things, but there are also some bad things, the lack of control. What if tomorrow a corporate takes over the practice completely changes the culture? It’s what happened to me. And then you have to jump ship and start your patient base all over again. You lose that security, you lose that control and security control are too major reasons we explore today and why one may consider to become a practice owner. And particularly we’re talking about a squat practice. A squat practice is when you buy a building and you turn it into a dental practice. So whilst the themes we cover in today’s episode with Dr. Shabnam Zai, it does apply to buying an existing dental practice because we talk about leadership, we talk about being the boss, being the principal. A lot of our advice, especially when we talk about money towards the end, is about when you are doing a startup or a squat. Hello, Protruserati I’m Jaz Gulati, and welcome back to your favorite Dental Podcast. You’ll find out why I don’t think owning a practice is right for me at this stage of life. And maybe never, maybe you’ll never be right for for me, there are a few really good and really important reasons why I hate the idea of running my own practice. So you’ll get to hear about that later, but then you get to hear about so many benefits and good things and why it might be the best thing that ever happened to you, as explained by Shabnam. The kind of themes that we cover are: Is it right for you to be a practice owner? What are the sacrifices you have to make? What’s the most difficult thing you have to do as a practice owner? How long would it take for you to make a profit? Does it mean that you may have to give up your clinical dentistry? What’s the most challenging thing about being the boss? Dental PearlAnd so many other themes explored in this one hour podcast. Now this episode is eligible for CE credits as Protrusive Education is a PACE approved education provider, and so when you answer the quiz at the end on the app, you’ll get your CE and CPD. Talking of the app, the app has inspired today’s Protrusive Dental Pearl. I’d like to give you a quick win at the start of every PDP episode. So, as you know, we built this community of 4,000 of the nicest and geekiest dentists in the world. It’s absolutely magic. Waking up and seeing all these notifications and all these cases being posted, and all the advice that’s being given and all the, just camaraderie and kindness. Now, I’m very careful about promoting the app outside of the podcast. We have a very niche audience here of either the most engaged and caring dentists in the world, or dentists who want to be more engaged with what they do, and they’ve all found a home in Protrusive guidance. So if you’re not part of it, check out Protrusive.app that’s the website, www.protrusive.app. Make your account at the time of publishing, it is free to make an account. There are paid plans available if you want amazing value that we offer, but you can just join the community and meet your tribe. You can then download the app on iOS and Android. But recently Hannah Cooper for a dentist student in Slovakia posted a case and she said deep breath this is my first anterior case, and she felt really beat up by it. Okay. And I thought she’s being very critical of herself bless her. Okay. So she did some good work. And what I love is that Hannah, she made herself vulnerable. She really put it out there as like, guys, can you help me? And the advice that was given, the reflections by the Protruserati, shout out to the usual suspects. Okay, Mohammad Mozaffari, an absolute legend on the app, so giving with this time. So just a massive shout out to Mohammad. Massive shout out to Richard Coates. I love it every time you dissect a protocol, and I just love how deeply you think. Also, Richard did a special podcast episode just for us private podcast on the app, all about finances and the importance of investing as a dentist, you know, and saving money for the future. So you can check that out as well. And then Michael King, again michael King is another one of those dentists on the platform, which are just so giving with their time and expertise. So his is the pearl that I picked for today. Okay, he says, something that we’ve echoed on this podcast before and it’s relevant for everyone, whether you’re starting a new practice and then you’re looking at other people, or you are wanting to be better at clinical dentistry. Whatever it may be. His advice was in capital letters. Do not compare your work to what you see on social media. Much of what you see on social media is done by clinicians with thousands of hours of practice behind them. They’re also often showing the very best work carried out and the ideal conditions would superbly helpful and compliant patients. This is so true. More often not, this is simply not comparable to the real world. 99% of us work in a daily basis. Aspire always. Okay. So whenever you see something online, respect it, be inspired, aspire towards it. Achieve occasionally, right? Understand that you’ll not be able to achieve that kind of result all the time. But occasionally when you put the graft in, you can do it. But being very aware that social media isn’t quite real life, always be very aware. Michael continued to say that social media is one reason why many fantastic and very talented people from all walks of life and all professions suffer from imposter syndrome to the detriment of their mental health and the wellbeing of their clients. In my honest opinion, being so reflective, so early in career bodes well, and I certainly wish I had the confidence you have shown at that stage in my career. Carry on carrying on this lot here will always support and help. And Michael, like I thank you so much for the support and help you offer to all Protruserati on the app. And now, yes, I do want to applaud Hannah myself for being brave enough to post a case that didn’t go so perfect. And look at the learning. Look how much you gain from it. Look how much all we all. Gain from it. So what are your take home actions? Stop comparing yourself to stuff you see on social media and join protrusive guidance. Instead of duals scrumming on Instagram and Facebook, and seeing all those toxic fights that happen on Facebook. Come and join the nicest and geekiest dentist in the world on protrusive guidance. And with that, let’s join the main episode with Shabnam. Catch you in the outro. Main Episode:Dr. Shaza, welcome to the Protrusive Podcast. So nice to finally see you. Third time, lucky childcare reasons we had to postpone today, and I’m so pleased to be speaking to you. How are you doing? [Shabnam]I’m really well, thank you, Jaz How are you?  [Jaz]Yes, I’m very good. I don’t know much about you and I’m excited to find out. Like my provisional title was Boss Lady, right? Startup– [Shabnam] That by the way, because that’s not something that I really define myself as. So when I saw that, I loved it.  [Jaz]Well, how do you define yourself? Let’s start with that question, Shana. What defines Dr. Shaza? Tell us about yourself.  [Shabnam]So I am a dentist, I’m a mom, I’m a practice owner, I’m a coach, I’m an educator, I’m a speaker. Now, I actually have my own podcast and it’s strange because Jaz if you spoke to me two years ago, a lot of those titles didn’t exist, and I have really embraced myself actually in these last few years. I think early on in my career, I really defined myself as a dentist. And what I’ve realized over the years is there’s much more to me than dentistry, and I like investigating it now and experiencing it and teaching others about it because I think you can get so much joy out of life. I get a little bit upset actually when some dentists don’t enjoy work because I really, really love dentistry. I always have done 22 years in. I still really love being a dentist, but I think over that time I’ve had to challenge myself and do different things to keep myself engaged and active and content really. [Jaz]I share this same thing about you where I find it so sad when people are not engaged at work. If you look at the Gallup polls and stuff about workplaces around the world, that’s something like 87% of people who work are disengaged with what they do. And so I think of a dentist while they’re placing a composite, they’re looking at their clock watching, that’s like the worst position to be in, right? I want everyone to be really in love thinking about the tubules, thinking about the enamel being etched, like really engrossed in flow and what they’re doing. And so the mission of Protrusive the last six years has always been to fall in love with dentistry again. And I think part of that is continuing to learn, never staying stagnant, always changing things up for the betterment, not for the sake of changing up, but to be a better you than you were yesterday. So I definitely share that about you. And one thing I’m excited to unpack today is, you mentioned you’re a mom and a lot of the questions I have are centered around that because the vast majority of practice owners that I know are male. There are more women dentists now than male dentists, especially now 65- 70% from what I’m hearing of dental intakes, students are women, which is fantastic, but I want to know more about how you juggle it, that balancing act, that juggling act of motherhood, parenthood, and dentistry. So I guess, can I start with that? Can you tell me your journey about when you qualified and then when you look back now, what were the stages that led you to where you are today? When did you first consider practice ownership? Did you fall into it? Was it always a drive that you had within you?  [Shabnam]So when I qualified in my VT year, so for the younger listeners that’s FD and my principal mentioned, “Oh in about five years time I might be selling, would you be interested?” And I was like, “Absolutely.” And if I’m honest, as that was the first time I actually thought about owning a practice, it wasn’t really a dream of mine. I just kind of fell into dentistry. In fact, I didn’t wanna be a dentist, I wanted to do chemistry. I just changed my mind at the last minute. And so he offered that and I was quite excited. And I’m a bit of a core. I love learning. So I threw myself into skilling up and the desire to grow was always there. So I scaled up on composites, on Invisalign, on crown lengthening, implants, everything. And then time went on and I was a really good associate and I was building up the practice. And then I kept going back to my principal saying, “Oh, when should we become partners or when you’re gonna sell?” And time was going on. And if I’m honest, the defining factor for me was having my daughter. So I had my daughter and when you have kids, you’re like, “I really want my kids to fulfill their dreams.” And in that moment I realized I wasn’t fulfilling mine. I was waiting on someone else’s decision before I moved forward with mine, and that’s when I kind of thought I needed to do something else in case this doesn’t happen. So then I started looking at practice ownership and it was a long process. I personally don’t like doing things on my own, so I always wanted to do it in partnership. I had a couple of dentists that were interested in setting up practice with me, and I spent five years looking to buy a practice. I’m based in northwest London. [Jaz]That’s a long time.  [Shabnam]Yeah. And I was eight months pregnant. And they’re kind of looking at me going, “Are you sure you want to be doing this?” And I kind of was a bit frustrated with that because opportunities are rare. Practices in London are even rare. Especially where I wanted to live, so I couldn’t really miss the opportunity just because I chose to have a child. So I kind of wanted to proceed anyway. And if I’m honest, there was a lot of negative comments about me being a female mother buying practice.  [Jaz]Wow.  [Shabnam]To the point where–  [Jaz]Who were they from? Who was saying these negative things?  [Shabnam]So interestingly, when I found my location, I wasn’t expecting to set up a squat. I was always looking to buy and there’s a lot of stuff I didn’t know and I looked back on that time and it was incredibly stressful and overwhelming. because I just didn’t know what I didn’t know. And I remember going around the showcase with a video of this location being asked more questions and not knowing the answers to them. And I remember there’s an accountant then, and then he was giving me the stats of how many squats failed. And then he started sending me articles on it afterwards, and I’m like, I’m trying to hire you as an accountant to facilitate this purchase, and you are actually telling me stuff not to do it. And he’s like, I’m not sure you’re a lady, like you’ve got young kids it’s gonna be a lot. And if I’m honest, at that moment it kind of made me a bit more determined to do it.  [Jaz]It had the opposite effect, very good. As someone called Grant Cardone says,” There are haters and then there are naysayers.” And so what this accountant, he falls into the category of a naysayer he doesn’t want you to fail, okay? But it’s a bit like when you tell a spouse or someone you love, or your parents, you want to do something and they just want you to have a nice, easy life. Right? Because they love you and they say, “Listen, are you sure you want to do this? You want to take it easy?” They’re not haters, they are naysayers. And you sometimes need to listen to that inner voice, it sounds like you did. And ignore that because that’s just noise. You need to cut through that to get to your focus, get to your goal. And so tell us how that evolved and when you actually ended up getting practice and how did you come to that decision? [Shabnam]So after five years of looking to buy, we realized that we weren’t finding things. And my business partner’s husband actually said, “Why don’t you set up your own?” And we hadn’t really considered it at that time. You needed D1 planning permission. So we just started looking at sites and we looked at sites. And then what happens when you’ve got two kids under four and you find your dream location? So Nikita and I sat down six years earlier and wrote down what we wanted from our dream practice. We wanted a half an hour commute. We wanted to be a private practice, not a specialist. We even divided up, I was gonna do compliance, she was gonna do accounts very early on, get that very clear out of the way. And we wanted three surgeries, step-free, all these things, parking, and we got it. There’s a park in northwest London. So my dental practice is in a park, and it’s three surgeries, step-free, six minutes drive from my house.  [Jaz]Wow.  [Shabnam]And it just happened, and Nikita just started maternity leave on Friday, so she was nine months pregnant when we found it. We went to see her on the Monday. She gave birth on Thursday. And Friday I was at the showcase trying to figure out how to set up a practice.  [Jaz]I love that it came to be, and I think the lesson from that, from a lot of the books I read about motivation, self-development, one of the lessons I learned is we are goal seeking beings. The way our brain works is that it hones in on a goal and then you kind of have to set this goal and kind of let the universe work it out for you.  [Shabnam]That’s why I pay Jaz write stuff down. I’m already– [Jaz]I love that. [Shabnam] Writing stuff. Even when I told you this podcast, I wrote it down and then for whatever reason it didn’t happen. And I was like, “It’s gonna happen.” And it did.  [Jaz]And so once you have that vision, you trust the universe to make it happen. Your subconscious mind actually works behind the scenes to pick decisions to make it happen. I’m a big believer in that actually. Now I use someone who’s quick at making decisions or are you generally someone who labors about it, thinks about it. So tell us about that.  [Shabnam]Yeah, so as I’m now a business owner, I am very quick at making decisions. What I realized one of the most successful outcomes of building my practice was that we made such quick decisions that from signing the lease to finishing the build was 8 weeks. Like it was fast. And at the time we didn’t appreciate that, but it came down to making quick decisions. I’m normally a researcher. I like to analyze things, read everything, and consider things. [Jaz]They seem counterintuitive. How can I be a researcher and analytical yet make quick decisions at the same time? Tell me about that.  [Shabnam]So you divide and conquer, so you kind of decide on the things you need. So contracts that I’m signing, like I’m doing clinical waste at the minute and they’re signing me in for 3 years and I’m like, “I don’t wanna sign for 3 years. I need to know those terms.” Because I’m financial cost of the practice. What kind of door handles we have, that’s a quick decision. Sometimes I go to my gut. I think nowadays I listen to my gut more than ever.  There’s been times in interviews when I’ve kind of given people the benefit of the doubt saying, “Oh, I can train them. I can kind of build them up and in my gut, I kind of knew at the interview it wasn’t quite right. And it came true. So now I just stick to my gut and I kind of know what’s right for me, and I think that’s what you need to know. So what’s right for me might not be right for you. My values are different to you, although some of our values will overline, some don’t. And as long as I pick what’s right for me, and that’s the best thing about Nikita, my business partner, we have very similar values. So if I’m not there and she makes a decision, I wholeheartedly know she’s gonna make the same decision as I am. Which makes me feel very safe, being in that partnership. And we have a very similar outlook on dentistry and the practice, so some people go into practice to make money, they have a business. That wasn’t our rationale. We did it for job security. We like doing dentistry a certain way with certain materials. As moms, we had to kind of start work a bit late, finish a bit early. Our husbands also had demanding careers and not all principles would allow you to do that in the practice.  [Jaz]That controls you getting. [Shabnam]That in the practices we in, because we’d worked there for so long and built up loyalty and that, but we knew in the future they were gonna be bought out by corporations. And that practice that I was going to buy is now so expensive. I couldn’t afford it anyway, so I knew I was a brilliant associate. I built the practice up, but at the end of the day, none of that goodwill belonged to me.  And then I worked in Wimpole Street, so I was working at the NHS one day working in Wimpole Street the next day. It was like seeing an exempt patient and then charging 400 pounds for a checkup like when I say I’ve done it all. I just went out there and tried stuff and what it made me realize is that for me, the patient’s the most important thing and for me to be able to control their environment, how they’re treated, kind of really just building what I wanted. How are my patients to be treated and have that job security for myself. That was the reason I set up a practice so I could practice dentistry. How I like to do it without anyone telling me I can’t. And I will take the financial risk for that because that’s okay at the end of the day. [Jaz]I like the theme of security there. People often go in about how can I eventually make profit and then have my exit plan, retirement plan and all that, I guess comes with it. But to have that control and security, and there’s various reasons we could explore. Someone might buy a practice, but just peddling back a bit. One quote that reminded me of when you were talking about making, being quick to make decisions is one of my favorite quotes, is that successful people are quick to make decisions and slow to change them again. And then unsuccessful people are slow to make decisions and then very quick to then change them basically.  [Shabnam]Yeah, the thing you not making a decision is the worst decision. The people are so, I meet so much– [Jaz]People who have sat on the fence. [Shabnam]Yeah. They’re so worried about making the wrong choice. What I’ve realized in life is bad stuff happens to me all the time. People look at me and they think that, “Oh wow, you’ve got it all. You’re married, two kids, got your practice.” I’ve had an incredibly hard life, but at the end of the day, I don’t treat it as a barrier to me. I just think life happens. How I react to it, when stuff does happen, how I manage it, that’s what makes me successful. I know that whatever happens in life, I’m going to negotiate it because I have to, what other choice do I have? And at the end of the day, sometimes these things happen for us, not to us. And a lot of dentists I speak to because I didn’t know what I didn’t know. And if I’m honest, I could have enjoyed the process of setting up a practice a lot more if there was a bit more guidance, but at that time there weren’t these amazing face groups. There weren’t these podcasts, there weren’t all these people out there mentoring. Like none of this existed then. And actually people gave me very superficial like advice on how to set up a practice. So I didn’t really know till I did it. And now I realize 70% I could have done in advance. I could enjoyed it a lot more. And it’s mainly, it was like I wanted a checklist because I’m quite post court driven and there wasn’t one. So I made my own checklist and now I help other dentists and I give them my checklist and I just take that pressure off them. But actually nowadays with chat GPT, you could just type in and say, give me a checklist of how to set up a squat practice. So was the value in what I give them isn’t really the checklist, it’s that understanding and that mindset that it’s possible showing them how to navigate those obstacles when they face them. Because when I was building my squat, my son got pneumonia. He was in hospital for three days. Like, what do I do? Stop building? No, I’m still going to work. I have capacity to manage that, but that’s life, and you just have to kind of embrace that there’s hardness in it, and running a practice is incredibly hard. I tell people that all the time, it’s not easy, but I’m a different person to who I was seven years ago, and there is no course in the planet that could teach me the skillset that I have now. So for someone that likes to grow, it was good for me. And what I’ve learned most is that in dentistry, whilst clinical dentistry is good, I love clinical dentistry. I Still do lots and lots of courses and masters and everything. But actually we need to learn to invest in ourselves a bit more in our own skill sets, like manage ourselves as people better. And I think one of the questions you wanted to ask me was about what do I find hardest as a practice principal? And I’ll be honest, the hardest thing for me is actually time management. Because as soon as you manage your time well, like you allocate time to a job, I’m the kind of person, I just get it done. But if you don’t have the time for it, then you have to start prioritizing things and so you can’t– [Jaz]Well, that’s what it is. Time management is simply priorities. If someone says, I don’t have time for the gym. It’s because gym is 6. They only have time for five priorities and gym is a sixth priority or a seventh priority. When you make something a priority that’s in your top priorities, time is no longer an issue anymore. I learned that slowly over time. So you have to make it a priority and you have to be a little bit smart and delegate and allow a team to be empowered to do all the things so you can lift it off your shoulders so you can actually do the bigger picture things. Have you read the book, the E-Myth Revisited?  [Shabnam]No.  [Jaz]Have you heard about it?  [Shabnam] I have. Yeah.  [Jaz]So it’s about everyone when they’re in a business, the Technician, so the Technician is like the dentist. The dentist who’s doing day in, day out, they’re doing the restorations, the associate going home, not having to worry about it. Just because they’re good at doing an MOD composite or an onlay or veneer, doesn’t mean that there’ll be a great. Manager. And just because if you’re a great manager, doesn’t mean you’ll make a great entrepreneur. So when you are in your position, you kind of have to either wear all three hats, which is very difficult you have to be the technician, IE you’re working clinically in your Scott, you’re being the manager, and you’re being the entrepreneur, the marketing and sales behind everything, that’s your vision. So to do those three are very difficult. So which one of those three do you identify yourself with? And then where do you get the other two varieties from in your business?  [Shabnam]So it’s interesting. So my practice is now seven years old and I wear all those hats and when I first started out, I wasn’t going to do marketing because that was Nikita’s thing. You know, we made that list seven years earlier. And what I found was I’m actually very good at marketing, networking, and building the practice. In fact, I think 30% of patients come to the practice because of me and the random things I do, I can’t even quantify what I do.  [Jaz]Tell us more about that. Can you tell you 30%? Is that google AdWords? Is that you going to networking events? Is it you putting a poster up in a local news agents? Like what do you mean by your attribution? [Shabnam]So when they come to the practice, they say, how did you hear about the practice? They heard about it through me. So whether it’s a school mom or the local cafe owner or going to a networking event or some of my old dentist, my old trainees. I used to be a VT trainer. They come to my practice, so patients come from everywhere.  I have a lot of patients that travel really far as well to come see me which is really nice. And so they just me, and that’s why I tell people about dentistry, like so many people are worried about squats opening up. I opened my squat up, another one opened up, but since I’ve opened up, maybe like 10 have opened up within a two mile radius. [Jaz]Wow.  [Shabnam]And when I say close, within 500 meters of my door. Like very close. I’m not worried because they’re not me. It’s not a female led practice in a park. It’s not me. And what I give and what they give is different and their patients are really happy with them. And my patients are really happy with me and my practice and my ethos and my vision and my practice is very much designed how I wanted my practice to feel. And people that like that, I kind of get the patients that suit my practice, which is amazing. When before that didn’t always happen. Going back to those hats, so recently i’ve kind of been sitting down and you know, whilst I can do everything, I’m competent at everything. What am I really genius at? That’s what I really sat down and thought about. And as a result, I’ve actually decided I’m gonna do more clinical days. because my genius is with patients. I love that interaction. It gives me so much joy. That’s what I love. My business partner, she actually realized she likes doing more than management. So now we are changing our roles slightly where she’s taking some of the managerial roles off me that I’ve been doing for the last six years, and she’s doing it and she’s actually really enjoying it. And what she’s good at doing is outsourcing and delegating. So now she’s getting other people to do the menial task, and then she’s doing more of the oversight marketing. And you don’t know until you try stuff. So we’ve just learned over time, and as I get older, I really love patients. Even when I’m not seeing patients, I’m in my office chatting to the ones at reception. So yeah, that’s my genius, I’d say now– [Jaz]How many days clinical are you now?  [Shabnam]I’m doing two clinical days a week.  [Jaz]See, yeah, you would do six days, right? Yeah. So a lot of people who love dentistry, they think that, okay, if I wanna love dentistry, then I wanna continue doing it. And then they might open a practice and then very soon they might realize, hang on, everything else is collapsing. because I’m too clinical. I also need to be a business owner to take a step back and work on the business rather than in the business. And that could be a potential mistake. And then I heard somewhere, this is just Facebook, University of Facebook, where it says that once you get to a point, when you own four practices, you either have to really scale down, if that’s even a word, your clinical activities, or give up your clinical. And the magic number was 4 apparently. Any thoughts on that?  [Shabnam]So my aim was never to have more than one practice. Like I said, I just wanted job security. I wanted a space where I could treat patients how I wanted. So my aim was never to go more than one. I was talking to a dentist recently who’s working four and a half five days, and he wants to set up his own practice and I said, work four days from now.  And he was kind of like, “oh, but,” and I said, “You need to get your head out the hourly rate thing that if I cut a day, I am losing money. Because you can spend that day investing it in yourself, building your dream to make it a fruition sooner. And actually that time you’re going to get back tenfold. And when you have a practice, you need that day for admin anyway. So just start setting yourself in that rhythm now. So then when it happens, it’s natural for you. And when I set up the practice, I was working six days a week because the bank wouldn’t give me a loan, unless if I gave up my associate job. So I was working at Wimpole Street, I was working in that, my VT practice, and I was working in my clinic and that part, my son was 2, my daughter was 5 But I had to prepare my family for it, we had discussions. I built up the support network so I could be successful. I think when you have a business, you have to be realistic of what you need from your family. So on Monday I went for a date with my daughter. We went to Leicester Square, watched a movie, went to Chinatown for dinner. I like on purpose, I prioritize having a date with my kids. I don’t do that every day. because obviously I’m busy. But they don’t need me a lot. I realize they just need me a little. And I’ve always told them if you need me to tell me. So my son called me the other day and said, “Oh mommy, can you take me to football one Saturday?” And I was like, “Sure, it’s not gonna be this Saturday because I’m working, but I will take you.”  And then I do, I keep my promises. Same with my husband. So I kind of have that communication and that again, something I’ve learned you meant saying, how do I manage my family life? I just have to be honest and also, my family want me to be successful. Like initially I thought I was taking me away from my family and working more days than I was before, but I knew in the future, like now I can close my diary and go to sports day. I can pick, drop my son to school today. I actually have more time with them now and– [Jaz]As a parent, I think it’s about quality of time rather than quantity of time. Like if you’re just giving four hours in a day, but then you are also doing the house chores while you are looking after them and stuff, that’s not focused time. It’s much better to give them one and a half hours of really focus eye to eye, really every facet is explored in your relationship during that, rather than multitasking, trying to do the chores and trying to do emails as you are also looking after them making them do homework, it’s much better to do it, like you suggested. [Shabnam]But Jaz I didn’t know that. I figured it out and that’s why I’m now doing these kind of things because you said you didn’t know me. I don’t need anyone to know me. I’m not like really want to be famous or anything, but I just wanna see people, what’s possible. And there’s people that have done it before you that I, in fact, as a dentist I was working with and she wanted to buy the practice she was working in.  So, but she messaged me, she said, “I actually don’t know what a principal does.” So she’s like, “I’m just being honest. I work in the day I don’t know what they do. So I said, “Sure, I’ll tell you that.” And then she was having some issues with her practice manager and anyway, so I ended up coaching her and as well as building the skillset of being a principal. I think you need to pretend to be a principal before you become one. So you need to treat yourself like a business. How would a principal act in the situation. Anyway, it transpires the practice she was working in. After asking some challenging questions to the practice manager. Practice manager actually did fraud on the practice for about 50 grand, which came to night. She left and I was like, look, you are gonna buy this practice. Anyway, we sat down and kind of made her goals and everything, and actually over the course of a year and a half, like she was renting a flat and she actually really wanted to have another baby. She wanted to buy a dream house.  There’s a lot of things she wanted to do having that time to sit down and really invest in herself. She invested an hour every week. I went to see her in February in Manchester, and I was in there in her new house next to this big kitchen island that she’d always dreamed of carrying her baby. And I was like, two years ago, this was impossible. You told me this was impossible. And she said, yeah, I can’t believe it. Sometimes when you take a step back, you can actually take a bigger step forward. And people, sometimes the dentist are just in the routine of just going to work, coming home, doing the things, going to work the next day, have do this, have, do that. And actually that’s kind of, you lose a bit of the joy and actually sometimes when you celebrate little things on the way, the little things, I’m not saying you need to go on tropical holiday, like, I like just having a cup of tea in my garden. That’s a win for me. It doesn’t have to be massive, but just planting those little bits of joy your day, it get, builds your confidence. There’s a way and people can help you see that for yourself. And I don’t know if you’ve ever had a coach, but having a coach– [Jaz]I do.  [Shabnam]Yeah. I can tell  [Jaz]It is very empowering, the role of a coach, is to get it out of you. Everything I’m realizing now is already inside me. All the things I need to do, I already know I need to do them. But a coach is just surfacing.  [Shabnam]Yeah. [Jaz]It’s resurfacing and accountability is real magic in that I think a couple of themes that–  [Shabnam]I didn’t have anyone to help me do that, and I feel like now try not to regret, but I could have done this years ago, but it’s okay it happens when it happens. I’m happy where I am now. [Jaz]You could have done it perhaps with the faster, better, cheaper, all those things, right? All the benefits of having someone as a mentor, as a coach. Is that what you mean?  [Shabnam]Yeah. And it doesn’t have to be about dentistry as well. That’s what I’m trying to tell people. It’s like we define ourselves too much as being a, a dentist. And I think now that I’m trying not to do that, being a dentist is part of my life, but I’m also a business owner. I’m also a wife and a sister and a mom and you know, I try and be whole.  [Jaz]I love that. And I think literally today I shared on my story, I wanna just take 20 seconds just to mention this, right? It’s on my story now. I shared it from someone, is that how we are taught to measure success is job title is like a pie chart, job title, and then the other half is salary. A better measure of success, which I wholeheartedly believe in there’s like 8 pizza slices if you like, to this pie, right?  Good relationships, financial health, free time, making a difference, lifelong learning, liking what you do career and good health and wellbeing. That for me is a much better measure of success and I think it goes in tandem with what you say. I mean, that should be like blown up and put everywhere and I’m loving the themes that you are exploring. One thing I’m gonna touch on is I get asked all the time, Shabnam,” Jaz I can see you. I see you have leadership qualities.” Look, I was president of SUDS at Dental School. I’ve always taken on leadership roles, i’ve always been happy to. I’m a leader in Team Protrusive. There’s 10 people in Team Protrusive now, I manage all these people. So I’m an entrepreneur in that. Thank you so much so I have all those things it can get very busy running this education business and whatnot, and I love it. I love what I do.  And so people always tell me Jaz Why don’t you run a practice? And two reasons. One is I already have my project. I already have something that I get fulfillment from. And for me, running a practice would be a distraction from my bigger aim of making dentistry tangible. But number 2, and this is the one I really wanna pick your head on, is I absolutely categorically hate compliance. Like I hate reading contract. I’ll be honest with you, I don’t even read any contact. Associate principal, I go by trust. And the day that I have to pick up the contract and read it, that’s the end. Like, you might as well rip it in half. I’m old school i’m old fashioned that way, okay? And I know that’s not the way to do it i’m not condoning it. The point I’m trying to make Shabnam is I’ve got enough self-awareness to know what I’m like, what my values are, and I am gonna be miserable and terrible at compliance. The only way I could do it is like you, by teaming up with someone whereby the other person, like in my practice I work in now as a very happy associate, Chris does all the boring stuff, the compliance stuff and John does more the clinical director kind of stuff.  That I can see myself doing with someone, but I just hate the compliance. So do you think there’s a certain personality type that would suit practice ownership and all those extra responsibilities of compliance, CQC all that kind of BS that I absolutely hate. [Shabnam]So I do compliance. Okay. When I worked in Wimpole Street, I remember they had their CQC–  [Jaz]You’re far too fascinating.  [Shabnam]And I was like–  [Jaz]How?  [Shabnam]Picking things on the wall or like, and I was like putting this above the taps and he’s like, what are you doing? I was like, you’re gonna lose marks for this and I came in the morning early and I did, like I say I was a superstar associate, but it takes a lot of time. Compliance takes. 10 hours a week. I’m a bit of a control freak. I can’t delegate stuff, but you need good people to delegate to. What I would say is, if you don’t like compliance, it’s okay. Now. There’s so many things out there that you can delegate it. It’s a task it can be delegated. You can hire someone to do it, but at the end of the day, it doesn’t matter whether you set it up yourself in calendar tasks or whether you have a compliance portal to do, there is a human being that has to do it.  If you don’t wanna do it, you just have to hire someone to do it, and you’ve gotta hire someone that’s meticulous and organized and persistent because getting people to sign policies every year is soul destroying. Getting people to send me CPD certificates, like my associate’s great to send it to me, but I have to compile it, I have to organize it. It doesn’t bring me joy.  [Jaz]Same here and I would hate, I would absolutely hate through that. That would completely set the fun out of practice ownership for me.  [Shabnam]But people say what? Practice ownership. But I was talking to another dentist the other day, and he unfortunately has scoliosis of his spines. He’s just qualified and he’s an FD and he is thinking about setting up a practice. And I said, but why practice? Why not something else? You don’t have to do business with dentistry. Dentistry could be your career and you could do something. I know people that are dentists and then have other things they do. [Jaz]Well, dentistry is vocational, but if you look at physics, some stat like 70 to 90% of those who study physics go into finance. And so, if you think of it like that, then yeah, when you do dentistry, you get all these skills and evidence-based and being analytical and sociable and personal but you can pivot. [Shabnam]In COVID, I am a dentist, I’m a practice owner overnight. Everything stopped. My son was shielding, so I couldn’t even do clinical. I didn’t do clinical for nearly a year. So in that situation, I was really vulnerable. I couldn’t work as an associate. I was basically my receptionist for my practice, and the practice was actually shut for four months, nearly five, I think. And it made me realize how vulnerable I was, and I was really upset with myself that I didn’t have any other external income. [Jaz]Do you think that having a business-like practice gives you that extra layer of protection?  [Shabnam]No. I felt that I didn’t, because I was a private practice. I got no funding, nothing. It made me vulnerable. I had to find money to pay the bills, to pay the staff. I had no income coming in. It was a squat.  [Jaz]So you’re disappointed in yourself, but then based on that experience, have you changed anything about your sources of income or anything like that to shield yourself to, God forbid a COVID Part two? [Shabnam]And I’m looking to buy an investment property. I set up my online course teaching dentists how to set up their squat practice, and I now coach people as well.  [Jaz]Okay, good. So that’s diversifying. And so you’ve got your business hat now, and you’ve been through that period of being a practice owner during a time where nothing was working. And so you’ve decided that, okay, you can’t put all your eggs in one basket, which is the lesson there basically. Have you ever done an exercise like strengths finder?  [Shabnam]Yeah.  [Jaz]You’ve done that, right? And so, or going back to that self-awareness and knowing your strengths and knowing what you’re good at. One strength, which I think is really important to have as a practice owner is managing people and being able to listen to them and inspiring them. And just generally being a people person.  Are you and your partner both that way minded, or is one of you better with dealing with your team and having conversations, those really important conversations with your team? How do you split that up? And then my follow up question will be, as everyone has said, who’ve ever owned a practice, staff is the most stressful and most difficult thing. [Shabnam]Yes, definitely. So, when I first thought of a principal, I thought of someone very alpha, very dominating, very like, this is how we’re doing it. Very dominating, and that’s not me. So that’s why I thought I could be a principal. I’m more collaborative. I have a lot of empathy, and firing people for me was very difficult. I do the firing in the practice, and the reason I do it is because I wanted to challenge myself, so I had to find a way to do it that I felt comfortable with. And the way I did it is with metrics.  So I measure things, I have my values. And often because I measure things so well. The people that are on probation normally come to me and say, “I’m not doing very well. I think I should leave.” Which is great. So I found a system now where people themselves identify that they don’t fit with my practice. Not that they’ve, I never hire anyone that’s bad. I have lovely staff, but they identify themselves. They don’t have the right values to fix with how the rest of the team works. So that kind of has happened over time. I’m more soft and chatty and talk a lot, and sometimes the message gets lost in all the chat and the key is a lot more direct. And I think to be a leader, you need to be more direct. You just have to be very clear and then you have to follow up with it in written words. I lead my way, I’m very much a team builder. I’m very collaborative, but I think Nikita is much better at getting things done. Does that answer your question?  [Jaz]It does. But then what is the most difficult scenario you’ve had surrounding staffing and people management? Can you share a story that might shed some light to these difficulties that one must expect to face if they own a practice? [Shabnam]I think it’s just I have high standards. Like, I’ve had nurses in the past that don’t want to perform to my standards and I don’t wanna come down to them. So I just say, “This is what I’m expecting.” And then I go, “This is what I would like you to do.” I probably think the hardest thing for me is making time to have those conversations. You need to have them regularly. You need to document them. That’s the hardest thing I find.  If you document things, well then, from a HR perspective, everything is easy. because everything’s been documented. You’ve given them opportunities and things like that. Nikita laughs at me, she’s like, “Whenever we have a problem in the practice, I’m like, oh, isn’t it great that happened?” And she’s like, “What do you mean it’s great That happened?” And I said, “Well now we know how to deal with it.” She’s like laughing. I’ve always happened to see the good side in everything that happens to me, even if it’s terrible. So I think that’s why I’m struggling to find a particular terrible thing. Because I don’t feel anything.  [Jaz]I think it’s because, like you said, you know, hiring and firing and the fact that people don’t meet your standards. But then again, you use that as an opportunity to grow and systematize or improve the protocol so that you know something never happens again. And so that’s a lesson in itself. I wanna talk about the Forever associate, because that’s a trend I’m seeing. I’m a fan of it obviously because and I’m in that category where I’m like, I’m happy to be an associate. I went through that period that you discussed earlier in the episode whereby I was very happy working in Summertown Oxford. Beautiful practice, lovely patients, I loved it there. I was looking for a property to buy near there. Me and my wife were gonna move there kind of thing, but a corporate took over, and everything turned to sh–. It just went upside down.  The culture was lost, it just sapped out all the energy. I was miserable. I went from absolutely thriving and happy to miserable. The clinical dentistry, I was still the same, but the environment and the culture shifted so much that I had to leave. But I’m very good at making, like I said, quick decisions. I recognize, okay, this isn’t for me anymore. I moved on from there. And so I like the idea that you said about the whole security and protection for any associate. We are left vulnerable because the day the practice gets sold or changes hands, you are not in control of that anymore. So I completely respect that you said that. However, there is a very happy cohort of associates who earn well, they get home, they don’t have to worry about the light is not working or the suction pumps.  So that’s not working a recurring theme in our practice at the moment, and they can just not have to worry about that aspect of running the practice. The patients are pretty much given to them, although nowadays associates are really good at bringing their own patients in. What advice would you give to these happy associates. Do you think they should change because you strongly feel that everyone should have a business? What are your thoughts on that?  [Shabnam]So I would say I became a better associate once I became a principal. because I can see both sides now, and I understand the challenges a principal faces. I also can see the opportunities. So when I went back as an associate, I was different. I printed my own price list, I organized my own open days, I promoted myself in a way that I never had before. I just kind of sat there and expected things to come to me. I just do whatever was there. I was a bit more proactive thinking, actually, no, I have more control over the situation.  I can make it even better, I can improve things here. I can improve the materials and the equipment. I always have brought my own equipment anyway, but I brought more things that I like, things that I didn’t wanna be without. So I felt more happy as an associate because my clinical dentistry was beautiful. It doesn’t matter where I’m doing it. So I’m a better associate because I became a principal saying that if you’re a forever associate, just be happy with it. I think a lot of people just wish they, “Oh, I should do this, I should do that.” That dentist I mentioned that bought the lovely house and had the baby at the end of the day, maybe practice ownership at that moment in time wasn’t right. Maybe it will be in the future, like be open to it, but don’t say definitely no, but don’t say definitely, yes.  Maybe you’ll be an associate forever and that’s gonna be the right decision. I think you need to know what your priorities are in life, and then you have to see whether the practice ownership aligns with that. And if it does, you do it. And if it doesn’t, you don’t and you’d be happy with it. I think people regret things too much and I think you just shouldn’t be happy with what you want and don’t feel you have to compare yourself to other people and do what others are doing.  [Jaz]I think there’s totally a place for the Happy Forever associate. However, one thing I will say is that, I agree with you that you don’t have to have a practice, but one thing I strongly believe in as a personal value is that everyone should have a project or projects on the go. And so I never really resonated with the term goals. People always say, Hey, Jaz what’s your goal with Protrusive?  And I’m like, “I’m just enjoying making content and serving and making dentists fall in love dentistry again.” But what is your goal? And then I never understood that until I read the book Psycho-Cybernetics by Maxwell Maltz. And a lot of people don’t get it when they say goals. But then he said if you switch the word goals for projects, suddenly it makes sense to you. And I’ve always had projects. So Protrusive started as a project. Now I’ve got Intaglio making mentorship accessible to all dentists. I’ve got the education, I’ve always got these projects on the go. So even if you are a happy associate, I feel as though to have something that you can call your own, something to build on. Now this could be a gardening, a really good gardening project. It could be that it doesn’t have to actually make you money or anything, but having projects on the go, something to really think about, something to pour your love and energy into. If it’s a business, great, that’s amazing as well. But I’m a big fan of everyone having projects and not just staying stagnant, always having something to work towards. [Shabnam]Definitely, and I think you said it really well because that’s what I’m saying. You shouldn’t just be a dentist, you should be a person. You should have hobbies, you should invest in your health. I was working five days a week. I cut down to four, and on that fourth day I said, I just wanna improve my clinical skills. I’m not quite sure how I want to do it. I did a course with a guy called Richard Porter, and he was– [Jaz]Legend.  [Shabnam]Yeah I think it was a registrar at the time at St. George’s. He said, you should apply for the clinical assistant job. I was like, okay. So I did. I didn’t get it the first time. I got it the second time, so every other Monday I used to be on the restorative department with him and Peter Briggs, and Peter Briggs was actually assisting me do an endo with the microscopes. Crazy.  [Jaz]Wow.  [Shabnam]And it was a great experience clinically, I wasn’t getting paid for it, but I was investing that time in myself for clinical skills. I could have paid to go on a course. On the other Monday was my mom’s day. I used to take my mom out, shopping, doctor’s appointments, whatever. So that was my project to keep my mom well and happy and to also improve my clinic. And I think you can do both. But I did it by reducing the clinical day, but I cut down from five to four. What was interesting, my income didn’t change.  [Jaz]Oh, I hear that all the time. You know, people always say that you can go from five to four to three and a half, and income stays the same. And I think the reason for that is because you’re more focused, you have more energy, you can actually put more thought into it. You can treat and plan better the clarity that you have. And also by the time that you get enough experience to be able to do that, you already have stability in your books and you are able to offer treatments that are more refined and bigger treatment plans for the sake of the fact that you’re doing more comprehensive dentistry. [Shabnam]Yeah. [Jaz]You’re diagnosing better.  [Shabnam]And also I think you just decide to identify something that you’re not good at and maybe just work on it. So for me, public speaking was an absolute hated, it just felt terrible. I read, didn’t know what I was saying, just terrible. And so I started talking to school kids. I see kids when it’s too late, I take teeth out. I get really upset by preventable disease. It just upsets me. So I said, right, I’m gonna go to all the schools because none of the kids could get NHS. I said, I’m gonna teach them preventative dentistry. So I did. So I started talking to nurseries and I talked to like 15 kids and I told Nikita and I said, “I wonder, it would be great if by the end of the year we could speak to a thousand kids.” So I was like, right, let’s do it. So it’s like a mini project like you said. So we started to contact some on nurseries, some more schools, and then Nikita accidentally booked me an assembly. So from going 20, I went to 180. And Jaz by the end of the year, I spoke to three and a half thousand kids.  [Jaz]Wow.  [Shabnam]And when people say, how did you do that? I was like, I don’t know, just I didn’t know how, I just wanted to speak. That’s all I wanted to do. And by doing that, I got more confident speaking and then I just started putting myself out. Then just trying to do these other things where now that’s not a fear for me more. Now I feel confident speaking anywhere I go to the Dentistry Show, podcast, whatever. I’m happy anywhere now.  And now I’m thinking, what should I do next? And you know, that’s kind of just ticking things off. I wanted to be better at swimming. Seven years I’ve been saying I wanna be better at swimming. I wasn’t actually doing anything about it. This afternoon, I have a swimming lesson with my son. He is the best cheerleader for me. He’s like, mommy, you’re doing really well. Because he is the one that told me, he said, well, if you wanna be better, you have to practice. I went, you are right. I do. And you know, so I think of inclusive parenting a lot. I don’t think it’s work and my family like they’re separate this or that. It’s this and that. I do an open day, i’m designing a poster. I ask my daughter, what do you think of this poster? She’s a great critic for me. She’s got great taste, and you don’t realize that they pick stuff up. Like my daughter, she’s 13 now, but when she was in primary school, she set up a slime business. So I want to set up slime. Okay, so I’ve bought her, I’m investing 20 pounds of materials, and you start the business. But Jaz she made a logo, she figured out her price list, she did upsells. She had these little  [Jaz]That’s amazing.  [Shabnam]Yeah. She made different colors, she centered them. She made only certain number of certain colors because she knew they were the most popular. I’m not joking. The day of the sale parents were coming to my house with cash in an envelope to reserve colors before the sale.  [Jaz]That’s amazing. What amazing life lessons entrepreneurship. You’re, you’re treat, you’re, you’re teaching your daughter– [Shabnam]Profit. I was like, what? This is really, I’m not doing it anymore. I was like, well, you’ve got a good business. And she’s like, I don’t wanna do it.  [Jaz]What an excellent experience.  [Shabnam]How did you learn to do that? And she said, oh, I just know. But she didn’t just know. She’s just pick stuff up over time and just, you know, so you become a role model and they think things are possible. So you need to be a role model to your kids. Even if you don’t have a practice, you can be a role model that you can renovate your house or whether you just become good at cooking. My husband couldn’t really cook that much, and now he does nothing’s fixed. You can always be better at whatever you want to be better at. [Jaz]It’s having that growth mindset, everything you’re saying is totally revolving around that. And I love the fact that you involve your children in what you do. That’s amazing. And going swimming today and having that quality time again, it’s quality time with your child, which is great. And so let’s touch on parenthood.  A lot of times when we’re having children, my wife was pregnant and I’m starting this business. Or I often hear, oh, we had our third child the same week we bought our second practice. I hear this all the time. So we’re at that age where you’re having kids and then you’re also starting new businesses, new ventures at the same time. So it’s never easy. It’s all these, you ebbs and flows and fantastic highs and terrible lows and that kind of stuff.  What advice would you give to someone who has identified. Themselves as, okay, I think I want to do this. I want to become a principal. But they’re worried about juggling that family life. I know we touched on it earlier, but any other concrete advice you wanna give to someone who wants to juggle parenthood? Any advice you can give them with practice ownership?  [Shabnam]Yeah. So you can only control what you can control and when a practice becomes available to buy or Squat Practice, you can’t control that. So you’ve got to decide like, do you put your life on hold because of something that may happen in the future? It depends how big a passion it is for you. How much of a priority is, if it’s a massive priority, you’re just gonna make it happen regardless.  So I think be really honest with yourself about what your priorities are in your life and that will help you make the decision. And life just happens. You can plan everything. I think sometimes it’s scared to get things wrong, and I’m like, you’re going to get things wrong just accept you’re gonna do things wrong. It’s okay. And as soon as you let go of the fact that there is no perfect time, like I know someone that bought a practice and then got a problem in his ear and then couldn’t work for like eight weeks, he had to have surgery, couldn’t work. Why you owning a practice and not be able to work for eight weeks? You don’t plan that kind of stuff but it happens. You just have to have the mindset that whatever happens, you’re gonna manage it, you’re gonna do the best you can, and what more can you do? And you have to be honest, sometimes practices don’t work out and that’s okay. But if tomorrow anything happened to my practice, I like say I still pinch myself when I walk into my practice. I still can’t believe it’s mine. You experience something, it’s never taken away from you.  It is just a foundation that you’re gonna build on in the future. And you build more things or different things based on that experience. So business side is hard, but you need to identify what is it that you really want in life. And I think that’s the reflection that everyone should do earlier. because you can actually just be at peace with yourself. And having kids and like we found the practice, Nikita was nine months pregnant.  [Jaz]Like I said, always the way when I hear it. Well, you mentioned on the business, this final chapter of this podcast, let’s talk about money. You know, how much cash in the bank should you have before even thinking, okay, I’ve got enough that I’m gonna take this risk. How much do you potentially need to borrow? Obviously everyone’s financial backgrounds and scenarios and bank of mom and dad and all that kind of stuff can factor, multitude of ways. But like what kind of anchor could you give to someone who’s perhaps a young dentist and has no idea? Like at one stage you probably had no idea how much money is enough.  [Shabnam]Yeah, totally. So I laugh, Jaz when people say, how much does it cost to set up a squat? I laugh because it’s completely the wrong question to be asking. The reason I say that is, is because how much your practice is gonna cost depends on you, depends on what kind of practice you wanna have, what location you wanna set up in. Do you wanna have a corporate, do you wanna single practice? Like it depends on you. What is your vision?  If you are happy with a very cheap chair and minimal materials. Your costs are gonna be very different to mine. I could have done a two surgery practice when I set mine up. I chose to do one in the end because I wanted the nice chair and I wanted the thick Corian Surface. I wanted a really nice finish. So everyone has a pot, and how you allocate that pot is up to you. So if you’re gonna be setting up a squat. You’re gonna be putting down at least 30% deposit. Okay? If you’re buying a practice, it’s 10%. Now how much you’re going to borrow and how much does it cost to set up a squat? So squat, roughly two surgery, squat costs between 250 to half a million. Now you’re gonna be like, that’s a very big variation. [Jaz]And is that a freehold or– [Shabnam]No lease hold. Just the, okay. Yeah. And the thing that dictates the cost of the practice the most, the biggest deciding factor for cost for a practice build is the location. Like if it’s listed building, if it’s over two stories instead of one’s floor. What are the supplies like electricity, water, pump, piping, things that you don’t even know about, that kind of stuff. If the logistics for the supplies aren’t there, you have to bring them in. That’s gonna make it expensive. I know a practice that was on a hill and they had to pump the water up, and that pump was a massive issue for them and it increased the cost a lot. I spoke to a dentist who’s very competent and he messaged me when he was thinking he was setting up his squat and he was in the process of doing it. And I met, touched base with him recently, a year or so later, and it took him over a year to set up the squad. And he, initially, he was thinking it was gonna be about 270. In the end, it cost him over 350 And I remember the end, he was like going, do I really need to buy an ultrasonic bath? And I was like, come on, do not cut corners now. But at the end point you’re like, how much do I spend on this sofa? How much do I spend on pens, and paper, and printers? And there’s a lot of things you forget because there is no checklist, like I said. So there’s a lot of things you need to factor in. The biggest thing I would tell everyone on this podcast to do currently is find out how much you can borrow. People are asking how much does it cost to set up a squat?  But how much actually can you borrow? Like if your budget is only going to give you like 300, then you wouldn’t consider anything more than that. So it’s almost like when you’re buying a house, go to a broker, give them your initial financial figures, get a kind of mortgage and principle, find out roughly what they’d be happy to lend you, and then that’s your budget. And then you kind of shop accordingly. And if that budget doesn’t align with your vision of the practice you want, then you need to do something about your income.  [Jaz]Great. That’s it. I’m very happy with how to think about that. I hear all the time that when those who choose to start a squat or a brand new practice, because of how long it takes, could take six months, it could take a year, could take longer. They’re working as an associate while that’s being done and they’re visiting the project, visiting the site, and overseeing how it’s run and stuff.  So people need to bear in mind about that sort of transitional period where you’re kind of working an associate while the squad is being developed. So any advice you can give on that, but then also the numbers I classically hear for the first one to three years, you’re working like a dog, you’re not making any money, you know there’s no profit yet, and thereafter, then it starts to grow. How true is that based on your experience and the experience of those in your network that you know?  [Shabnam]Yeah. So you have to be realistic about what you can manage. And also time is money, and also expertise costs money. So as I mentioned earlier, you have above cash and you decide how you spend it. So I decided to do compliance myself, which meant I did the entire CQC application myself, I filled in the forms, agonized over it, did everything myself. But by doing that, I saved 3000 pounds and then we spent that somewhere else. Someone else might choose to pay someone to do that all for them and then do it that way, and that’s totally fine. So I think you need to know what your skill sets are and what you are happy to take on board. Also, I know people that project manage practice builds and like this guy, it took him over a year to actually open up. So if you think of his time that he spent managing it, all the decisions, all the things, I got an all-encompassing company to do my practice for me.  So they designed it, built it, they project managed it. I was realistic. I’m a mom. I’ve got two kids under 4 I’m working as an associate. I don’t particularly like dealing with builders myself, and they’re smart, they choreograph things, they get the electrician on the right day, they get the chair delivered on the right day because of their network and their contacts. I was able to order my chair before I even had my lease, before I even had my finance.  They’d already pre-ordered it for me. because they knew it might not happen. Like if we didn’t get the loan, it would’ve ended there. So they had faith in me and I trusted them and they did a fantastic job. And like I did, they did my build in eight weeks. And then the thing that took me longer was the CQC inspection. I did it and they had to wait for the paperwork to come through so we couldn’t open until we got the certificate.  So I prefer to pay experts to run the project for me. Others may choose to use local builders and manage the project themselves and learn about the regulations and take on that responsibility. It depends on you as an individual what you are happy to do. For me, outsourcing it was the right answer, but for others they wanna do it the slow way. Save money, do it on a budget, and it’ll take longer and that’s okay, but time, I’d rather have the practice open quicker myself. And in terms of profit, so I opened up my practice. I think the first month that we were profitable was probably around month 15, 16.  [Jaz]Okay.  [Shabnam]And then at month 17, COVID happened.  [Jaz]Oh my goodness.  [Shabnam]Month COVID happened and then we were closed four, five months. Like I said, I wasn’t clinical because my son was shielding and we had one surgery because I decided on that lovely Corian and the one chair, which I regretted because now I need a follow time and, and another chair quickly. So in the end we didn’t take money out of the practice. We actually installed surgery too during COVID, which was another, I think 60 grand or something. So we had to put money in, put surgery two in, that made the practice run better. And now we are still currently a two surgery practice, but we are planning to do phase three soon and we’ll open up the third room and yeah, I think what you said is realistic.  One to four years you do work like a dog. It’s hard work. I only do two clinical days a week, but I’m working full time. But I like what I do. And I enjoy having a team and when I read my Google reviews, it just fills my heart like it. I feel like it bursts. It just makes me so proud. And also I can give dentists the environment that I wish I did have, but not just the mentorship, but also the environment in which to do it. So that’s what I love providing for my team and my patients benefit from it as well because I don’t do it all myself. I can’t do anything without my team. My team are everything to me, and I’m very grateful for them.  [Jaz]Well, as I say, opportunity comes knocking. The problem is address it, overalls, and it smells like hard work. And we all have to, you know, put our graft in. Okay. If it’s something that worth having, it won’t come easy. There’s gonna be a barrier of entry. So knocking worth having comes easy.  [Shabnam]Yeah. People feel frustrated, and they feel stuck where they are. And if you feel frustrated and stuck where you are now, what I’ll say is you need to take action. You’re not a tree, you’re not stuck where you are. You can do something like you were in your practice in Summertown, you can move. It’s stressful moving jobs it’s not easy, but you knew that was the right thing to do. So taking action isn’t always easy. [Jaz]And same with you. You are proactive in the sense that if you just remained reactive and waited for that practice to come available, then you’re very proactive looking at practice. Yes. It took five years. Okay. Which is mad. But then again, you know, it took my wife eight months to decide on our sofa, our home sofa, had no sofa for eight months. Right.  And so the reason why me and my wife would never make good practice owners because I’m very quick at making decisions, but I don’t wanna deal with any compliance. My wife is very slow at making decisions. Which is why when she wants a new car or something, I was like, that sounds great. And she’ll never actually buy one. Okay. So, which is great. So it actually works out. But yeah, I think you’ve gotta understand yourself.  [Shabnam]Yeah. Can I tell you something? You know that practice that I did VT in he still hasn’t sold it.  [Jaz]Okay? So there we are. You have to be the captain of your own ship. You have to take matters in your own hands, and I think that’s a big lesson that we can have from Boss Lady today. Shadnam thanks so much for spending time with us today. Where can we learn more from you? How can we find out about your coaching? How can we find out about your education? How can we follow you on social media? [Shabnam]Amazing. So yeah, you can go to shabnamzai.com and follow on Instagram, Dr. Shabnam Zai and I’d love to have a chat with any of you.  [Jaz]Amazing. Well, I’ll make sure I put those links in the show notes so everyone can check it out. And you know, you obviously are very experienced in the sense that you’re actually thinking about this. You’re actually helping people about this. I think it’s great that you shared what you did on here, and if anyone wants more, you make a great mentor for them, please do register yourself on Intaglio where we have a database of mentors and people might wanna book you one-to-one as well as maybe doing your sort of coaching program. So do consider making a profile on an taglio.  [Shabnam]Okay. Amazing. Thank you, Jaz  Jaz’s Outro:Well, there we have it guys. Thank you so much for listening all the way to the end. How are you feeling? Do you think like practice ownership is for you or maybe like me, you hate some parts of it so much that it may be never right for you. Maybe you are happy as an associate like I am, but to remember guys, I have projects. I always have projects in the go. Being the best dad in the world is a project of mine. Honestly, it’s a big part of what I think about how I plan my day. I take my son to swimming. Cricket, we’re thinking of maybe starting coding on Wednesdays. Like there’s so much I do with my kids and that for me is a really important part of my life and if I had a practice, I don’t think I can maintain it at the level I wish to. I was actually at dinner with one of my best buds, Clifton. I was speaking at the Dental Tubial Study Club at In Brighton about TMD for GDPs. And I said to Clifton that if Protrusive could grow and grow and grow and become like on the level of let’s say, spear education, ripe, global, all those big names out there, but if my children hate me, then that is a total failure. That is not a success.  If Protrusive goes completely, capoot goes bankrupt, and all the hard work we’ve done over the years goes to the toilet, which we very sad indeed, but imagine that happened. But my children absolutely love me and have a very strong, unbreakable relationship with them. That to me is success. And so whilst I do think I’d make a good leader and I’d run a practice like a very well-oiled machine, I’ve chosen other priorities now.  And that’s not to say that you can’t be an amazing mother. You can’t be an amazing father. But certainly you can imagine, guys, you guys are already saying to me, Jaz how do you balance everything? And it’s because I know my limits. I know that I’ve got all these wonderful things we do with Protrusive and Intaglio all the courses. Being a clinical dentist, I do 18 hours of clinics every week, and I love it, but I can’t possibly run a practice because I’m loving what I’m doing already. And as you heard earlier today, where there was a phase when I wasn’t loving what I was doing because the corporate took over. I was very quick to make a decision. I was very quick to move. So if you’re looking in the mirror and you’re not happy with the person you see, you’re not happy with the environment that you are in, you feel that you’re not progressing, you are staying stagnant. How about that change? How about some soul searching and what a wonderful job Shabnam did today? So please do check out her website and her educational ventures. I will put them in the show notes below. Thank you Shanan for inspiring everyone, and thank you once again guys listening all the way to the end. If you haven’t hit that subscribe button, please do. If you know a buddy who really needs to hear this episode today. Please send it to them. Put it in your Practice WhatsApp group. I’d love you forever and ever for it. I’ll catch you on Protrusive guidance. Don’t forget the quiz to get your CPD. Thank you so much, team Protrusive. I’ll catch you same time, same place next week. Bye for now.

Are you living your career by design—or just letting it happen to you? Do you know what your ideal day as a dentist looks like? What about your ideal week? In this episode, Jaz is joined by Dr. Andrea Ogden to explore how you can design a career—and a life—in dentistry that feels purposeful and fulfilling. They dive into why many of us get stuck on autopilot, chasing goals we’ve never truly chosen, and how to break free by aligning work with your values.  Andrea also shares practical techniques to help you fall back in love with dentistry, so you can build a career that energises you—inside and outside the surgery. https://youtu.be/XDxlUFeEpbw Watch IC060 on Youtube Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 00:00 Teaser 00:21 Introduction 04:49 Guest Introduction – Dr. Andrea Ogden 06:05  Andrea’s Journey in Dentistry 08:51 Pivotal Moments in Dentistry 14:51 Trial and Error in Career Development 15:51 Current Role 16:59 Identifying Strengths vs. Enjoyment in Dentistry 18:18 Challenges for Young Dentists 21:51 The Importance of Career Awareness 24:05 Impact of Social Media 26:57 Understanding the Decline in Dentist Morale 31:51 External Factors Contributing to Stress 35:09 Internal Factors and Cognitive Dissonance 41:17 Practical Steps to Reignite Passion for Dentistry 47:32 Resilience Through Adaptation 48:59 Community and Support Networks 51:46 Enjoying the Journey 56:30 Outro Key Takeaways:  Dentistry is more than fillings and crown preps—it’s a career you can shape to truly excite you. Choose Variety & Joy – Build a mix of roles that energise you, not just ones you’re good at. Ditch the Comparison Game – Your journey is unique; stop measuring it against 15-year veterans on Instagram. Guard Your Values – Burnout often comes from a mismatch between what you believe in and where you work. Align the two. Create Space to Reflect – Slow down, think, and use SMART goals to plan your next step.  Find Your Tribe – Mentors, colleagues, and community will keep you inspired and resilient. Celebrate the Wins – Small or big, they’re proof you’re moving forward. Loved this conversation? You’ll also enjoy Passion and Values in Dentistry – PDP014 #CareerDevelopment #InterferenceCast #BreadandButterDentistry This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes  B: Effective management of self and working with others in the dental team. C: Maintenance and development of knowledge and skills within your field of practice. D: Maintenance of skills, behaviours and attitudes which maintain patient confidence in you and the dental profession, and put patients’ interests first.  AGD Subject Code: 770 – Practice Management and Human Relations Aim: To provide dentists with strategies, insights, and practical steps to rekindle passion for dentistry, align their work with personal values, and develop sustainable career satisfaction. Dentists will be able to – 1. Identify personal values and career drivers that contribute to long-term job satisfaction. 2. Recognise common stressors affecting dental morale and their underlying causes. 3. Apply structured decision-making frameworks (e.g., SMART goals) to career planning. Click below for full episode transcript: Teaser: There's a definite difference between doing more of something or because you are good at it and doing more of something because you enjoy it. You know your values are a compass. As to, you know, where you are gonna go in, in, in life. I think if you are listening to this conversation and you are really struggling, is that the first thing you need to do is you- Jaz’s Introduction:Hello Protruserati. I’m Jaz Gulati and welcome back to your favorite Dental podcast. This is the interference cast, like the nonclinical arm, but a very important arm of the podcast. One of the things that Andrea mentioned, is that when she was studying in dental school, that’s what it was all about. It was just about studying and becoming a dentist and passing your exams, and I resonated with that so much because our date was 6th of June. I knew that on 6th of June 2013, we were gonna get our results.  And I could not imagine life beyond the 6th of June. Like it was all about am I gonna become a dentist? This is what I’ve been building up my last sort of eight to nine years to do. Like I wanted to be a dentist since I was 14, but I couldn’t even think about the future and what it will actually be like to be a real dentist in the real world. Now, fast forward so many years, I have a lot of real world insight and I’d love to share it with you today along with Andrea. I love people like Andrea because they are all about helping us feel fulfilled in dentistry.  There are plenty of people out there who perhaps dentistry didn’t go the way they planned. They leave and now they want to coach you on your exit plan, which I understand, but what I don’t believe in is making permanent decisions based on temporary feelings and actually attempting to figure out exactly how to make dentistry work for you. Now, some things I didn’t discuss in the conversation with Andrea, because she was on a roll and I want to give her the space and time to talk about all the wonderful things, including the latter part, the end of the podcast, whereby she actually gives real techniques, is about five techniques she shares to help you feel more fulfilled from dentistry. But one thing I wanna just talk about while I have this opportunity in the intro is the following. Have you actually put pen to paper to write down what your ideal day actually looks like? Like you are actually allowed to have an ideal day. Have you thought about it?  I didn’t do this until a few years ago, and it made a big difference to my clarity of thinking and where I want to take my career. And the other one, of course is what does your ideal week look like? Once you’ve decided what your ideal day and ideal week looks like, then make that your goal, that’s your aim.  Why wouldn’t you make some decisions right now to make your ideal day and your ideal week become a reality. For example because I think examples really help. I’m someone who if I don’t exercise at least three or four times a week, I don’t feel like I’m living to my truest value. I become grumpy I don’t feel like I’m enjoying my life as much as I could be. And so I know in my ideal week I need that.  Now, I’ve had a few years in my career where that wasn’t happening, especially when we are building OBAB that was such a huge project. I had to wrongly sacrifice some health for that. But now I’m back on track. And so slotting that into the ideal week for me is really important, and you make it work and you make some key life decisions. And something that you do with your significant other, you decide that you design your perfect life how do you actually want it to look like, where you’re gonna live? What gym membership will I will have to make sure this all happens. And so it’s about living a life of purpose, allowing you to live to your truest values. And that was just one example of me making sure that I designed my ideal day and my ideal life to make sure I get to go to the gym 3-4 times a week. Another thing that was important to me is like I’m someone, I’m not good at multitasking. I think most, most of us aren’t, and we shouldn’t be multitasking. It’s better to focus on one thing, and I’m particularly bad and like sometimes I get distracted and I feel like really overwhelmed easily. And so when I’m in clinical mode, I’m in clinical mode. And because I love my clinical dentistry, it’s not a big deal for me to do a 12 hour shift. I know it’s not for everyone, but I’m more than happy to do an 8:00 AM till 8:00 PM if it means I can work less days. So for me that made perfect sense that I have a really long Monday and now I don’t have to work a Thursday anymore, for example. And this has only just come to fruition. It’s something that we agreed on about a year ago, and then we had to wait for my Thursday patients to diminish, if you’d like. And now I really consolidated my clinical days. This allows me to be in the zone on Monday. And whilst I don’t get to see my kids much on a Monday, I get to make up for it on the other days. because now three days a week, I get to do either school drop off or a pickup, or both. And the main point of sharing this detail with you, my friend, is that everything I’m trying to do is with great intention, it’s on purpose and it’s by design. And it doesn’t happen overnight. It actually took a discovery process first, and then you put your action plan, and you relentlessly chase that. And that ideal week may look different for everyone. But if you don’t decide what your ideal day or ideal week looks like, then you’ll never get it. If you don’t know where you’re going, how do you know when you’ll get there? Alright, that’s quite enough of my rambling. I’ll catch you in the outro. Enjoy, enjoy, enjoy this podcast with Andrea. Main Episode:So Doctor Andrea Ogden, it is absolutely a pleasure to have you on Protrusive Dental Podcast. How are you?  [Andrea]I’m very well, and I’m very excited to be here. So thank you so much for the invitation to come and talk to you today.  [Jaz]For those of you listening on Spotify, Apple it’s a sunny, beautiful day today in the UK for once. And Andrea’s looking bright and vibrant and that would really, I think be a great descriptor of some of the content I’m seeing from you, Andrea. And the top word I’d probably say is relatable. I reached out to you because I’m loving what you’re putting out to the universe. So much of the podcast over the last six years. Our tagline is Fall in Love with dentistry again, and I’m very much, when I do some speaking, I say, find your niche, find a way, and fight for it to make dentistry work for you. And everything you’re putting out there is just, I’m loving it and I think we can learn so much from you. And often with these kind of episodes, Andrea, I get so many messages saying, you know what? I really need that and that’s what I want everyone to achieve. And so to start with, Andrea, I wanna learn about your journey because you do reference your journey a lot in your posts and stuff, and I think you’ve got a really interesting one. So can we start with that, Andrea, and tell us about yourself?  [Andrea]Yeah, sure. I think if I’m gonna talk about my journey, it’s hard to kind of think, well actually, where do we start? And the reality is that I probably need to go back all those years to when I filled out that UCAS form, when I was doing my A Levels. And, I feel like there’s four places for the picked four random dental schools that didn’t really put a lot of thought into it. Just was like, no, I really wanna be a dentist. It’s the only way I’m gonna be happy and I’m gonna find fulfillment and achieve my potential. I sent the UCAS form off and I didn’t even get a single interview. So I was like, oh so it wasn’t like I got rejected, like not offered a place, like they didn’t even wanna interview me. So, I think when I look back at the fact that that happened and I went and did a degree in human biology and then applied again, I was successfully offered a place. But I suspect, in fact, I know that that failure right at the beginning, definitely played a part in many years while I was at dental school. There was definitely this fear of failure that I might not make it, that I wasn’t gonna graduate, that I might get thrown out. And looking back that was crazy because the pass away exams, but that fear was definitely there. And so for many years it was all about becoming a dentist, rather than giving much thought into what it would be like once I became a dentist. And so, that plus the fact that I don’t come from a medical or a dental background. I don’t have anybody to mentor me or explain the realities. I did a bit of work experience and obviously, you learn stuff where you’re at dental school, but I had no idea. And I think looking back at that time at dental school, I don’t have any memory of getting any careers advice or, even being given any kind of skills about the opportunities that are available to you once you have a dental degree. So when I graduated I think I was just kind of like, “Oh, okay, so now I’m gonna do what everybody else does. Which I’m gonna go and do well, it was vocational training when I did it, and then I got myself a nice little associate job and I really thought that if– [Jaz]MFDS and all that kind of stuff  [Andrea]Yeah. Did all of that, it was tick box exercise.  [Jaz]Yes, yes, yes.  [Andrea]Everybody does this, I must do this. And I really thought that what if you are a successful dentist, then you earned a practice. So I needed to acquire the skills that you need to manage a business, which you weren’t taught at dental school. So I was like, okay, so this is the plan, this is what I’m gonna do. And there were definitely a couple of key pivotal moments. The first one I remember when I was an associate probably, few years in as an associate. And I just had that moment where I was like, is this it? Is this what I’m gonna be doing for the rest of my working life? Being in this one room, working with a nurse and the patient and then I just had this sense. I had so many more skills and potential, that I hadn’t tapped into. And that clinical work in general practice alone was not gonna enable me to do that and to grow in those things. The second thing was when I had an offer accepted to buy a practice, and at the time I had a seven month old baby, I was driving, but this moment so clearly I was driving down the road, my seven month old baby in the back of the car. It just hit me how much additional responsibility I was about to take on. My husband’s not a dentist, my family aren’t dentists. There was that moment where I was like, hang on a minute just stop and think about this. This might not be the right choice for you, why are you doing this? Are we just ticking boxes because you think this is what you should do? Rather than what you actually want to do, or need to just take some time to think about it. And that really did set those two moments. Definitely set up a chain of reactions, chain of events that made me evaluate not just what I want out of my career. I want out of my life.  [Jaz]Andrea, did you go ahead and buy that practice in the end? Or did you make a decision that actually this isn’t for you after all? [Andrea]No, I made a decision that this wasn’t for me. I think the sale was likely to fall through anyway. We were literally at the very early stages. And then, something came up with bank valuation, all that kind of stuff that I was like, “Actually, no, this is my chance to get out, this is not the right decision for me at this time. Let’s just stop and let’s just think about this and take some time and work out where it is that we’re gonna go from here.  [Jaz]Have you read the book, the E-Myth or the dental version of the E-Myth?  [Andrea]No, I haven’t. But I’m gonna make a note of that so I can definitely reach it today. [Jaz] There’s so many things that you’re saying there because it argues like, for example, that yes, let’s apply to dentistry, but like one step back, and not even related in dentistry, but it gives an example in the generic book The E-Myth Revisited. It gives an example of someone who just loves baking. They’re just amazing at baking.  And then everyone says, “Look, you need to sell your goods. Your baking is the best, you need to sell.” And then eventually she opens a shop, and then she’s there like 5:00 AM, baking and stuff. And then she’s there serving customers. And then it grew and it grew. And then eventually she’s not baking anymore, she’s just doing the account. She’s managing people, she’s doing this. And the thing that she was in love with, right? Which is the baking. She was no longer doing anymore. And so that is like the the technician. Then we also have the manager and the entrepreneur. So these are three different roles, and as dentists, we get shoehorned into playing all these three roles.  As a business owner, you’re like the entrepreneur, you also become a manager, and then you also a technician. You still have to do the implant, still have to do the orthodontics, you still have to do what is very challenging work, and this can be a real source of burnout and stress because you’re trying to wear so many hats and everything is like brand new and like you,  Andrea, like I think very few people are fortunate enough to have clear mentorship, whether it’s family or close colleagues that they can rely on. A lot of people are just making up as they go along. And that’s scary. So what did you do thereafter when you decided that okay, a really good judgmental moment for you, really good insight that you had, potentially a good insight where you decided that this isn’t for me. How did you pivot from there?  [Andrea]I think the first thing I looked at was: What was it that I really enjoyed in dentistry? And I got into teaching very early on because my first associate job was in a foundation training practice. So the FD was often coming in. I wasn’t their trainer, but they’d often come in for a chat. I’d help them get bits of teeth out, find canals, and I got a kick out of it. I realized quite early on that to be part of somebody’s journey is a huge privilege and even if you’re just a teeny, tiny bit. So I think that was always kind of there and I thought, “Actually no, I need to do more of this. I’ve done my postgraduate certificate in dental education. I applied to be an educational supervisor in my own right. And then naturally it was kind of, so that was kind of already going on in the background and it was that moment actually after being in the car with my eldest. I was like, “Okay, we need to look at how we can take this further.” And around the same time, there was a job that came up to be a training program director in the East of England. And I didn’t think I was gonna get it, but I was like, I have to apply for this. Like, we have to see where this can go. And you know that was at that point. That was definitely, the biggest pivot because that changed my working week. I went from being five days as a clinical associate to actually doing three days and then two days was involved with foundation training and that kind of initial variety, that increased variety in the week and actually having to learn all the different skills of working, within a much wider team and managing budgets and dealing with the trainers and the FDs, all these skills that I didn’t realize actually, I didn’t know I had to acquire those and learn quite quickly. And I was like, ” I really enjoy learning stuff. I think most dentists do. That’s one you sign up to a lifelong commitment of continued learning. Okay this is something else I hadn’t realized about myself. How can we do that?” So it was definitely, as you said, most dentists, they don’t know and it is this kind of trial and error and just–  [Jaz]I think that’s okay, Andrea because I think it’s important to have you need to trial. I always say you need to kiss a lot of frogs before you find your prince charming. And in the context of finding out what your niche is or finding out if you should specialize or not, or finding out, what kind of career you want to have, and sometimes you need to figure out that “Actually I’ve done enough endo to realize I don’t enjoy this, and actually I really enjoy digital dentistry.” Like for whatever it could be. They get a kick out of doing the lab side. They get a kick out of Cerec. In contrast to you that you felt as though that this is not for you to do it for the next few decades with the nurse, whereas other people get a kick out of six days a week working in that room. [Andrea]Yeah.  [Jaz]And they just love their clinical tiny details of dentistry, whereas other people feel like they just want a variety in the week like you. So is that what your week looks like now, Andrea?  [Andrea]Yeah, my week is incredibly varied now. I think because after I finished working as a training program director, I joined the BBA as a member of their staff. Ultimately, that’s really the amount of things, different types of things that I do during the week, whether that is giving talks to foundation dentists or students, whether that is project work. I still work clinically. As a dentist, for me variety was always a key thing that I wanted to tap into. Like you say, for many people, if they absolutely love working, doing that clinical work, then that’s what’s right for you. The point is we’re all different. And it’s about understanding who you are and what makes you tick and why it is that you wanted to do dentistry in the first place, and how can you enable that? And you’re gonna learn stuff about yourself throughout, along the way. Like, I didn’t realize that I like teaching when I started doing dental school. That was the last thing I thought about. So you discover these things that you are like, “Okay, well that’s good. How can I, how can I do that a little bit more?” But I think probably one thing I probably need to mention is. I often hear people say, “oh, you need to find out what your strengths are.” Like let’s say you’re good at root canal site, you should do more root canals, I suppose, like your, the baking analogy that you were talking about.  But there’s a definite difference between doing something, doing more of something, or because you are good at it and doing more of something because you enjoy it. Because you can be good at something but not necessarily enjoy it, and therefore that’s not necessarily a strength. So I think the two have to come hand in hand.  [Jaz]I think usually they do, but there are instances where they don’t. But I think sometimes you are, you become good at something because you enjoy it, and then you follow that path, and then that’s the ultimate. You are in a very privileged position, Andrea, in the sense that you’ve touched the lives of main trainees. You’ve had to influence to mold them, to support them, and that’s a really special thing to do. What have you learned from that experience in terms of what are the struggles? What’s the plight of the young dentist nowadays? In what ways some of them potentially feeling not so fulfilled? What’s keeping the mup at night? What would you say to our colleagues listening and watching right now that might be relatable? Kind of like the content that you’re posting out. What are the main challenges we face as dentists?  [Andrea]Well, I think, there’s two main challenges that people have after they’ve graduated and particularly after they’ve finished foundation training. And the first one, I think it’s a very similar experience to what I had, is that if you don’t have the information about career options, you end up just doing what you think you should. I mean, when we look at people that go into dental school. We’re high academic achievers. The vast majority of people have kind of gone through A levels, then they’ve gone into dental school and it’s all mapped out. So if you do very well at your A Levels and you apply to dentistry, you’re successful, then you progress to year one, and then you pass your exams and you progress to year two and so on and so on. And then you do foundational vocational training and then all of a sudden. Unless you do DCT and specialty training, like there’s—  [Jaz]Which is why so many do it, Andrea, I, I think so many are doing it because they feel like, “Well, this just seems like a path and therefore I should do it not with any sort of real conviction or enjoyment of it, or actually a desire to do it other than. I think this is the next step because it kind of is a path that’s already been made, but it’s not necessarily your path. And then some people do it because they’re afraid to go into practice and they’re afraid of the, the, the big bad worlds out there.  [Andrea]Yeah. I think that can definitely, definitely be a factor, especially because you know you’re gonna get more support. Whereas you don’t necessarily know you are gonna get that continued support in practice. I think that is a huge jump to go from that a structure to that autonomy that you have. I mean, it’s hugely exciting the fact that you are in control. You make the decisions as to where you want to take your career, which postgraduate training you are gonna focus on. But because it is such a huge leap, I think it can feel tremendously overwhelming. And again, as you say that can be a factor as to why people choose the more prescriptive route, at least initially, just to, to help them with that.  [Jaz]I mean, I can definitely relate to this, Andrea, because when I qualified, I did the DC- the DF1, then DCT, and then DCT2 because at the time I thought I wanted to go down the specialist route, and so I was keeping my options open. I was keeping my hand in practice at the same time at the Saturday job, so I wouldn’t descale, and then thankfully, that gave me enough knowledge and experience to know that, “Okay, I actually don’t want the hospital pathway for various reasons.” I joked in a lecture the other week that if you had to just convert hostile dentistry into a Disney character.  Then, the sloth from Zootopia, right? It would be that. So for me, it was just like, maybe it’s the way my mind works, I’m like this is all over the place. I need to be quick. And so for me it was like, “Okay, private practice or, OR practice certainly is the way forward for me and I’m glad I look back now. I’m glad I had enough insight at the time and I knew that, okay, this really isn’t for me. I could do it, I’d probably be good at it, but it’s gonna be soul destroying for me to go down that path. Right. And so I felt really confused. I had no idea what to do. Should I join the rat race? Should I do an MSC?  I was considering at the time, I just made a bold decision. Me and my wife moved to Singapore. We worked in private practice there for 18 months and we came back because my wife got homesick, but then I never looked back because it gave me that foot into practice. And I love what I do clinically now, but that was part of my journey of confusion and figuring things out and doing something bold and everyone’s journey is gonna look a little bit different. [Andrea]Absolutely. But I think you touched on the key point: you kept your options open, right at the beginning. So you could gain a maximum amount of information from all of the people that you’ve met, so you could make an informed decision.  And I think that’s the issue that sometimes if you don’t have the options you don’t know what’s out there, then how can you just like when we tell our patients about treatment options, how can you make an informed decision about your career and your life? It’s very interesting. But I think that’s ultimately been one of my big passions through the work, through the BDA is to develop their career hub. Because it used to just really frustrate me that there wasn’t anywhere that you could put all that information in one place about these are all the jobs that you could do with a dental degree. This is what you need, this is where they’re advertised. You know, these are the kind of routes that you can go down if you want to do X, Y, or Z. [Jaz]I was just making notes there, Andrea, because it just reminded me that the whole thing as, as a parent, they say the days along with the years are short. And the other thing the reason I mention that is because in dentistry sometimes you have a really tough day and we think like really small in terms of the timescale but if you actually remember where you’re gonna be now compared to 10 years time, there’ll be a huge difference.  Think five years, think 10 years rather than think just next year. And you’d be amazed because if you, if you think that, if I don’t make this really important decision now, or if I mess up one year, then this could, the end of my career is gonna go down the really bad trajectory. That’s not ideal way to think because that’s not true. You can have a couple of bad years or a bad year or a bad few months, but then whatever that means for someone, I think people will be able to relate to what that means for them. But it’s not career defining because our careers got wonderfully long in a good way, and we get to mold and reevaluate it and reshape it at many checkpoints. Is that something that you think as well? Is that fair to say?  [Andrea]Yeah, I totally agree with that. I think the other thing I’d probably add to that is the fact that you don’t need to achieve these things tomorrow. Like it is, your career is long. And I think going back to your question about the challenges that new graduates are facing you know, I didn’t graduate in an era of Instagram and social media, and I think there’s something called social proof bias, which is in the absence of an answer.  You do what everybody else does. And I think when we are looking at social media in particular, there are some things that photograph a lot better on social media than others. So obviously, you know, cosmetic, whether that’s composite buildups or veneers or smile makeovers, photograph beautifully.  Whereas if you have a picture of a perfectly executed molar endo, it might not gain the same traction. So see the algorithm is, is gonna show you certain things. You’ve also gotta remember about the context of the post. Is that there to educate you or is that there to market to potential patients. And so it makes me think of this famous equation by a guy called Tim Urban that happiness equals reality minus expectation. So if you are at dental school and you are seeing a lot of these cosmetic cases, because that is what is coming through on social media and you think, okay, well that’s what I need to do.  So my expectations are that I’m gonna graduate and I’m gonna be able to do this. But obviously that takes time. That takes postgraduate training, it takes an all sort amount of resource. So when you graduate and you are not there, or you think, “Gosh, I’m so far away from that, then your reality is way lower than your expectations. So you are in negative happiness. And I think that’s a challenge that certainly I didn’t have. But I think I’m seeing that in a lot of new graduates.  [Jaz]Totally agree. And then the next question I had, which follows on so nicely from this is about stress burnout. And I’m gonna say it’s important to address these sensitive matters, but suicide in dentistry, we’ve lost a lot of colleagues over the last few years and we have been for decades. And so. Is there a net benefit of social media in dentistry? I don’t know. I think there’s so much good I see in social media, but comparison is a thief of joy, right? And so we are comparing, especially now someone qualifying and they’re seeing the work that’s been done by someone 10, 15 years, but they forget the journey. They just see their outcome and they think, I need to be able to do this. And everyone’s like in as fast paced. And that’s maybe keeping them up at nighttime. So social media could be a source of stress and resentment if someone falls in the trap of comparing themselves, right, and comparing what, where they are compared to where their peers are, for example, which is a, a dangerous thing to do. Why else do you think we are in a situation where many of us in some of the BDA polls, you know, are quite striking the percentages are feeling disgruntled or upset.  [Andrea]I think that’s actually on the surface of it. You turn around and you go, Oh, it’s because of a high patient, increased patient expectations, it’s because of increased financial pressures. It’s because of increased fear of litigation. But I think actually, if we’re gonna examine this question because we want to improve our wellbeing and reduce the amount of stress that we’re under then we need to actually understand it a lot better and break it down. So you mentioned the BDAs poll. So every year the BDA is part of its evidence that it presents to the doctors and dentists review body surveys, its members. And over the last eight years, the data has shown that the morale has reduced. From about initially 2015, about 40% of dentists said that they rated their morale as either high or very high. And in 2023 that had kind of gone down to about 20%.  [Jaz]Wow. [Andrea]It harped. And what I find really interesting is that back in 2015 about 50% of dentists surveyed would say that they would recommend dentistry as a career. And fast forward to 2023, that’s now reduced to about 35, 36%. So when you look at those surveys and you say, “Okay, well, what causes you the most stress?” Interestingly, for practice owners, like 90% of them said it is increased practice cost. And for associates it’s fear of litigation. And then the list kind of goes down. I think it’s, you know, and number two is staff. Like how easy it is to recruit staff. How, if you are an associate, what’s the staff turnover if you don’t have the same nurse all the time. And then it becomes about financial concerns. And then I think number four is hitting NHS targets. And so, we can look at those and go, “Oh yeah, okay, so that’s why, why dentist stress?” But I think it’s important to remember that they are external fractures. And so with external factors, you are limited as to how much you can control them. Then we’ve gotta look at the nature of the job, which if you are in general practice, it can be isolating. You could be in a big practice, but you could end up working in a bit of a silo if you’re, if you’re not careful and you don’t, you know, if there isn’t that kind of culture that, everybody helps each other out and you all work together. Plus like the huge amount of mental load that comes with the job. I think the fact that as a dentist as you said, you’re doing all of these things. It’s not just the one job as a self-employed individual, you are the accounts, you are doing the actual clinical work. You are, you know, and all you are making–  [Jaz]Communications with labs and patients and letters.  [Andrea]Absolutely.  [Jaz]And planning itself, the whole just, getting a decent treatment plan. When you are conflicting in your mind that what is the best thing to do, that takes up so much choice, fatigue and decision making skills in your head. [Andrea]It does. I mean, the list just goes on and on, doesn’t it? And I think, the problem is when you’re making decisions all the time is that your brain doesn’t get chance to shut off. And then when you leave work, you are still replaying some of those events and decisions throughout the day. So you can leave work, but mentally you are still there. And so when you don’t get that level of respite, and obviously you get home and you’ve got, you know, other financial constraints and pressures, whether that is a mortgage to pay or the kids to pick up or who, we’ve all, got whatever— [Jaz]Life, just everything else in life. [Andrea]Exactly, so it’s really, really fast paced and I think because we don’t get that time to, if we’re not careful, to just pause and just, reflect and think, “Okay, you know, I just need to take some time just to slow down and, I mean, I can’t meditate, but if you can, that’s great.” But whatever works for you, but you just need a time just to kind of slow down. And I think also, the kind of people that I’m naturally attracted to dentistry tend to be high achievers, people who we wanna do a great job. I mean, whether we’re perfectionists or not, but we wanna do a great job and we wanna help people. And so when things go wrong, as inevitably, sometimes they do, they don’t work out as as well as you’d like them to do. You know, if you are naturally, I don’t wanna say a people pleaser, but you wanna help somebody, then you can take that failure very personally. So I think that contributes to that. And then we’ve got the other internal factors which are really specific to you. That is when you’ve got a clash of basically internal stresses usually come from a clash of values. So that means that your action or your environment is conflicting with what’s really important to you, and that makes this kind of internal cognitive dissonance, which you might not spot. You might not even realize that it’s there. But over time massively contributes to burnout. And so I think, your values are a compass. As to where you are gonna go in life. And I think sometimes I meet people that are like, “oh no, dentistry is just not for me.” And you are like, well actually, is it? And when you really delve down into it and you look at the kind of things that are causing them stress and draining their energy, you are like, well no, actually it’s got nothing to do with dentistry. It’s just a mismatch between your environment and your actions. So if we can change that, then actually that will make the world of difference for you. [Jaz]I think I’ve never had an episode where my neck is hurting so much. because I’m nodding so much. It honestly is like the cognitive dissonance, I talked about this a couple of years ago, right? And I’m so glad you mentioned it again because like, I don’t wanna talk about specific scenarios because of the international audience, but let’s say an example I’ve used in the past is you go on a course, you learn how to find MB2, okay. And you learn how to find it. And now, when you are working and you’re like, you don’t have much time to do this endo, and everything’s rushed. And you know how to find the MB2, but now you don’t have the time or the tools to find it. That’s a source of stress. That’s a cognitive dissonance in itself. [Andrea]Absolutely.  [Jaz]Or you know that you should be doing things a certain type of way, but because of the environment you’re in, you are having to take shortcuts or just something that may have worked in the past few, but now because you know better or different or you want to be a certain way, but you’re not able to be your true self that eats you up inside. Especially like you said, for us who want to do a good job, and many of us do love our clinical dentist and we work in microns and we wanna be proud of what we do, but we’re not able to do it.  [Andrea]Yeah, I think that you’ve hit the nail on the head. I think you know that there’s lots of examples that I can can give of that and it could be something as simple as you really value family time, but you are having to work really long hours, you’re having to stay behind because you know, you don’t have enough time to do your notes and your referral letters during the day. And so actually that’s a massive conflict of your value. Like actually it’s got– [Jaz]I’m so glad you mentioned that non-clinical one. I’m very pleased. And the other one would be like, you value your health and fitness, but because your working so much then you neglect the gym. You have the gym membership. You only go once a month, but you are at your best. You have the most energy when you’re going three or four times a week, but you’ve sacrificed that for work or for something else. [Andrea]Yeah. And I think another example that something I’ve certainly experienced, and it took me a while to work it out, was that for me, actually autonomy is, is really important to me. And so, you know, if I’m working in an environment where I lose control of my list and that, you know, the reception are putting in patients here, there, and everywhere for one dentist that they might love that.  They might love the challenge, whereas I want the day to be separated into this is when I see emergency patients, or this is when we do this kind of treatment. And if I lose that sense of autonomy, then that causes me a huge amount of stress. So it’s about understanding what specifically triggers you. And you only really understand that if you’ve actually put in the work, which can be quite uncomfortable work, to be honest as to what is important to you and why.  [Jaz]Hard now is an easier tomorrow, as I say. So with with that, let’s talk about the final phase, which I’m the most excited for, right, is let’s talk about some practical steps every dentist can take to fall in love with dentistry again, and ensures that it fuels them and it doesn’t feel like it’s a chore or a burnout, and it helps us to reconnect with why we got into the profession. In fact, actually that reminds me of, there’s a book called Can’t Hurt Me. David Goggins, and then one of the techniques he uses is you reach into the cookie jar. So he’s an ultrathon runner, right? So let’s say he’s done like 80 miles and he is running and he is getting a little bit tired, and he is losing his energy, he’s losing his focus. He reaches into the cookie jar where he remembers, he searches inside, he remembers a time where he was successful or he conquered something and he tries to tap into that energy.  And something I haven’t spoken much about before, but is something I think is relevant to hear is many of us okay, the vast majority I think at some stage when you’re doing the UCAS form, for example, Andrea, at one stage you really, really, really wanted this, you really wanted to be a dentist.  Like if you tap back to that energy when you’re 18, 19, 25, wherever how much old you are, when in your individual journey at some stage you were like, you sleepless nights waiting for the results to come out, to find out if you’d become a dentist and that’s what you really wanted at one stage. And to remember that and to tap into that energy. And that’s our version of a cookie jar to help you, to ignite you to do the hard work that you need to do, like you said, Andrea, to help make sure that you carve a professional life you that serves you.  [Andrea]Yeah, . Tapping into to that original why is fundamental, but I think also it’s important to say that, once you’ve tried different stuff, that why actually might change a bit. And that’s– [Jaz]That’s okay. [Andrea]And okay.  [Jaz]Great. because I’ve seen so much practical stuff shared by you on Instagram, can you share your top tips that you give to your trainees or you educate on to make sure that someone listening today can really go away and I think that’s a great , I can apply these few things to make a big instant difference to my fulfillment.  [Andrea]Well, I think the first thing to say, just because we’ve touched on stress and, tragically increased suicide rates. I think if you are listening to this conversation and you are really struggling, the first thing you need to do is you, you must seek support and there’s lots of support out there, and that’s Samaritans BDA has, it’s a health assured counseling service. Your indemnity provider may have counseling support as well. So if you are really struggling, then there’s absolutely no shame. It’s, as we’ve talked about, it’s kind of an insane job when you think about it. And so we are all gonna go through periods of time where we are not doing too great. And what’s important is that, you access professional support when you need it. When we kind of, if we are just looking at how can we make life more fun. How can we, improve our life in practice? I think, we’ve kind of touched on this already. The number one thing you’ve gotta do is get clear on what is it that you liked industry, what is it that actually does excite you? And then look at how you can do. More of it, but to even kind of have these thoughts that we’ve been having. When we were talking about how rapid everything is and how our brains just are going a million miles all the time. I think the number one thing that I would advocate is that you just find a way of stopping. So I can’t remember who it was that I heard say this, but basically if you are looking about even making any kind of change. It could be a small change, it could be a big career change. I mean, who knows if you are driving a car, you can’t reprogram the sat nav while you are still driving. So you need to be able to have time just to pull over. And not saying stop working, I’m saying see if there’s a way that you can actually dedicate time during the week and put some real boundaries around it. Like, okay, well, you know, on a Thursday night between whatever, I’m just gonna, I’m just gonna sit and I’m gonna think I’m gonna do some work on this. I’m gonna do some Googling, I’m gonna,– [Jaz]It’s protected time.  [Andrea]Absolutely create some protective time. If you really are thinking that, you know, you’re not actually sure whether you dentistry long-term is for you, then actually I would, you need to think about maybe just having that protected time, but perhaps even just reducing either clinical afternoon or a clinical day. But these goals need to be smart, so there needs to be a time specific element to it. Otherwise, we just get carried away and we do other stuff. But if you are like, “Right, okay, in the next four months I’m gonna make a decision about where I want my career to go, or what kind of post-graduate training, or what kind of jobs I think I’m going to shadow, or what I’m gonna find out what’s right for me.” So create protective a time–  [Jaz]Finding a mentor of a certain kind was giving an example like, I want to get a mentor in implants and I need one local to me, could be your main thing that you’ve identified that’s gonna help you to, to go to a next gear.  [Andrea]Yeah, absolutely. But things need to be, I would say it needs to be time specific to make sure that you are actually gonna do it.  [Jaz]It’s human nature because if you don’t have any urgency, then everything else will just fill up and that will get left behind. So I, I totally agree. If you actually write down a specific date and specific time and where you’re gonna be at that time when you’re gonna make the decision, then that can be quite a powerful, like it just gives you your mind some clarity. [Andrea]Yeah. Absolutely. So having the protected time to be able to do that is going to really help you. So yeah, so we’re getting clear on our why we are creating protected time to kind of do go through that thought process and then putting the work of whether that’s, like you say, finding the mentor, doing the Googling, doing the research—  [Jaz]Doing the shadowing for maybe some areas that might interest you, that you think, okay, I could pivot my career into sleep, or I could pivot into endodontics and then actually doing your due diligence and, and shadowing. because you might decide, actually that wasn’t for me because X, Y, and Z. [Andrea]Yeah. And I think, for some people, if they’re in a similar situation to what I was and they like variety and obviously we get a lot of variety in practice anyway. But if you want variety as in different types of jobs, I think that dentistry is incredibly unique. Like I truly believe there isn’t a degree out there that gives you the amount of flexibility and opportunity that a dental degree does. The fact that I do clinical practice on one day, and then I might be talking to somebody else on another day, or I’m working on my computer, on a project on another. It’s actually, when I look at it, it’s all insane. And obviously that gives me a tremendous amount of pleasure. But the fact that I can even do that, I can’t think of any of my friends that have done. Other degrees and qualifications that have that level of variety to their week. So, you know, it could be that you think, well, do you know what actually, maybe I’d like to go and demonstrate at a dental school, or, you know, just do that as a general practitioner, half a day. A week just,—- [Jaz]Or even, i’m just thinking out loud here, dental charity work, dental aid- Absolutely. Some people have gone into that and they love that they get so much fulfillment from their career from that.  [Andrea]Yeah, no, there’s absolutely loads of things that,  [Jaz]Oh, business. But the business of dentistry, sorry. So some people get a kick out of owning three to four practices, and then for that reason, they only had to, I read someone from a colleague I really respect. He said, when you get to about four practices and you own four practices, you really kind of have to think about giving up clinical dentistry because it’s a big ordeal if you’re gonna manage to a high degree of success. But that might be different for different people. You know, you might still keep your hand in clinical, but certainly you might find that the whole marketing element and hiring and the, and the managerial stuff you get. Kick out of that and having a vision for your practice and employing the right, not employing, but hiring the right associates in your team and building that team. And it’s like a project development. That could be your calling.  [Andrea]Yeah. Completely. And I think another thing that we need to do is look at, you know, especially when we were talking about stress. because obviously we’re all under stress to some level, obviously, how much and what that stress is, it depends on you and your individual circumstances. But I think certainly when I was a younger dentist, I would hear this word resilience and I would think, “Oh, okay, well I’ve just got a tough up. This is what it’s like. I just need to keep cracking on and eventually it might get better.” And so there was definitely this misunderstanding between resilience in terms of toleration versus adaptation. And so it’s just if you are finding that some” Oh gosh, you know i’m driving to work and I’m feeling it today. Like, it’s an understanding like why it is. And then once you’ve worked out those specific stress triggers, how can you manage those? Like, if it is like the example I gave about autonomy and the diary, right? It’s actually quite an easy one to fix. You know, there’ll be some things that are harder to fix, and you might be like, actually, no, this is not the right environment for me. I need to change environments. But again, it’s getting clear about what it is that’s specific to you that causes you stress and anxiety, and then coming up with a manageable plan as to how you can either adapt to it or ultimately, if you can’t do that, then remove yourself from that. The final bit of advice is actually, no, there’s two. There’s another one that’s just coming to my head. So, community, community is a such an important part obviously you’ve built this incredible community through Protrusive and, but you’ve really going to find your tribe. And it is not just about finding a community online. It’s about finding people who you can pick up the phone to you see face to face, who understand what it is like to be doing your job. Because dentistry is so, so unique, it’s very hard to explain it to somebody who’s not a dentist what the realities of the job are and why it is can be very challenging sometimes.  [Jaz]I just wanna give an example of that, Andrea, my, my wife she’s a dentist, she’s a community dentist. She’s now pivoting into private practice pediatric private practice, got MSC in Paeds. Massive imposter syndrome. She’s being kept up at night.  She’s having this huge imposter syndrome, and I’m saying, Sim you can be absolutely great. You can be fine. But, then I got her in contact with the Dental Mums network. It’s a new network that’s been set up and she’s going to their, like inaugural conference in a couple of weeks time, which I think is wonderful. That’s like, she’s finding a real in-person event. The magic of in person, you can’t be replaced and she’s gonna go there and won the talk. Is all about Impost syndrome and these are really high achieving women in dentistry that’s gonna inspire her and to, to find that source of inspiration from, and then look, yeah, look online as well, but look beyond and look, find local as well. And be willing to travel or pick up the phone to find that tribe. Totally agree.  [Andrea]Absolutely. And that’s one example of the, many of these, these groups and I’m seeing more and more spring up which is fantastic. It’s the issue I would say that you just need to be aware of is that if it’s only like yearly or couple of, twice a year that you are going to these, these conferences, see if you don’t have a local network, see if you can build that, see the BDA have branch and sections events, there’ll be local dental councils. There’s lots of things that you can get involved with. And also by having that element of community, it’s not just about support, it’s about career opportunities as well. Think about, because we are such a tiny profession really, that the nature of many jobs don’t, they don’t even come to the online boards. So to find out about these kinds of. That’s in practice or these other kind of weird and wonderful opportunities that come along, you need to have a strong network in order to be able to access them or even know they exist. So community really is key. The final thing is that you need to enjoy the journey. And I think going back to the, what we were saying about tick boxing, it’s so easy to kind of steamroll it down this road of, I’m gonna achieve this or I’m gonna get this. Qualification without, and then you get it and then you’re like, okay, what’s next? What’s next? Let’s go, let’s go. And actually, you know, you have what you have achieved just to even qualify or graduate as a dentist is amazing. Like it’s huge. You have to be able to, if you are looking at the next mountain, you have to look at the mountain you are already standing on. And I think we can be quite bad at that sometimes. And just going, well actually, if you’d shown my 18, 19-year-old self. Who I am, it’s gonna blow their mind. But it’s having that kind of realization that, you know, well done. You like that. Just having, having that bit of recognition for yourself and it’s not even just looking at the big things. I would say if you were in just one of the massive things that will make a difference to you in practice is looking at your micro wins. All get really focused on. I don’t think that prep point as well as I don’t think I’d got the angle of this or like that could have been better and like we’ve become super self-critical. And actually you are like, no, what, what did go right today? What difference have I made to the people? I got this person out of pain. Or it could be something really simple but just by taking a moment to think about it actually. I make a difference on a daily basis. And so, yeah, what a privilege. What an amazing privilege that is. And you know, I think that really is kind of the message that I keep, I keep going on about, is that we are in such a privileged position. We have this incredible degree, we have incredible qualifications and so many people don’t have that privilege. And so the last thing we wanna do is. Is, you know, not utilize it and, you know, not be, not be happy. Because ultimately, you know, if you are happier in what you do, then that doesn’t just affect you, it affects the people you live with, definitely. But it impacts your patients. I mean, there’s a growing body of evidence to say that happier clinicians have better outcomes. So this is, it’s vitally important, it’s essentially, life is short. Let’s not waste it. Let’s think about things. Let’s give some intention as to what we’re gonna do with our career and our lives, not just for ourselves, but for those around us as well. [Jaz]I’m applauding. I love that. That was fantastic. I can’t, I can’t wait to share this with everyone. Andrea, I’m just gonna I guess, round it off by saying, I agree that this is truly a phenomenal profession, but if you’re feeling at this moment in time that, hey, actually it’s not, it’s not feeling like a great profession. Everyone’s saying that, oh, it’s so much flexibility. Then you’ve cornered yourself, you need to embrace the difficult period. Of either discovery or action taking, taking massive action, picking up the phone, writing an email. The worst thing you could do is just be stagnant and watch the entire world collapse around you and not do anything about it. One thing I have been good at over the years is taking it by the scruff of the neck and making. Brave decisions and key decisions and sending those emails and having that conversation with my principles wherever it could be to make sure I carve out life by design and by choice, and not wait for things to happen to me, IE being proactive. Okay. And that’s so, so important, Andrea. How can we learn more from you? How can we reach out to you? How can people send you a box of chocolates and flowers for the mood that they’re in right now?  [Andrea]The easiest way is yeah, if, if you wanna send me stuff that’s I’m sure we can provide some form of address. But yeah, the easiest way to contact me is actually through Instagram at Dr. Andrea Ogden. Then you can find out everything you need to know about me and the one-to-one coaching that I do.  [Jaz]Excellent. So you’re doing coaching and you’re sharing so much on Instagram, so I highly encourage everyone to follow Andrea. I’ll put her link in the show notes. Thanks for helping us to fall in love with dentistry again. I think it’s so important to do so much CPD on various aspects: cosmetic stuff, composite stuff.  This is the important CPD right here, reminding yourself how to get out of a tough spot, how to reengage and get refuel, reinvigorated from your career. This is an annual exercise, every monthly exercise. Okay? And so this is so important, and thanks for helping us put this together, Andrea.  [Andrea]Oh, it’s been my absolute pleasure. It’s been so lovely to talk to you. Thanks for having me on.  Jaz’s Outro:You as well, Andrea. Thank you so much. Well, there we have it guys. Thank you so much for listening all the way to the end. Look, sometimes when you are given advice, you enter paralysis or choice fatigue and you don’t know what to do. Listen, just do one thing. Pick one technique that Andrea talked about, or I talk about the intro and implement it. Maybe that’s gonna be writing down what your ideal day and ideal week looks like. Even if it’s so far from what your reality looks like at the moment. If you actually put pen to paper in some protected time to, to actually discover what does your ideal day and ideal week look like, and then for the next few years or few months, or wherever your timescale is that you choose, you relentlessly chase that, my friends, and feel free to share it if you’re on Protrusive guidance right now. Put it in the comments or start a new community post. We are all friends here. It’s a safe space, and we’d love to hear from you. This episode, by the way, is eligible for CPD or CE credits. Protrusive Education is a pace approved education provider, and now CP credits are valid all over the world, including us, Australia, New Zealand, you name it. We have two main plans that. All you have time for is the podcast, and that’s where you wanna get the CE for. Then we have the podcast plan, but if you also wanna access all our master classes that we have and some of the best dental webinars you’ve ever seen, I promise you you’ll never laugh so hard and learn so much from these webinars that we have. And that’s from our Ultimate Education Plan. So you can choose your protrusive flavor. I’ve put in the show notes, by the way, how to get in touch with Andrea and her Instagram link. If you like this episode, please let her know we need more people like Andrea in the world. And you know what? We need more people like you in the world. Thank you so much. For reaching all the way to the end. It shows that you are dedicated, it shows that you really want to make a difference for yourself, for your loved ones, and for your career. My friends, I’ll catch you same time, same place next week. Bye for now. And of course, thank you so much, team Protrusive for behind the scenes, all the hard work they do. Bye bye now.

Is gold really dead or making a comeback 2025? Are zirconia and biomimetic dentistry sounding the final bell for precious metal restorations? Is there still a place for gold in modern practice—and when is it actually the best option? Dr. Lane Ochi joins Jaz for a rare live podcast episode to unpack the current and future role of gold restorations. From skyrocketing costs and lost lab skills, to emerging alternatives like milled cobalt chrome, this episode covers everything you wish dental school taught about gold. They even dive into clever tricks for temporizing gold and discuss the surprising lab workaround that may save your patient money—without compromising function. https://youtu.be/QWhY2_Oghd0 Watch PDP236 on Youtube Protrusive Dental Pearl: You can achieve profound anesthesia for lower molars—including cracked, heavily worn ones—using Articaine buccal infiltrations instead of an ID block, even in dense bone cases. 🔑 Key nuance: Ensure blanching of the attached gingiva and infiltrate through the papillae for better effectiveness. Watch the detailed technique breakdown (including patient feedback): https://youtu.be/cCXacw5DE4M?si=gDmYTKiFYxhYvbj3 Articaine works—master the nuances!  Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Use gold in tight spaces, short preps, or when longevity matters. Simpler preps = better milling, easier seating. Burnish when needed—but focus on great impressions. Talk to your lab. Explain your margins, internal spacing, and cement plans. Treat the patient, not just the prep: comfort, cost, and communication matter. Highlights of this episode: 0:00 Introduction 2:06 Protrusive Dental Pearl 06:19 Welcoming Dr. Lane Ochi 09:40 The Resurgence of Gold in Dentistry 14:11 The Importance of Preparation and Cementation 18:17 Cost-Effective Alternatives to Gold 21:39 Burnishing Gold Margins 26:53 Partial Coverage Margin Designs 29:04 Retention vs. Resistance in Tooth Preparation 43:14 Vertical Preps with Gold 45:05 Immediate vs. Delayed Dentin Sealing 47:23 Challenges with Temp Bonding and Solutions 49:13 Recap 50:02 Lab Considerations for Gold Crowns 54:53 Perforated Gold Crowns 57:24 Temp Bond Troubles and Fixes 59:59 Gold vs. Ceramic Longevity 1:06:25 Gold Crowns on Implants 1:08:44 Wrapping Up and Final Thoughts  Unlock webinars like this one by joining the Protrusive App. Studies Mentioned in the Episode: Marginal Gap of Milled versus Cast Gold Restorations Marginal Fit of Gold Inlay Castings Longevity of the Tooth Restoration Complex : A Review Catch another episode from Dr. Lane Ochi: Cracked Teeth and Dentistry’s Tough Questions with Dr Lane Ochi – PDP175 #PDPMainEpisodes  #BreadandButterDentistry #OrthoRestorative 🎓 Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES). 🗓️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician” 📍 February 18–19, 2026 · Chicago, Illinois Don’t miss Dr. Jaz Gulati and Dr. Mahmoud Ibrahim as featured speakers, presenting on “Occlusion Basics and Beyond” This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes B and C. AGD Subject Code: 250 OPERATIVE (RESTORATIVE)DENTISTRY – Preparation technology Aim: To provide clinicians with a comprehensive understanding of the rationale, techniques, and clinical considerations for using gold restorations in modern restorative dentistry, including when and how to use them, cost-effective alternatives, and how to communicate value to patients. Dentists will be able to – 1. Justify the use of gold restorations based on their mechanical properties, clinical longevity, and adaptability under occlusal forces. 2. Compare gold with alternative materials (e.g., zirconia, cobalt chrome) in terms of fit, performance, and cost-effectiveness. 3. Explain the principles of traditional and modern gold preparation designs, including vertical margins, bevels, and resistance features. Click below for full episode transcript: Teaser: Zirconia is not turning out to be the product that we wanted it to be. It does break and you know, unfortunately, even three Y, it's not self-healing. Why do we still call it the gold standard? Because it works. Longevity is there. Teaser:Well, Mrs. Smith. What is your desire, longevity, or pretty? The beauty is that when they looked at the occlusal margins, the ones they could finish, the state acceptability was-  Jaz’s Introduction:In this world of lithium disilicate, and zirconia, is there a place for gold? Many years ago, it was agreed that nothing beats gold. Gold is the best because it gives you absolutely brilliant longevity. It’s kind to opposing tooth structure and you can burnish the margins. What does that actually mean? We’re actually going to cover it in this episode. What does it mean? Is there a place for Gold in 2025 and beyond? I’ll tell you, the last time I did a gold restoration about three years ago, I had to sell my left kidney to pay the technician. Gold is expensive. Are the benefits of gold worth that expense? Or perhaps, just perhaps, there’s a viable alternative to gold, what you’ll find out today. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is a slightly different one. We did this live. This was a rare live podcast with one of my heroes and mentors, Dr. Lane Ochi, one of the geekiest and kindest dentists I know. And to see him communicate with us on Protrusive Guidance, our network. And every time we all get stuck and we’re like, oh, what do we do with this query? Or something like really obscure and geeky about material science or how things were done back in the day and we’d always tag Lane. Dr. Ochi is an absolute pleasure to have you as part of the community, and thanks for doing this live with us. So for those who are now listening on Spotify, Apple, or watching on YouTube, just bear in mind that I do lots of shout out when I do a live on Protrusive Guidance. It’s very much responding to the chat, engaging, serving. So you’re gonna hear lots of names being shouted out. Dental PearlNow, every Protrusive episode we give you a Protrusive Dental Pearl. This one is already spilling the beans. It’s giving the secret away of this podcast. It’s gonna blow your mind, right? Many, many years ago, this is probably the first meeting I ever went to, like maybe 13 years ago, it was the British Society of Restorative Dentistry Meeting. Maybe I’ve told this story before to you guys. I’ve been speaking to you guys for six years now. I can’t even keep track anymore of what I’ve told you and what I haven’t told you. Anyway, back then, we are moaning about the price of gold. Now I had a check, and actually since that meeting, the price of gold has doubled. So here we are in 2013, moulding about how expensive gold is, and now the price has doubled 12 years later. So we asked the restorative specialist, what should we be using? And so what this specialist said back then, which always stuck with me, is to consider the use of a milled cobalt chrome. That’s right. A milled cobalt chrome for your indirect restoration such as crowns and onlays. So since then when I’ve got second molars and I’m tight for space, I’ve been doing non precious metal crowns and onlays and I’ve been pretty happy with how they fit and especially with how much they cost. And did you know that something like cobalt chrome is so kind to enamel. So any opposing enamel, it is so kind to it, but is this like a forbidden cheat code and there’s a good reason why we perhaps shouldn’t be using this? Well, stay tuned my friends, because I asked this question to Dr. Lane Ochi and let’s see later in this episode, what he had to say. But as far as the Pearl is concerned, that specialist believe in it. I believe in it. In fact, recently if you’re on Protrusive Guidance, you would’ve seen me do a live, I treated a crack tooth case and I walked you through exactly why and how I prepared this for a cobalt chrome restoration. I show you the entire prep, the cementation, and this is available with CPD CE quiz. We are a PACE approved education provider, as you know. So if you’re curious about metal restorations for compromised second molars, when you’re lacking that space, check it out in the Premium Clinical Video section of the app. And speaking of the app, I just wanna do a shout out to Dr. Jamie Adamson. Jamie said on the app, thank you, Jaz, for the availability of your VertiPrep course. Fitted my first anterior VertiPrep crown today and just plunked it on loving the soft tissues especially. Appreciate your commitment to helping the Protrusive community. Well, Jamie, to you and everyone who’s started to do VertiPrep since doing VertiPreps for Plonkers, thank you for implementing what you’re seeing online. So I always worried when I created VertiPreps for Plonkers because I was like, can you actually learn VertiPreps online? Do you not need a hands-on? And honestly, with the loop mounted footage that I have, or it is very possible and we proved it. Dozens of you have been posting your preps and your cases and so we discussed the lab protocols, materials, troubleshooting, and because we have all that and the images and full protocol videos, it’s as good as shadowing someone. In fact, I had a student shadow me recently and she’d actually shadowed many dentists before. And the same thing that happened to me is that when I’m shadowing someone, I’m like over their shoulder. I’m trying to see what they’re doing. I’m trying to like make notes and what’s really carefully how this dentist is doing something so I can learn the nuances. But it’s actually very difficult to see what the dentist is doing. So what I do when anyone shadows me is I sit them on the sofa opposite. I give them an iPad on my laptop and I switch on my loop mounted camera and they can see everything and I’m speaking to them as I’m doing the procedure and they are absolutely gobsmacked at the end. It’s like, wow, what a powerful learning experience because your vision is so clear. That’s why my friends, you can learn VertiPreps online. You can learn Sectioning and Elevating online. You know this already because I know you go on YouTube and you type in certain procedures that you’re about to do, whether it be delicate layering of anterior bonding or certain steps and dentures. The University of YouTube already exists and does a good job. I’m just here. Pack a punch and contribute to this education. And the best of it happens on Protrusive guidance. A quick shout out to three individuals from PG who I just wanna give a lot of love for. You guys are just mentoring and helping out and contributing to such a huge scale. Mohammad Mozaffari, Richard Coates. Richard also did a podcast recently about finances, like how should we budget our finances? That’s a private podcast only available on the app, but you can check it out. And also Harpardeep Kaur Ratia, our friend from California, you three in particular, have just honestly upheld the values of the nicest and geekiest dentist in the world. Alongside our guest today, Dr. Lane Ochi. So thank you. And now let’s get to the main interview and catch you guys in the outro. Main Episode:It’s so great to see you again. How’s life? How are you? Tell us about just, just a flavor of life as it is at the moment. [Lane]Life is wonderful. It’s so fun. To, dabble in dentistry as an educator still. I am an associate for one of my mentees in helping them learn how to let go and bring in their own associates so they could spend more time with their family. And it also is a deep appreciation of why I really wanted to step away from full-time clinical dentistry to be a full-time grandfathers, it’s just this whole life balance. I’m glad I was young enough to make this decision to enjoy, so I’m probably the happiest I’ve ever been. So thank you for asking. [Jaz]That’s exactly why I asked. because I knew you were gonna say that. I’ve been seeing these images of you and your grandkids and honestly your fitness levels and how much you’re trying to maintain that. It’s an inspiration, so I think it’s a great to live up to like everyone knows you here, even on the podcast for everyone knows you. So many of us came to join you live when London, when you came recently. But just for a few people, can you just give us like a one minute highlight of like, imagine your career clinical dentist career was made into like a, an Instagram reel of 60 seconds. What would be in the highlights? [Lane]Yeah, that’s easy. You’re looking at the ultimate beneficiary of mentorship. So, I have been so blessed that so many doors were opened. And the doors were opened by generous souls like you. I mean, we don’t have enough anchors and mentors that invite people to come and learn, and that’s, you know, that’s basically it in a nutshell. So, God bless you, thank you so much for everything you do.  [Jaz]I mean, it is a real shame ’cause those of you who don’t know you just stumbled on, you’re a new grad and you’ve never seen Lane before, like if you just type in his name in Google see is an amazing plethora of educational things he’s done like even online that came later in his career. But what I’ve seen and what I’ve heard, and you have actually just even on Dental Town, the amount of forum interactions and amount of people who you’ve mentored is just amazing. And that theme of mentorship will keep coming up every time we meet. And you are the original Dental Geek. So an absolute pleasure to have you again laying your old nickname. We’ve got so many questions for you. Gold, right? We’re gonna talk about Gold. So before you joined, I dunno if you were there for that bit, I asked everyone in the chat, how many Gold restorations has everyone placed since COVID and I set about five, and most of the answers were zero. Miles said, yes, he has placed Gold he didn’t say how many, I don’t think. But the numbers are low. Okay. Now, because as a new grad, I was not really taught how to do Gold. I was more PFM and then I had to kind of learn it and to fair I kind of was making up a little bit, reading Shillingburg, and trying to my patients, like the whole thing about burnishing the Gold margins. There’s so much to talk about today, but the place to start is, maybe it’s a terrible place start, but is this is our conversation is this podcast the last goodbye for Gold. Is this like a farewell to gold? Or, would this conversation, can we see a indication for gold still in 2025 and beyond? [Lane]I think this is, you know my, one of my favorite ways to start a lecture is if you’re gonna quote me, please date me. Honestly, I think we’re gonna see a resurgence in Gold. Zirconia is not turning out to be the product that we wanted it to be. It does break, and unfortunately, even three Y it’s not self-healing. It just turns out that the crack propagation occurs very slowly. It is by its very nature, probably going to fracture in areas where we don’t have a lot of room, meaning the lower second molars, upper second molars. And as that happens, you’re always gonna find a subset of patients and doctors who want value longevity over aesthetics, especially second molars. And with that, I think, the beauty of Gold is exactly the polar opposite of Zirconia Gold strength is that it’s weak, meaning it wears, it adapts. Our bite is constantly changing. So the most bite forces we know is our second molars. So I think as the profession moves on, as we mature, as our patients get educated with us, that we’re gonna find a place for Gold again. Because people just don’t like replacing broken things every 5 to 10 years. They just don’t, I mean, those are from Dental School. I mean, talking other dental students we didn’t know S from Shinola yet they’re here 45, 46 years later. Cemented with crap water-based zinc, oxy phosphate, cement. [Jaz]Well, that was one of my questions, like, okay, so you’ve answered it already. And I love how you really explained the properties goals very, very simply. The whole self-healing, use the word zirconia, not being self-healing, but really we’re trying to say gold has those properties, it adapts with us. And, and the longevity and the data supports Gold long term. And you said an interesting thing that it was done by students, so inexperienced operators with cements which are not as good as the cements we have today, yet in your mouth, they’re still there, still functioning well. And in your career as you were doing, like, did you find, you had a phase where you tried some new ceramics and then they failed, and then you tried other materials and you were fine that they failed, but perhaps you were just seeing Gold just standing the test of time. What kind of recollections do you have written in terms of longevity of materials?  [Lane]So you know how long disilicates have been around? Can I ask. You know, when they were introduced.  [Jaz]Does anyone know in the chat, does anyone know in the chat when disilicates were introduced? Because my guess, where they were popularized was like early two thousands, but you are probably gonna tell me they’ve been way before that. [Lane]1980 Dicor disilicates. And I have Dicor machine in my garage. I was one of the first people to purchase it based on the recommendations of the ceramic expert at the time, Ken [inaudible] And they all failed miserably within like three years. So I kept the machine to remind me that, we have to be careful not to be beta testers. There’s a reason Legacy concepts are called Legacy concepts because they’ve stood the test of time. I mean, how long has gold been used for in our profession? I mean, generations. And it still has, why do we still call it the gold standard? I mean, because it works. Longevity is there. That’s why, why can you, if you, if we ask ourselves, you know, more modern materials, right? Why do we make a distinction between bonding and plonking on things with cement? So typically, my learning curve was with all ceramics. I bond by cuspids forward, I plonk and cement molars. And I based my material selection based on how I wanna do things. So Gold’s no different [Jaz]Nowadays I see those who are using Gold. I remember attending a Jason Smithson lecture and he was actually treating student, a dentist student. And the young dentist said, “Hey, this Gold you’re about to do for me, can you bond it?” So that scenario of the lower second molar where I will go for metal for cost reasons, I have been shying away from Gold. And we’ll come to that okay, we’ll come to that and alternatives in cobalt chrome and that kind of stuff, which I have been using rightly or wrongly, and I’ll get your advice on that. But when we have an option, like we’ve got a gold, we can either cement it or we can bond it. Is there any advantages? Because now young dentists are comfortable with bonding. We’re doing our lithium disilicate, we’re enjoying our rubber dam. In those scenarios, could the bonding give us additional benefits? [Lane]If I reflect on my first use of the word legacy. Because we use such crummy cement, you know zinc oxyphosphate is 10 times weaker under compression and shear than our resin based cements today. So our cements are far superior. And the thing is, is that our preparations for Gold were designed with intent to have resistance features, right? So, you try on a lot of these indirect restorations in Gold. Sometimes you couldn’t even take them off without cement. So we’ve probably modified our preps a little bit. I know I’ve modified my bonded preparations to take advantage of some of these resistance features like I do like potholes and isthmuses, and I think we’ve had a conversation about that in the past. But MDP is a very interesting product. It will bond metals and so I would not discount resistance and retention features. But yeah, we can bond gold and you know, Panavia is a wonderful cement. It gives us enough working time because I heard you while you were trying to get me up and live, asking about burnishing. That was the beauty of zinc oxide phosphate cement. We could manage the setting time by what we call delayed mixing and using a cold cement slab. So we had plenty of time to work with our margins. Well, resin, glass, ionomers, panavia all give us the same amount of working time, so we have much better products that can be utilized in the way that you mentioned. So we can bond metal, absolutely.  [Jaz]I think you’re saying all the, for me, what I was expecting to hear is that the word space, when you’re tight in space and you’re cramped for space, those small clinical crowns, that’s exactly when I’ve been turning to good old metal again, not gold for cost reasons. We’ll come to that, but I find the, sometimes, if I can’t put my slots and grooves in, or if I just have a doubt that okay, perhaps I wasn’t able to deliver as much retention and resistance form option to bond is quite attractive using MDP using Panavia. So I’m glad you’re not against it for any reason. I don’t know I worry about it going against the initial intentions of how Gold was classically used and I was thinking, “Hmm, is this like a forbidden cheat code that we shouldn’t be using?”  [Lane]Not at all. So again, every question in our discussion begets another observation. The reason that we can’t get away with subtractive milled restorations on short preps is that we can’t mill it fine enough to get in there. The simplest thing and one of the beauties of our modern cements are their film thickness is so thin because the thicker the film once our cement film thickness goes past about 50 microns, the retention of a crown, the sheer force strength, the sheer strength of the cement drops off the table. So subtractive milling unfortunately won’t get into all that fine detail on grooves and boxes and potholes. So again, this is where lost wax or milling differently. This is kind of an interesting thought, and I didn’t think I’d mention this, but we know from studies and a very good one was done by Russell out of one of my residents the San Antonio Grad Pros program looked at cast Gold restorations and milled Gold restorations for marginal fit. And it turned out that untouched, the milled Gold restorations fit better than the wax invested in cast Gold restorations. But when you cleaned up the inside of a cast restoration, it fit better than a milled one. But the mills were pretty darn close internally as well as marginally.  And so one of the cost savings we can look at is not only using lower percentage gold, or even non precious based metals, that they can be milled and the cost goes down because there’s less labor, there’s no loss of material. Technology and legacy are slowly coming together. They really are.  [Jaz]Well said. And so this brings us very nicely to, I did a live webinar recently where I just talked about how I treated this particular scenario of a second molar small clinical crown that was cracked. And as I have been opting for a base metal, I’ve been opting for a cobalt chrome milled. And I was told by a mentor many years ago that this is what he believes in. Because the price of Gold is getting extortionate. And well, he’s been getting good results and we know that cobalt chrome is kind to opposing metal and feel free to lay in to give me a slap on the wrist. And tell me that Jaz, perhaps you shouldn’t be doing this for whatever reason. I’m happy to change my ways, especially if you tell me to. What do you think? Because when I lasted a Gold restoration, my lab bill was approximately 400 pounds, and so that’s a lot. And it’s probably, I don’t know double that now based on gold, based on the pure gold weight, right? So that’s a lot. So these cobalt chrome onlays, which fit really well. I’ve been happy with them. How my lab are making it, it was about 160 pounds. So what do you think about this choice I have made? Should I stop?  [Lane]No, not at all. At $3,300 an ounce, that was Gold spot price this morning. US dollars, it hit 35 what, last week? So it is, unless you are willing to charge your clients the gold difference, and they’re willing to pay it, then it’s really kind of off the table. Now we can drop down, and still be in the precious metal world, I mean, we can have noble metals, less gold, more platinum, and more palladium, but you’re still faced with the same costs. There’s nothing wrong with non precious at all. I mean, I think it’s great as a metal. It sucks as a metal to support ceramics, unfortunately, with non precious for those of you who don’t know, we bond, we have to create an oxide layer on our metal. For the ceramics to bond to. And if you look at ceramic failures on PFMs and you see metal, it’s typically a non precious metal. And what happens is the oxide layer just continues to grow over time until it gets so thick that it breaks off. But as a metal itself, as for an onlay partial veneer gold, or got partial veneer crown, it is a wonderful material. The only downside to it is that we can’t burnish the margins as well as you could with high noble Gold. But you know, our ability to capture tooth detail, iOS or PVS and machine, you really don’t have to touch your margins. If you’ve captured a good impression, digitally. Or with conventional analogue impression material. [Jaz]That’s extremely reassuring. Now, Lane burnishing with the base metal option, like the cobalt chrome that I’ve been using. Firstly reassuring that if we do all our impression work scanning and we get good quality data, we can get good margins that don’t need to be touched. But with Gold, the whole burnishing, firstly, what actually is it and was it always necessary or was it when you felt as though, I’m going to do it here because I want to improve the margin that wasn’t good enough. [Lane]You really wanna hear the answer to this? But there are over 280 something ways that the crown won’t fit. It’s quite fascinating. And the burnishing came around from the concept of the MU angle, which is a bevel on a shoulder. And the logic is that as crown horizontally seated, if you had a bevel angle, it would seat. Faster than the horizontal component. Well, that’s fine in physics, but nobody took into consideration loot cement between the tooth and the crown. So you actually ended up with a restoration because we were prepping bevels, because that’s what we were taught.  Depending on how old you are as a dentist, as the crown seeded, it didn’t really fully seed on the bevel, so you had to burnish it to make it fit. And burnishing simply is taking advantage of the physical properties of Gold and manipulating it and pulling it from the Gold onto the tooth. And so it was an ends to a means because we did not understand all the interactions and our choices. And the other problem, again, with zinc oxyphosphate cement, even the most careful mixing, its film thickness is very unpredictable. There’s no measurement. You just feel, and so it’s temperature. So our castings didn’t always fully see, so we needed an out. And that’s where using higher percentages of Gold, this is where type 3 was typically used for onlays, type two for inlays because it’s softer. So we can manipulate the Gold. And it worked well, but you also had to understand what you were doing. And just like when you teach us how to finish our composites, we spin composite onto tooth. Well we have to make sure we do the same thing with Gold. We would take [inaudible] sand paper discs, course medium to fine and we would rotate it from the gold onto the tooth. So we’re pulling, burnishing and making up for all the little errors that went along the way. Remember, I referred back to Johnson that the cast restorations required work to fit as well as a milled restoration.  [Jaz]I’ll tell you something really embarrassing. When I was a baby dentist, I must have placed my first or second gold restoration and like one of the few in my career. And I’d heard, oh, you can burnish the margins. I had no idea what this meant. So I asked my nurse for a burnisher a ball burnisher and I just rob because I thought, okay, maybe this is what they mean, right? And there we are. So it didn’t mean that at all. I didn’t see a difference. I was like, what the hell is this? What’s all this fuss about? But obvious the actual, you’re dragging.  [Lane]You’re just dragging the Gold. And you know what? This where the first marginal fit, clinically acceptable margins came from. It came from Christensen. And if you don’t remember the study, Gordon just prepped a bunch of MOD onlays on by cuspids, fabricated restoration cemented them. He finished anything on, we’ll call it the occlusal bevel. So anything near the occlusal, he finished the proximal bevels, but he didn’t touch the gingival bevels and made sure his evaluators couldn’t see the gingival bevels. So, the most evaluators noted that a margin at the gingival where they couldn’t feel it was clinically acceptable at about, 50 microns plus or minus the standard deviation. But the beauty is that when they looked at the occlusal margins, the ones they could finish, the acceptability was about two microns.  [Jaz]Wow.  [Lane]When you can finish, get at it, you can finish it, it is evident. And that was, again, the beauty of gold is it adapts to occlusal changes. It’s soft enough that you can pull it and adapt it, you know, to the tooth. So it was again, an ends to a means. But now that we’ve eliminated a lot of these uncertainties, by milling. You have to remember what we were doing back then. You know, what were our impression materials? PBS was nowhere to be seen. Additional silicones were nowhere to be seen. What were we using? Hydrocolloid, you know, polysulfide. These are terribly inaccurate materials.  [Jaz]Fine. So I could see the necessity and why you would do that with the better scanning and pressing techniques. I can see how that equation’s completely different and in our favor. Which is great. So bevels are out. Does that mean that if anyone’s replacing preparing for their first or very few Gold restorations that we get to do that we should be opting for shoulder chamfer?  [Lane]Well, for partial coverage where you’re capping a cusp, you could follow what you do for ceramics, just a longer bevel, it could just be a shoulder, it could be a butt joint. Again, ’cause we, we don’t need to finish. Let me back up a step further. So, so the best closing margin angles when there is cement looting agent present, doesn’t matter what the looting agent is, is an exit angle of a either 35 to 45 degrees, which is just like a light shafer or 90 degrees, which would be a butt joint at the occlusal. So both of those, if you keep in mind, exit angles or angle that the restoration meets the tooth, if you have one of those two criteria, 35 to 45 degree bevel or just a butt joint, 90 degrees, those are gonna seat very well– [Jaz]In terms of angle. Okay. So is the angle of the finished margin, is it, regardless of the material? The ideal 30 to 40 and also the butt joint? [Lane]For my preparations actually are pretty similar, both gold and ceramic at this point. So, yeah, I would say that this is gonna be tough. Okay. Without pissing anyone off. Okay I don’t understand a lot of what we see in Biomimetic dentistry. To me, the design of their preparations and their margins are wonderful in the compression dome concept. This is gonna work. Their designs, their margin exits are perfect for maximum compressive strength to the tooth. The problem is, the off axis loads and understand all indirect restorations fail to buckle lingual off axis loads. So this is where I prefer a little bit of a coming over a cusp tip, a little bit of a shoulder or a shafer versus just that kind of butt joint. So think of it in terms of resistance to coming off. We know that retention is this way, the path of draw resistance is if you put a groove in the prep or you have shoulders, right? It’s preventing off axis loads and puts your cement slightly under compression, under those off axis loads. So when it comes to capping a cusp, I think this is what the question is. Do you put prefer a bevel or do I prefer a Shafer around it? It depends. Both will work. One, you may pick, because you don’t want to drop interproximally and get longer axial walls and say a groove or a box, right? Versus, I’m gonna keep this whole thing high water, so maybe I’ll put a little pothole in and a little circumference or shoulder. Again, up at the occlusal third of the tooth. [Jaz]With the slots and grooves that you might place. I found in the past when I was a bit overzealous with them and I was going for, at this stage again non precious metal, but I found that. Sometimes my seating wasn’t good, there was rocking, I’d have to use a clued spray and then figure out where to adjust to get it to fully seed.  It was a real ball lake. And then now when I keep it simple with just one sort of a groove, things fit more predictably. They still have a good retention resistance form. Is this a scanning PVS error, manufacture error, all compounding when they got too many intricacies? [Lane]I think it’s both. We have to find that sweet spot that works in our hands, but more importantly works with the lab that we’re using to work with. So, you know, how many of, how many of us actually ask for the proposal of a single unit crowd? Have you done that?  [Jaz]So a proposal, like for example, like an exocad design, would that count as a proposal? [Lane]I’ve talked about the internal: The milling proposal. The actual milling.  [Jaz]No, not at all.  [Lane]You’ll do that and you’ll be kind of surprised at where you need to change your preparations. You know, we think we round over things enough, you know, we think they’re smooth enough. But then you have to remember, a milling machine can only mill to the diameter of the smallest milling bur. And so if it’s too tight or a little too sharp, the only choice the milling unit can do is over mill, which typically if it’s in the wrong place, can actually lead to a little rocking on your restoration. It’s not an internal high spot, it’s just there’s more slop. I suggest everyone do that with their laboratories, ask for the milling proposal. And so you can get, see the cutaway of where it is has to over mill. You’ll actually be quite surprised and based on that, you might change your preparation design to be simpler as you evolved to Jaz. [Jaz]I mean, I did that for my Zirconias and when I went to Marco’s coast course in Sicily and he showed us all these issues with milling and the bur and how you have to keep in certain dimensions, otherwise you have these cement gaps and yeah, cost as is just point mentioned about Sicily as well, but I didn’t actually draw two and two together for gold and it makes perfect sense. If we’re going for milling for gold or or non-pressure metal, similar complications can arise. So that’s a very good point. The next question I had was. Again, a stupid one and shows my inexperience in this is inlays, let’s say a gold inlay, right?  Would the entire restoration be gold or would it be that you’d build up a very generous core and then prep back so you that you are using the least amount of gold possible and therefore saving the lab fee and therefore you don’t have a heavy bit of gold? [Lane]Foundation fillings all day every day to, to minimize Gold content. And it’s a very interesting, I heard you mumbling about Richard Tucker. Tucker Gold Foil Study Clubs and Tucker Cast Gold Study Clubs still exist around the world. They’re not as popular as they once were, but they still do. And I used to like look at Dick and go, either your patients don’t brux, or Yeah, you’re just the luckiest guy on the face of the earth. because he would always, base up an inlay, the pulpal floor. And he put a pothole indirect with more retention into the foundation filling. And what’s the point of that? Well, he understood buildups much better than a young lane did. And so yeah, you could do that. In fact, it’s so funny back in the days, I remember when I, when I graduated from well, let’s see, I started dental school. You’ll love this story on the board, professor, first, professor, oral surgery on, on medical history. Writes the number 35 on the board, never mentions it again.  Whole lecture goes by and at the end of the lecture, typical professor, are there any questions? And I go, yeah, what’s 35? Do we need to know that? Is it something important? He goes,” Oh that’s the spot price of gold per ounce. Right now, if I were you, I would take all your student loans and by every ounce of gold you can buy because I guarantee you it’s not gonna be 35 by the time you graduate.” Fast forward to the time I graduated. Gold was 900.  [Jaz]Wait, it went from 35 to 900? [Lane]900 bucks an ounce. So we were still as students then we had to wax and cast, you know, we had to do all our own lab work and the school and ways to try to save money in the wax pattern room. We would sit there, they would make us like, try to use a round burn and scrape out like the inside of the wax pattern to cast it to save gold.  [Jaz]So that we need to build a foundation, build a core to, to save one goal. It makes sense. And so that make, that makes total sense.  [Lane]But by the way, a number of older studies, they, they haven’t been replicated in a while, so I don’t really cite them very much. Showed that just in vivo studies, teeth prepared were foundation fillings replaced. They could be amalgam, they could be composite, they could be whatever, tended to leak less than castings fit to a preparation without foundation fillings. So again, I think it goes back to this whole milling internal accuracy. If you have too many undulations that your poor casting has to fit on, it’s either gonna hang up on a high spot, a tight spot, right? So it, it does make sense.  [Jaz]And then what about minimal thickness? We talk about ceramic all the time. Minimal dimension. What about good old gold? Right? We’re, we’re in a tight spot, we’re in a second molar it’s a tight spot. And we’re thinking, are we gonna have enough space? How much is enough? 0.5, 0.71 millimeter. Oh God. How much do we want in the load bearing areas?  [Lane]Right. So this is the beauty of Nickel Chrome. Half a millimeter’s more than enough, right. Obviously if you’re gonna use type two gold, half a millimeter is not enough. If you’re gonna use type three, depending on the parafunctional habits of the patient, you’re probably okay. But they will wear through it. And so you go to type four, which is, you know, the hardest. Yellow metal we, yellow gold we have. But yeah, with the materials you’re using and Jaz, half a millimeter’s fine, we can expect good.  [Jaz]So with the ones with the non precious metal, I’m using half a mil, which is great. But then when, when those who are using gold, you said, just remind us again for the younger colleagues, type one is the highest gold content, the softest not used very much type 1, type 2 is more for inlays. Type 3 for gold and frameworks. Sorry for Onlays and Frameworks, is that right?  [Lane]Yes.  [Jaz]Talent and frameworks.  [Lane]Yeah. That’s a good, that’s a good, kind application and type four is the hardest noble gold. And so, when you don’t have a lot of room, half a millimeter, it would be well indicated. [Jaz]Okay. That’s great. And then when we are temporizing, so if it’s half a mil occlusal and then buccal lingual is no 0.3, no 0.5, whatever it might be thin, where if you ever try doing as, I have a bis-acryl, it’s gonna be like onion skin thin and it’s not gonna work. So what techniques do we need to employ to provisionalize for gold? [Lane]When typically, and we’re going to the short tooth, limited occlusal distance, I cement it with Duralon and water. That’s just my go-to. I just accept the fact that I’d rather, let me back up. So the beauty of most foundation fillings, it usually involves some immediate dent and ceiling, which usually means that you have less sensitivity at delivery. So for most gold, if you have a retentive enough prep and you can use something like, reinforced ZOE, like B&T or IRM, you don’t even have to numb a patient to deliver the restoration. When we get to the shorter teeth where we need to use Duralon and water, it’ll retain the provisional quite well. Oh, and by the way, I also Arab braid quick, lightly a braid, the intaglio of my provisional when I’m worried about it coming off. But then you have to numb the patient to typically ultrasound off. Most patients would rather get numb again.  I’d rather numb them schedule an extra 15 minutes, even for mandibular block than get that phone call at 10 o’clock in the evening or on the week and say like, provisional came out, and by the way, we’ll bring it in with you. I bid on it, so. [Jaz]I’m confused there. So the provisional itself is like Duralon, like actually just molded on, or is it just like it — [Lane]Yeah. With Bis-Acryl.  [Jaz]Okay. But don’t you find that bis-acryl was like, too thin, too weak to see through with those thin dimensions for gold? I have not had a problem with that. [Lane]If you’re really, really that concerned. You know, ’cause I think there’s a, there’s a second question in here is that bisci, krills by nature are very brittle. And so that’s, we worry about breaking them, but they’re only brittle when they move. And so that’s why you need a pretty strong looting agent, temporary looting agent, because what happens, what they lift it just ever so slightly, then they bite down on it and it pops off, or the, it cracks. So the workaround, I, I don’t fond, I may, I can count the times I had to do this on one. Two, three, maybe four fingers is to use PEMA, you know, like SNAP or, or a PMMA, like Jet. But that’s so much extra work and typically not necessary. So  [Jaz]Great. No, that’s reassuring. because that’s physical is what we all have so we can use it and just to use Poly F, Duralon, something like that makes total sense. Couple of questions from the audience. I’m gonna then revert back to some of my questions I had is, any thoughts on gold vertiPreps? Gold Verti preps.  [Lane]Well, where do you think  Verti preps came from? The vertical prep is nothing more than the feather margin, which was the go-to standard for gold, again, for a number of reasons. Cost, right. And, again, we didn’t quite figure out how to work out all the issues of fit and finish. You understand that at the end of the day, you want what we feel clinically is a sealed margin. We wanna look at a radiograph and hope it looks pretty. So the beauty of a VertiPrep crown, be it gold or zirconia, which is radio opaque, is, it always looks like it fits beautifully. And so, that’s really where the whole VertiPrep is just a rebirth of the feather margin. And by the way, the bat burs are nothing more than gingival rotary curettage diamonds that were created. All we had for impression material was hydrocolloid, which has horrible tear strike. So we would trough the tissue, the gingival, away from the margins to create enough horizontal space for the hydrocolloid to capture the margin, not tear when we remove the impression material. So VertiPrep, the baters, it’s just one big complete circle. You know, what was–  [Jaz]Wow.  [Lane]Once is now new. [Jaz]Yeah, I love that. I didn’t know. I can visualize now how it creates a space, but some people may just put cord for longer or may use a laser. That’s how you are pretty much using it to create the space.  [Lane]Right, and again, we didn’t have lasers in the fact that we, all we had was ElectroSurge good old fashioned ElectroSurge. And man, let me tell you, patients aren’t happy when they smell a barbecue and they realize it’s coming out of their mouth.  [Jaz]I always warn my patients before I use my thermo cut on high speed, no water. And I say it’s gonna smell like a barbecue. And no patients have taken offense just yet. But Julieta asked, would you still use, I know you have good, good opinions on Nick from what I’ve read before, immediate dentine ceiling for gold restorations. Because I know you talk about delayed dentine ceiling, immediate dentine ceiling. So what do you advise for gold restorations? Does the material choice have a factor to play here? [Lane]I don’t think it matters quite honestly. Again, the nice thing about the immediate dead ceiling is no postop sensitivity, right? And probably the need many times you don’t need to anesthetize at delivery. But if you’re gonna hang your hat on biomimetic dentistry, and I’m gonna get in a whole bunch of trouble for this, they really do hang their hat on immediate dent and ceiling being superior to delayed dent and ceiling. Well, I can assure you now there are two good systematic reviews and one RCT. An RCT Randomized Clinical Trial, right? No difference. After a few months, the immediate dent and ceiling is no better than delayed dentine ceiling. So I don’t think there’s anything wrong with it. I would do it because for patient comfort and predictability. Yeah. So absolutely go for it.  [Jaz]Great. Thank you so much. Harmit. Hello Harmit. You say the biggest headache she’s had recently is physical temp bonding to my immediate dentine ceiling. What would you place to prevent this glycerin? So, yeah, that’s something, once you’ve set it all up to place a glycerin and cure through it, you lose the oil, the oxide inhibited layer and, and that’s all fine personally.  I don’t know about you Lane, but I don’t have this issue. I just allow the patient’s saliva to do that separating medium for me. I don’t tend to have that issue for many years now. But anything further you can advise on that.  [Lane]No, I’m the same. I just use saliva. May, may I ask though? You know, I think it’s also bis-acryl specific. I know I get sent things to evaluate constantly and I noticed a couple products. I can’t mention their names because I don’t remember their names. I had trouble with saliva. It would adhere to my immediate dent and ceiling, but I have no trouble using luxatemp so I don’t know what you’re using Jaz but yes,  [Jaz]We’re using pro temp. It’s been fine. I haven’t had that issue. I’ve had it, I’ve had it before, years and years ago. I just make sure I don’t dry the tooth. I let the saliva be there and I’m able to remove my provisional and that’s not been an issue. So maybe try that Hermit, if you, maybe if you’re drying before you placing your physical, that could be then encouraging that to happen. But of course you can glycerin cure like many of us do. April, I’m gonna come to your question again higher, but April ask when he talks about Duralon plus water and not Duralon plus the sticky mixing liquid, it comes with, is that what you meant?  [Lane]No, good question. So basically like one to one to one, like one scoop of powder, one drop of Duralon, the poly acrylic acid and one drop of water. So you’re just adding some water to the polyacrylic acid to dilute it, which also thins it. You’re not going, oh, yeah, it’s perfectly adjusted cement, you know, you push it down. What, how’s that feel? I can’t feel my teeth touching because it was too thick. And then you go through and adjust, and if you’re point half, if you’re half a millimeter thick, you’re gonna cut through it and piss yourself off. So, , it does help to add the, a drop of water to the polyacrylic acid so that it thins it. And so your rest, your provisional seats better. Yeah. Great. Great question. I’m sorry, I was not.  [Jaz]Good question. April. Well done. Excellent. Do you still use a silicon putty index for your temporary stents? [Lane]Well, yeah. I, I use the, I basically use the non hydrophilic modified PVS I use Silginat by Kattenbach. For provisionals, I just use the cheapest PVS fastest I can find, I use a plastic triple tray because I don’t care if it destroys a little bit. So, you know, keep your costs down on that part, you know? You could really keep out and just use alginate, but God forbid your patient breaks or loses a provisional, then all the money you saved, you lose in time having to freeform one. So , just the DVS.  [Jaz]The same. And I’m glad you mentioned about the plastic triple tray because that’s exactly what I do for temps. I know Richard Coates messaged me earlier today. He said he watched my crack tooth walkthrough video, and he was like, oh, that’s a good idea. So I probably learned it from you. So we talk about indications for gold. When you are stuck for space, that’s small clinical crown, there’s still a, a place for gold, fantastic self-healing material. More 0.5 millimeters. All you need really anymore is a bonus, but don’t give too much, build a foundation so that you’re not having too much of it. You explain what burnishing is and why it was historically needed, but nowadays, if we do a good job, good capture of the margin, but we may not need that skill anymore. But it’s a fantastic ability for gold that we had. You talked about cement choice. You know, we talked about bonding panavia, we didn’t talk about it, but I guess any GIC based cement. Any of these modern cements will do. Considering in your mouth there’s 45-year-old gold crowns that were, were cemented with not the best stuff. The oxy, as you said. Any anything lab consideration? You talked fantastically about milling actually, and how we need to be mindful of that and the parameters. Any other, the lab considerations nowadays for the labs who are, so they’ve invested so much in going into zirconias and, the whole, even the modelless future that we’re, we’re facing, if you like. Anything to bear in mind either picking the right technician or anything to advise the lab? I just check that they’re doing this.  [Lane]Yeah, I think it is just opening, having a conversation with them. You know, it’s what the parameters that we’re now looking at labs is internal milk, internal spacing. Don’t give me too much. I do need enough for looting. And, this dialogue goes across the board, not only short teeth, right? Shorter teeth. We don’t want as much. For what I would call film thickness for cement. because that’s an analog. But we don’t want as much spacing as we would for a longer prep, right. Where the cement has to be pushed out through. And again, when we talk about full coverage now on a normal tooth, this is where I love some of the things that are coming out from the VertiPrep crowd is where do they excessively dye space, they dye space on the axial walls closer to the margins, right? Because again, as the cement goes down, right, if it can’t escape, it’s just gonna put lateral pressure at this. Lateral pressure may set up what we call missed fractures in zirconia. So the work around that is just give, make sure you have more room there because it doesn’t affect the marginal fit at all. It just allows the looting agent to get out of the way. You know, the labs don’t understand our our parameters and honestly, we do a horrible job of collaborating with our labs. We just assume they know everything and they don’t, and they don’t see delivery of things. So this is where, we need to educate them about everything from the occlusion we want, that we desire. The internal spacing of our restorations and you know, how fine, areas that we want mill. And I would tell you that it’s hard to find labs at mill metal. And so, you may not want to use your regular lab for that. You may wanna go to a milling, specific laboratory because it is different. I would emphasize we could get away, with zirconia because it’s so soft with maybe a three axis milling machine. But when it comes to metal, man, you better have a five axis machine, go on. [Jaz]I’m pretty sure the labs I use, I mean I use for the recent cobalt chrome stuff, I’ve been using a Precision Dental studio for those in the UK in Reading, as I do for so many so much of my work. And I think they all outsource it to like a spec specialized milling facility in Germany or something. Most likely. So that’s how it usually works. Peter asked about the cost and we, we said earlier that, you know, the cost is a major factor. It’s so expensive. But a great point that Lane made earlier is that, look, if your patient is really bought in and then they’re happy to pay for your time, plus the goal, then why not? Right? Yeah, for my patients, I’m like convincing them that, look, can I please choose a material that’s not as pretty, but because this is the best, because of the space considerations and they don’t wanna pay so much, and therefore the cobalt chrome works brilliantly for them. But if someone specifically is like, oh, you know what? I’ve had great success with gold. I understand. I’ve been educated by my previous dentist, that gold is the best. Then just make sure you don’t price it so low that you are, you’re not actually making your hourly rate. You gotta make it hourly rate plus the material. And sometimes you gotta find out, okay, what is the price of gold at the moment? Speak to your technician and quote your patient. Would you agree?  [Lane]It’s like a vacationing at a five star resort, there’s gonna be plus, plus plus costs, right? It’s, and they’re built in, but they’re there. Or if you prefer it, it’s just all a card pricing. I actually show them the lab bill here, here’s the invoice, here’s the goal. And they know beforehand they’re gonna pay my fee plus the gold, so they know they’re shown exactly what the gold price is. Now, I do hide the total fee, by the way, because some, some, sometimes there’s this disconnect between, how much profit we should be making patients. I remember when I graduated from school, what was it, a multiple of five. You should be, making five to, like, whoa, today that, that gets a little more difficult. You know, they just, again, patients appreciate the option, they appreciate the honesty that you’re showing them, but don’t. Don’t take off all your clothes.  [Jaz]Don’t chip out. I just remember this question I had earlier that I blanked out on, but I, it’s such a relevant question for me. because I often wonder, Hmm, should I intervene or not? Is I’m sure guys, we all have patients who have that lower molar gold crown, which is just now got like a two to three millimeter perforation and we can see the, the core material, but everything looks so nicely sealed. Should we— [Lane]Open it? Continue to monitor it,  [Jaz]Open it, right? So open it. So perforation means, okay, we need to now intervene, right?  [Lane]Yeah. You know, patients that love exploratory surgery, look, you know, the integrity of the restoration has been compromised by design. It your teeth wear out by the gold wore out, you know, this restoration may be perfectly fine, but it could be like mold, you know, in, in the walls of your house. It could be growing underneath it.  [Jaz]I love analogy.  [Lane]Right. Every ’cause everyone hates you understand, if you’ve got mold in your house and remediation is a big deal, then we could do a little exploratory procedure. I can make a a little bit bigger hole in there and look around and if it looks fine, I’ll cut back to some thicker gold and we’ll put a nice filling in it. Yeah we can go ahead and continue monitoring it. If we find that the decay is working its way underneath this, then I’ll stop and we’ll talk about what to do next. And so– [Jaz]Okay, that’s perfect. So the intervention is basically an investigation. And if you go in and it looks clean, just rebuild it at composite back to the same level again. And if not, then now and then you can plan the new extra criminal restoration. [Lane]You know what, who doesn’t appreciate attempts, right? It’s just human nature. Like, I trust doctor because he just doesn’t say I need it redone. He’s gonna verify, right? It’s the old trust but verify routine. And these little things are huge practice builders because the next time, even if you repaired it right, and some of you will, in the same breath, tell people, you know what? You should probably get another three, maybe five years out of this before we have to replace it. It goes by like that three to five years comes around and they wear another hole. And now you can say, well, now it’s time. And they go, yep. Okay. Let’s do it.  [Jaz]It’s a great step. And also then you gain that extra data about what the situation is, is the mold situation or not. Again, I love that analogy. I hope everyone enjoyed that as much as I did. Okay. Some questions now as we are wrapping up. Final couple of minutes. Okay. Hello, Vassi-Anna Bent. She ask, my clinic uses temp on that. I always think it’s too thick. Do you think I can do the same technique of adding a drop of water prior to mixing previously lane? We’ve used Vaseline? Is that acceptable?  [Lane]Yeah. Temp-Bond, if you add water to Temp-Bond, that’s what causes it descent. So don’t do that. Vaseline, yes, it’ll thin it, but remember Vaseline is a plasticizer, so it keeps the temp on from getting hard. So if the prep isn’t very retentive, you don’t wanna thin it with Vaseline because it will come off. But if it’s fairly retentive, then straight temp bond is fine. You know, the trick is to get to, dry the tooth, get it on quickly, and press firmly, and then have them bite on it. And I tell people to bite. It’s like, so. So many things, right? Taking a double bite PVS impression, the workhorse of of indirect restorations. You know, I need you to find your bite on the not numb side, or I’ll do a savior behind bite. And you know, you’re gonna need to keep your teeth together for five minutes. And when I say together, on a scale of one to 10, if one is completely open and 10 is as hard as you can clench, I want about a five. I just want moderate pressure. So when they’re biting on their provisional, I tell them I want a 6 or 7 And they go, oh. And you can see them bite a little firmer. So– [Jaz]I like that visual scale, if you like. It’s very, very, very good. Yeah. One technique I use for sometimes if your biral is a bit thin. This was taught to me by Sophie Lane who was taught by Attiq Rahman, who I’m sure you use this technique as well, is when you have a thin bis-acryl and you are worried about a cracking on the pressure of the cement is to just poke a little hole in it, an escape hole. So I think that’s what I was thinking, like, if you’re having a feeling, like a stick put a little escape hole, maybe politely lingually and then that’ll give it a nice escape and hopefully less likely to fracture. Yeah. Anything you wanna add to that lane?  [Lane]No venting is perfect, right? And again a little, just a little drop of flowable composite, zip hit it with the light and you’re fine and dandy. You don’t even really even need to smooth it most of the time, in fact. you know, when it comes to really short, short teeth, if there, if it’s an onlay you know, I’ll not only tack, a little bit a drop of a flowable on the margin of the buckle and lingual, I’ll lock it in underneath in approximately two, . [Jaz]Okay, great. Last questions. I saw research from Henry Kaye. I saw research suggesting that gold lasts 40 to 46 years. Would that reflect the body of the research? Hence, it would be okay to suggest that gold may be better value for money than a ceramic. I like this.  [Lane]Well, okay, so here’s the problem. When you’re looking at articles, the literature, you’re talking about all cohort, articles, right? So, Terry Donovan, the classic one is Terry Donovan looked at Dick Tucker’s nations, thousands of gold restorations, 40, 45 years and of course. Well, Dick Tucker did them. So attention to detail. A crappy fitting, indirect restoration is gonna have crappy longevity, period. It doesn’t matter if it’s submitted with panavia or zinc, oxyphosphate. So the truth of the matter is a well executed. A partial veneer, gold crown or even a gold crown will have a much longer run clinically in the mouth than anything else that we have today, meaning all ceramics because we just don’t have the longevity studies behind them. Again, lithium disilicate in its current form is pretty damn nice, but it took decor Empress two. Aris, which lasted a year before we got to emax. Same material, same company. It took four evolutions before we got there. And so again, we’re still talking 15 years, right? We’re not talking multiple generations. So there are people that are gonna go for longevity versus pretty. And I don’t wanna call it a marketing pitch to utilize metal in people’s mouths. It’s just a reality. Well, Mrs. Smith, what is your desire? Longevity, or pretty, you know, you’re say 45 years old possibly. If we make it pretty, you’re gonna have to have it redone once or twice in your lifetime. That’s just the odds. You’re 45 years old. You know, if we use metal and we’re conservative, you know, this restoration can last you the rest of your life. Okay. And just patients then pull their values into it. Right. It’s the patient’s why it’s not our why, you know? We’re, we’re just the providers of the how we do it. You know? We know what we do. Mm-hmm. We fix teeth, you know, it’s, how we do it is based on. The patients why? And this is why as you talk about Jaz understanding patients gaining their trust, don’t be in a rush to do a bunch of c when you first meet them. This is where trust and value are established. And so your words and your dialogues are actually being listened to versus just going in one ear and out the other. And that’s critical for all of us, no matter where you are in your career, because you always want to have the patient who is part of the decision process. You’ve heard my dear friend and my brother from another mother, Michael Melkers. I mean, he loves to quote Albert Schweitzer. Every patient carries within them their own best doctor. It’s our job to help them find that doctor.  [Jaz]Lovely. And Henry, just to add you, you mentioned, you know, better value for money. It was a paper I saw on the BDJ. It was maybe, gosh 10 years ago now. I saw it come through in the post and it was like, it had exactly that parameter, like, you know, gold this many years, therefore divided by the actual cost, whatever. And then, yeah, it came out the best in that regard compared to the data that we have for ceramics. And that’s exactly what Lane echoed and Julieta says, thank you. She always loved gold and now she knows why. Amazing. I love that. I guess last two questions guys. And then we will say a good thank you to Lane A higher asked, in what clinical scenarios might a THREEQUARTER or Seven Eighth Gold Crown offer a superior solution to full coverage? And what are the technical risks of these designs? I like this question.  [Lane]Well, again, at the whole concept of partial veneer is to save as much tooth structure as possible while, while protecting the cusps that are undermined, that you need to restore. So, properly done. There’s no need to do full coverage, right? Why? Why do you wanna do full coverage? You wanna cover from, let’s go from the top down. Alright, let’s do, why would we pick an onlay over a, a direct composite restoration Well, the cusps are unsupported. They’re gonna fracture. Then if there’s more of the tooth broken down, say the palatal cusp of an upper molar. Well, you know, now you’re going to circumscribe that, and that can be done with a three quarter crown, seven eighths crown may be necessary because, okay, now the buccal cusp of the tooth is broken. So we come around that we still have to cover the cusp. It’s just how much coverage do we need to integrate everything? There is a philosophy, this is my philosophy, so again, quote me versus date me. I would rather not for the reasons that Biomimetic talks about drop margins, past the gingival third of the tooth, not because of the more fringes and and strength, it’s just I don’t like margins, in non cleansable areas you know, it’s always still, I mean, how many patients do we see that still get, you know, caries on the roots, the buccal roots of their molars? So, that’s just me. But there’s really, in terms of longevity, a well-designed three quarter, seven eighths partial veneer crown is going to last every bit as long as a full coverage. And the reason we’ve gone back to partial veneer coverage and why I do like bio medic is that the more tooth we preserve means, the more we have to work with down the line. You know, there’s a point where a tooth can’t have any more work and we never wanna get there.  [Jaz]Well, whilst we argue about the, the merging data and how some of the data may be in vitro, and we need more in vivo to be able to substantiate some of the biometric claims. One thing Pascal Magne said in a recent podcast coming out tomorrow actually, guys on Protrusive, is he said, the meaning the real crux of biometric dentistry is if something fails, the tooth is still there to work with. And that’s gotta be loved, right? So, so that’s great. Thanks for your wonderful questions. Absolutely brilliant. Last ones a crazy one. What about a gold crowns on implants? I know of a madman who wants gold on implants? Are the, are there any strong contraindications? None whatsoever.  [Lane] Again, we started this whole conversation as gold’s weakness is its strength, right? Implants don’t have PDLs. Right? Think, about this. Can you, some of my biggest zirconia failures were all on Xs opposing all on X zirconia. They just broke and we’re talking well designed connectors. I mean, these, these things were thick, but yet they still broke. We sent them in for fractographic analysis. And the failure mode was, was again, one, was a tool grinding mark that just never healed it. But the sheer fact is that we, you know, having a softer, forgiving, adaptable material on top of an ankylos tooth, which an implant is, I think is a great idea. It’s just getting patients to accept it. So do it.  [Jaz]If Eliana, if you’ve got a madman go with it. Use it as an experience to, to deliver something that’s gonna probably stand the test of time. And you know, as we know, implants are ankles, as Lane said, so it makes a lot of sense, so amazing. We actually managed to r through all the questions. Lane wise, I love I just wanna show some appreciation. I love your just no BS way of just educating. Honestly, I just feel when you ask someone who’s a podcaster, and I don’t know maybe I’ve shown this publicly or not, but of any guest I’ve ever had. The history of Protrusive or maybe I ever will, you have been my favorite in the sense of easy to podcast because I ask something and you give a wonderful, coherent answer and then you stop and it’s like, wow, okay. That was like, you just put it on a plate for us and like you are like, okay, next. And honestly, it’s just brilliance. Thank you for your education style. Thank you for your wisdom. Thank you for all your contributions to our little community over this one year so far as we’re a baby community growing and thanks for everything you do. Everyone’s just pouring in with thank yous and it is just so nice to see. So Peter agrees with my sentiments there. And Miles, thanks so much for joining us to make things practical. Understandable. Amazing. Thank you so much, lane. Anything to add? Are you coming to, I know you hate flying. I doubt you’re coming to Europe anytime soon.  [Lane]No, but there, there’s these two guys that are speaking in Chicago, Midwinter at the AES next year that I think I will fly to see So.  [Jaz]Oh my God, that’d be amazing.  [Lane]For those of you who don’t know, for those of you don’t know, the American Equilibration Society is one of the premier restorative academies in America. It is a huge honor to be asked to present in front of this group. Mahmoud is online to speak at our 2006 meeting. So, you know, my hat’s off to you, from mentee to mentor. This journey is wonderful. Thank you for everything you do. The torch, honestly, my friend as, as a mentor, is a and an educator is being passed to you and I cannot think of a better person. So, keep doing what you’re doing, man.  [Jaz]I love it. So thank you so much. I mean, me and Mahmoud we talk about this the next year, February, and we get this major imposter syndrome because it’s such a amazing crowd and all these educators. And thankfully they gave us the paracetamol slot on the second day, first thing in the morning. But, it’s great. We’re hung over grumpy then. Perfect. Honestly, it’s so, I mean, what a what a what a lineup, right? We’ve got Jeff Rouse, Dania Tamimi, Łukasz Lassmann. So guys, I would love for as many people as possible in this chat here to come and join us in Chicago next year. You know, hot dogs on Michael. Michael’s gonna buy us all hot dogs. It’d be great. Oh, hot’s coming to a lovely, amazing place, so already what I love here is Vassi says, I can’t wait to re-watch this amazing presentation. And of course, for those in the future listening to Spotify and stuff, I hope you enjoy it as well. Lane, thank you so much from all of us.  [Lane]Thank you. It’s been a pleasure and an honor as usual. And hey, feel free to reach out anytime. If you know, I’ll leave one of my father’s favorite quotes about me. You know, most of you got to hear the real, heart Puller commentary in London. But my dad was always fond of describing me as well. He may not be able to dazzle you with his brilliance, but he’ll baffle you with his  Jaz’s Outro:Well, I like that. I like that very much. And it just wraps things beautifully with the, none of what you say is ever my friend. I love it. It is amazing. Guys, thank you so much for this rare live podcast lane. Thanks again for making time for it, and I’ll see you in the group and see you next year in Chicago. That was good. Bravo. Thank you. Alright. Thank you so much. Well, there we have it guys. Thank you so much for listening all the way to the end. If you’re watching on the iOS Android app or the web app, scroll down 80% in the quiz, if you dare, and you’ll get your certificate sent over to you. We are a PACE approved education provider. If you’re not yet a member, head over to protrusive.co.uk/ultimate. We’ve recently added splint course on there as well. So if you’re looking to learn occlusal appliances, you can check that all there. So if you’re looking to learn occlusal appliances and management of bruto and protecting that delicate restorative dentistry that you do, that’s now part. Of the Ultimate Education Plan.  I also wanna take another moment to thank my team, especially some new members that we have got Dr. Xyra who joined us about three or four months ago, and she’s responsible for really improving our premium notes.  Also, some of our infographics that we make, she’s spearheading that and honestly, we’re able to add so much more value thanks to Xyra Also, a shout out to Angel, who’s the newest member. She’s really helping a lot with getting these initial edits of the podcast before they enter an even media sequence, as well as a lot of the video work behind the scenes, including editing the 21 day photography challenge coming next month. And lastly, our new manager, Alex. Alex, has been messaging some of you on cursive guidance. Alex, you’ve been an absolute breath of fresh air. We are so lucky at Protrusive to have you. Thank you for looking after the protrusive so well, and being part of the team. I’m just so excited about how we’re going to grow our mission. To make dentistry tangible, prorate, watch this space. Honestly, it’s a very exciting time here at Protrusive and I wanna thank you all for being part of it. Thanks for listening. Again, I’ll catch you same time. Same place next week. Bye for now.

Can you apply the Dahl technique to localised POSTERIOR wear? Spoiler alert: hell yeah! How can the Dahl Technique help when there is posterior wear and NO space to restore? How predictable is building up posterior teeth (rather than the usual worn anteriors)? In this episode, Jaz dives into the ‘Reverse Dahl Technique’, a twist on the classic method typically used for localized anterior wear. Dr. Hans Kristian Ognedal from Norway shares his insights, explaining how building up posterior teeth with composite can lead to occlusion magic!  If you’re curious about this technique and want to see a real-life case study, this episode breaks it all down, with a special visual breakdown for those watching on YouTube or Protrusive Guidance. https://youtu.be/V8MTFfXmdlw Watch PDP235 on Youtube Protrusive Dental Pearl: Jaz shares insights from Hold On to Your Kids by Dr. Gordon Neufeld & Dr. Gabor Maté, emphasizing how modern children lose parental attachment too soon, turning to peers for guidance. This shift can lead to anxiety and emotional disconnection.  Takeaway: Kids thrive when their primary attachment remains with parents, not peers. Strengthening this bond is crucial for healthy development.  Need to Read it? Check out the Full Episode Transcript below! Key Takeaways The traditional Dahl principle focuses on creating occlusal space for anterior crowns. The reverse Dahl technique is a direct method for treating worn POSTERIOR teeth. Diet plays a significant role in tooth wear and dental health. Taking photographs of patients’ teeth can help track wear over time. Understanding the etiology of tooth wear is crucial for effective treatment. Building up dental anatomy is essential for successful restorations. Occlusion should be viewed as a dynamic system rather than a static one.  Patients can adapt well to this treatment modality “Patients that wear their teeth, they don’t usually have TMJ problems.” Highlights of this episode: 02:22  Protrusive Dental Pearl 04:50 Guest Introduction: Dr. Hans Kristian Ognedal 07:06 Understanding the Original Dahl Concept 09:31 Exploring Reverse Dahl Technique 13:30 Etiology and Patterns of Tooth Wear 23:46 Facial Patterns and Occlusal Traits Linked to Wear 24:44 Clinical Approach to Posterior Wear 30:26 Patient Comfort and Staging Treatments 32:11 Cuspal Planes and Guidance 34:21 Review Schedule and Observations 38:44 Longevity of Treatments 44:04 Contraindications and Patient Selection  45:24 Case Studies and Practical Tips 49:30 Night Guard Use 53:06 Final Thoughts and Education Opportunities If you want to learn more about Dahl Technique, be sure to listen/watch: Why do some Dentists find Dahl Distasteful? – PDP016 Dahl Part 2 (The Spicy Bit) – PDP017 Dahl Technique and ‘Maryland Bridges’ – GF001 This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes B and C. AGD Subject Code: 180 OCCLUSION (Occlusal functional concepts) Aim: To explore and understand the Reverse Dahl Technique, focusing on its application for patients with localized posterior tooth wear. This technique provides a solution when posterior teeth are worn, and there is insufficient space for proper restoration. Dentists will be able to – 1. Understand the principles behind the Reverse Dahl Technique and how it differs from the traditional Dahl Technique. 2. Identify the clinical scenarios where the Reverse Dahl Technique can be applied. 3. Comprehend the role of composite build-up in restoring posterior wear and its impact on occlusal reestablishment. Click below for full episode transcript: Teaser: I think it's a tooth where it's probably a modern disease of our own course. I think I disagree on that one. I think the patients that wear their teeth, they're able to load their teeth quite hard, much harder than I'm able to do. I have an interior open bite and the Class III, I've never been able to touch my front teeth. Teaser:I don’t wear my back teeth. I think I am not able to generate a type of forces that wears my teeth. But I think most patients who wear their teeth, they’re usually in full occlusion. I think having posterior where it’s more a function of consequence of how they function, how they chew, how they eat, how they swallow, how they process food when they take food into the mouth. Jaz’s Introduction:So whether you use it or not, I’m sure we’ve all heard about the DAHL technique, right? This is when you have localized anterior tooth wear, and what you’re doing in this case is you are building up the anterior teeth even though you don’t have space. And so because you’re building these teeth up, when the patient bites together, now they’re prematurely hitting their front teeth, the back teeth all open. There are like bilateral posterior open bites, and what happens over time is intrusion of the anteriors and you know, over eruption or Dento alveolar compensation of the posterior and the occlusion. Like magic reestablishes. So if you wanna go deep dive into that, check out our previous episodes on the  DAHL technique. Like these are some of the ones we did five years ago with Tiff Qureshi, and they are literally like Protrusive Wall of Fame. So do check out those and I’ll link them at the bottom. But today’s episode, my friends is on something quite different. It is same, same but different as they say in Asia, right? It is the reverse  DAHL technique. Now instead of having localized anterior tooth wear, we have localized. Posterior tooth wear. Think of that patient who when they bite together, their posterior teeth are just shot, right? There is exposed dentine, there is lots of erosion, and so you’ve got plenty of localized posterior wear. And then the premolars, canines and anteriors are maybe a little bit worn, but not that worn. And the problem we have is that yes, the posteriors are worn, but when the patient bites together, the back teeth are all contacting, meaning you don’t have space. So with the reverse  DAHL technique or modified  DAHL technique, what you do then is you build up the posteriors in composite, you leave the anteriors out of the bite, and then like magic, the posteriors will intrude and everything else over ups, if you like, and the context will reestablish. Now, our guest today, Dr. Hans Kristian Ognedal from Norway, does a wonderful job of discussing this technique and his experiences, and at the end, he shares a case. So for those of you who are listening, while you’re jogging on a train, while you’re driving, don’t worry, I describe the caseand the exact scenario. For those of you who are watching on Protrusive Guidance or on YouTube, you’ll actually get to see the images as well if you listen all the way to the end. I was quite excited to record this episode because it’s a, a new one, right? It’s a, it’s a new thing for me. I haven’t seen much published on the interweb about this technique, so hopefully you’ll learn something new. Dental PearlTalking of learning something new, every PDP episode I give you a Protrusive Dental Pearl. Now, as you know, I’m a family man, and for those of you on our community Protrusive Guidance, I’m always talking about the books that I’m reading, or actually I’m listening to on Audible. The current one, I just feel compelled to talk about it. It’s called Hold on to your Kids. Like I’ve got two boys, a 6-year-old and almost 2-year-old, and I think a lot about being a dad and being hopefully a good dad. I actually always wanted to be a parent. I actually love my role as a dad it’s my favorite title in the whole wide world. Quite often I’ll pick like, you know, parenthood books or relationship books because just like I’m interested in dentistry and I read their dental literature. I’m interested in parenting and being the best parent I can be. So I kind of am attracted to these kind of titles. Now, the book, again is called Hold Onto Your Kid, it’s by Dr. Gordon Neufeld and Dr. Gabor Matè. And it essentially talks about how in modern society, children lose the attachment to their parents too soon. And so what it talks about is that what children of modern society do is when they lose that attachment to their parent, they then gain the attachment from their peers. And then it’s like, you know, the blind following the blind and there’s a major cause of anxiety and disconnection from family. I’m actually now just getting into the really good parts of the book where it’s actually telling me solutions, right. You know, the whole several first few hours are talking about the problem, right? The problem of losing attachment to a children and how you cannot serve two masters so they can’t be attached to their peers. And attached to you as their parent. At the same time, they have to pick one. And the way that we have the schooling system, the way that we have social media and phones, that they’re constantly now messaging each other and they’re gaining their attachment from their peers no longer from their parents. Now we need that parent attachment for them to have a healthy emotional development and emotional security. So I’m listening in now to all the strategies we can use as parents to literally hold onto your kids and hopefully watch them grow into kind and courteous, and emotionally healthy adults. So I just wanna talk about this book and I want to share it with you, right? That’s my pearl for today. I know it’s not very clinical, but I like to talk about what’s important to me. And right now what’s important to me is parenthood, and I know so many of you are in the same boat as me, so check it out, hold onto your kids. It is quite heavy. It’s like one of those books, like, you know that book, why We Sleep? Like you can just summarize that entire book in one sentence, which is like, sleep is really important, right? So the vibe here is that parent attachment is very important, way more important than peer attachment. And so hold onto your kids, but really it’s the strategies that it gives you. So I’m just getting to good bits. Now. And if you’re interested in this, do check it out. I’ll put the link in the show notes now, let’s now join Hans for the full episode. I’ll catch you in the outro. Main EpisodeDr. Hans Kristian Ognedal, welcome to the Protrusive Dental Podcast. It was so nice, , just a few, a few months ago now, I think, to spend some, , time together in Bergen. And I was really amazed by this presentation that you gave, talking about this technique that we’re gonna talk about today. You know, Hans, I didn’t tell you this right, but this podcast right now, it almost didn’t happen. If you asked me 20 minutes ago if this podcast happening, I would’ve said to you no. Okay. Because we were having a Lego incident. We couldn’t find a Lego. [Hans]You couldn’t find a Lego. Oh yeah. The kids were going to bed and, , the Lego was missing,  [Jaz]I needed new Batman robot lego that we built yesterday and the issue that we turned the house upside down and obviously I was getting the blame that the Mrs. was blaming me. And then, anyway, she had tidy it away somewhere and she won’t admit it, but she found it and I’m so glad that we get to talk about, and this episode gets to happen tonight because you’re such a busy guy, man, and so I’m glad. I’m really appreciative of the fact you made time for this today. Of course, please, of course. Can you tell us about yourself, Hans? [Hans]My name is Hans easy way. I really enjoyed dentistry. I’m not a specialist, but I’m specially interested in dentistry. It’s my hobby, it’s my work. I enjoy every part of dentistry, I enjoy talking with colleagues, I enjoy treating different cases of all kinds. I love composites. I love ceramics, I love surgeries, and , the lecture you heard was about treating worn teeth. And lately that’s what I’m talking quite a bit about. And, and it’s also a problem that’s rising and you see more and more of tooth wear and yeah. So it’s definitely a challenge that has come into modern dentistry. [Jaz]Tell the listeners where in the world you are speaking from today, just so I want them get a better context. [Hans]I’m speaking from Stravanger Norway. It’s in the southwestern part of Norway right now. We are in March and we. Don’t have snow at the moment, but it’s just turned cold again, so who knows what’s going to happen. It’s generally a lot of weather on this side of the Northern Sea, more mellow. [Jaz]You showed me some images, family images of the weekend going skiing and stuff and I mean, that was really cool to see. And you’re a family man, but you’re a really great dentist, very well-rounded, and you know the amount of where you’re treating. I think we have so much to learn and unpick with you today, Hans. Yeah. I think want to start with just, just a quick review. I know I have episodes on this already, but for our younger colleagues just recap the original  DAHL principle that we kind of used today when we’re doing the anterior teeth. ‘Cause we’re talking about the opposite today. Yes. But just recap the anteriors. [Hans]To recap, the original  DAHL’s concept was about creating occlusal space for anterior crowns. And so they made from cobalt steel plate tooth that they either cemented or just attached to the front teeth and then the patient walked around, chewing on those and over time would create occlusal space for making anterior crowns. But  DAHL has evolved over time. And now that we have direct composites, most  DAHL cases are made with anterior composites. You build them up politically, and then teeth intrude or erupt and into full occlusion over time. So that’s the original  DAHL’ concept with a modern take on it.  [Jaz]And in Scandinavia and in the UK we’ve really embraced it. I feel like we are the pioneers when you obviously Scandinavia, but then UK is very popular treatment, here, whereas my dear friends in the States, they’re almost very skeptical about this. And what is your take on this? Did you know international friction to adopt it? [Hans]I think there are quite a few myths concerning occlusion. They’re kind of scary, so when I was a young dentist, we didn’t learn very much about occlusion, which is perhaps why I do what I do, because I don’t know, didn’t know enough occlusion or didn’t. Believe enough in occlusion we left. That hinder me. I think it’s a problem with breaking myths. It takes a long time to adjust to new information and or new information trickling down and especially on the  DAHL concept, which was a thing in the 60’s and 70’s, there hasn’t been much research on it after that.  And it’s also a fairly cheap technique. There’s no one willing to invest in it and invest in doing the research on it, because if you do it right, it’s really, really cheap and you can’t make money of it as a company. So that’s, I think it’s somewhat forgotten and somewhat lost in strong opinions on occlusion that confined around the world, if that’s fair to say.  [Jaz]That’s a really, really good point about a lack of interest from companies and the trade in this technique. ’cause it’s the way it is, right? And therefore that could be a fuel and the fact that it’s not been pushed about as much as it could. Now, what we’re talking about today is a different way of doing  DAHL. Now, I like to call this the reverse  DAHL technique, but what’s the difference between the reverse  DAHL and the modified  DAHL. When you say that, do you mean the same thing or what do you mean? [Hans]Yeah, I think we mean the same thing. I was able to have a conversation with Reyes recently on the  DAHL technique and what he’s doing, and I told him what I was doing and yeah, I think it’s the same thing. It’s just, I chose to use the word modified because I don’t think it’s really reverse. I like the name. [Jaz]I think it’s cool, like Opposite  DAHL technique, Reverse  DAHL technique. But yeah, I see it okay so guys, when we say modified or reverse, we, we mean the same thing.  [Hans]Because a reverse start to me would mean that you grind teeth down to let them over the rough. That would be the opposite of doing good. Well, the opposite of want to what you want to achieve.  [Jaz]Exactly. Now we know there’s the direct composite splint technique, which I did have the authors of that paper on the show two years ago. We know when you have a cracked molar and you actually bond composite. To make it in supra occlusion and then the composite will stop the cusp from flexing at the same time because that’s the only tooth and occlusion that’s going to intrude. Then when you take off the composite, you now have occlusal space. Is this something that you did first or you entered into, or I guess share your journey about how you first got into this? Was it from anterior  DAHL to in posterior a modified way? How, tell us more about that.  [Hans]Well, I started like everyone else doing the Anterior  DAHL, and then I started to struggle with what you do when you wear your molars. And in the beginning I did what I was taught. I was taught to do gold on lace you can make them really thin so you don’t grind away too much tooth, or if the tooth was damaged in other ways, you could do a crown. So that’s without touching the vertical dimension. So that’s where I started. And then I thought, okay, this is going to be really expensive for the patient, or some patient couldn’t afford doing treatment that way.  [Jaz]So when in those scenarios we have, posterior only wear the way you would manage it traditionally at the beginning was gold posteriorly to rebuild the structure or or protect the integrity of those posterior teeth, right? Now, when you were doing that, you were still conforming or were you opening the vertical dimension on the gold?  [Hans]No, I was still conforming, trying not to open the video. If I was, I would combine that with doing something interiorly because I was really afraid of opening the vertical dimension and-  [Jaz] Despite doing the anterior DAHL stuff. ‘Cause for me, early on in my career when I started to do dial, that was a massive help in losing that fear, right? When you start doing  DAHL and you do a lot of it, you’re like, hang on a minute, my patients aren’t dying, their condyles aren’t popping out. Maybe we’re okay.  [Hans]Yeah. Like I said, this is really early, so this is maybe 17, 18, 20 years ago, so because I’m not a young man anymore, but then it kind of progressed. I started covering exposed dentine, I thought, well, at least I’m going to buy this patient maybe a year or two.  And it’s really easy to do just flowable composites and when a referred patient to orthodontists to have work done, not particularly wear patients, but they were putting on, oh, we need to elevate the bite we’ll put on like three millimeters on this tooth and the patients didn’t seem to complain about it, and I thought, well, maybe I should try putting on a little bit more. And then I knew that if you want composites to last, you need millimeter and half. I thought, well, well, let’s try that one. Let’s try putting on a millimeter and a half.  [Jaz]So kind of like you applied the bite turbos in the orthodontic world to this setting. It’s interesting though, Kushal Gadhia, a restorative consultant once taught me years and years ago, and I love it because sometimes patients tolerate big changes in occlusion better than the tiny changes. And that was like a really funny thing to learn actually. And I think it holds true.  [Hans] Yeah, I think there’s some truth to that. If you’re off by a 10th of a millimeter, that might be quite painful for the patient. But if you build it up two millimeters that doesn’t seem to pose a problem. Patients usually tell me about, it feels a bit weird the first, first week or so, and then it feels fine, they’re not bothered by it. There might not be an occlusion at that time, but they’re not bothered by it anymore.  And some people just forget that they’ve had it done at, or they just function normally. Through the day, and when you see them next time, they’re almost in full occlusion. So I have done that on single teeth. I have done that on just a few teeth, but usually when I do posterior buildups are that high. It’s part of a full case where you do multiple buildups.  [Jaz]Okay, well let’s move on to that then. Let’s imagine a case of localized posterior wear, right? So we’ve got anteriors that typically look pristine, right? And maybe they have their mamelons got the incisal halo. They usually have good looking anteriors, but the posteriors are worn into dentine. I think it’s important to discuss the etiology aware in these patients. What have you found was, was the cause to factor in these patients that pattern aware? [Hans]The pattern aware. I’m not sure if I have a part in my lecture where I talk about the pattern aware and usually I divide the cause of wear. It’s, well, I’ll have to go back to what’s erosion, what’s attrition, what’s abrasion, and I find that in most cases there are some assets involved there’s some erosive component involved in where, and if you want to see that, okay, there’s no most likely an erosive component. Where’s that acid coming from? Is it internally or is it externally? So having a chat with your patient, having the patient make a chart of their diet for a week, for instance. And then you can go through that with your patient and try to pick out stuff. And you can see, because you can’t really tell if the assets from the external or internal. From the pattern of wear, because I think the pattern of wear is probably due to the way the patient chews, how the tongue covers the teeth, how the cheek covers the teeth. So you can’t really say, is this internal, is this external? So if I can’t find anything in the diet that can cause that type of erosive wear, of course we’ll have to look at, do you have some type of reflux? Is it, you might not have symptoms on reflux, but you might still have reflux. I’m not sure if you think know the term silent reflux and I, I apologize for my English. [Jaz]It’s oh, dude. You should hear my Norwegian. It’s not very good. No, dude. Honestly, you’re doing great. But they’re silent reflux, quite classically. People say that you have like this, like, like this, like a little cough that’s called kind of is pathognomonic of this.  [Hans]Yeah. But you have to kind of tease it out in the conversation because they haven’t really thought about it and they say, well, I haven’t really thought about it. And then you see them in a couple of weeks or a month later and they come back and say, well, yeah, actually I feel some of the things that you’re talking about. [Jaz]So at that stage from you, is it before you do the treatment, is it referral to the GP or how do you make sure that before you start treatment you fix it? [Hans]Referral to the GP, sometimes referral to gastro. There are some new guidelines and gastro in Norway. So now they start treating on suspicion. Instead, if you’re un under 50 years old and they suspect that you have some gastric reflux problems, they start just treating with Antiacid right away. So because they think that swallowing a camera and doing pH measurements is, is way too invasive and takes too long and costs the society too much money, so much easier to get a packet of tablets and try it out.  [Jaz]It’s like, you may not be treating the root cause, you’re just kind of medicating the issue. But that’s a, a whole different topic as long as the acid is not destroying the teeth, I guess. But ideally in a utopian society, it’d be different.  [Hans]If you are discussing the root cause, I think the diet, not the modern diet, is an underlying cause of most of these ailments. So diet is underlying gastric reflux, obesity, and also tooth wear. Because we live in a world where all food is you can get hyper palatable food that is really scrumptious to eat, sometimes very high in calories, sometimes no calories, high in acids, and zero nutrition. And I think it’s a tooth where it’s probably a modern disease of our own course. Whereas in the past, like if you see there, I went to the London Museum and saw the old Egyptians in there and had took pictures of their teeth, and they were eating drains with sand in it, and of course they’d bought their teeth, but now we know better. But now we’ve caused our own problems by having the food industry working.  [Jaz]So to add to that, professor Bartlett, when I was his DCT trainee, probably the worst train he’d ever had, but he, he taught me one thing, which was when you have the purely Attritive patient, the patient who’s like, you know, a severe grinder and you can imagine the tooth contact time for that individual, you know, during the day and night could be high in an imagined scenario, but even that patient will not wear away their teeth that much because ultimately enamel and enamel is like two similar AKA identical materials rubbing on each other. The wear is not that extreme compared to, let’s say, rough porcelain against enamel. The enamel will take a hammer, right. So actually when you put a one drop of lemon in the equation, you see serious escalation. So I’m glad you started with that, that actually acid erosion’s a huge, huge player. And when we see these worn teeth, don’t ever just think, oh, this grinding is, you know, 99.99% time, there will be acid erosion and that’ll probably be the primary player.  [Hans]I completely agree. I have some bruxist in my practice, there’s some psychiatry involved in bruxism, at least with a patient I see. They have maybe a tick, like they’re tapping their teeth or grinding their teeth and those cases are of course, really, really problematic to solve. And of course it’s also psychiatry, which means there’s less income. There’s yeah, all sorts of problems regarding those patients. And of course my composite doesn’t last as long, but you can redo ’em. That’s the beauty of this technique that we’re going to talk about is that you could just redo it, you can sandblast it and you can put on some extra.  [Jaz] As Tiff Qureshi who, who does so much for  DAHL and making  DAHL accessible to dentists around the world, and what a absolute legend he is. I love his term, you know, recycling the  DAHL, you know. Five years, 10 years later, recycle my patient’s on, on her second recycling of the  DAHL right. And it’s just amazing what you can do exactly how you explained.  Just find up on the etiology so why do patients present with localized posterior wear acid erosion a huge player. I, and please, like, correct me if I’m wrong, because I feel as though you have a lot more experience in looking into these localized wear cases. I feel as though these patients may have started with an anterior open bite type of occlusion whereby, they already had a heavier posterior occlusion, and then when you put the acid to compound on that, it’s like the opposite to the deep bite patient. Think of the deep anterior deep bite patient where they, they destroy the anteriors more and the posterior are sped it’s like the reverse situation. Where you’ve got the class three or the A OB, the posteriors are just get more chewing time, more contact time. And then when you throw acid into that, by the time the posteriors have then worn down, the anteriors now are getting in contact. This is just my theory and this is what, what do you think about this? [Hans]I think I disagree on that one. I think the patients that wear their teeth, they’re able to load their teeth quite hard, much harder than I’m able to do. I have an anterior open bite and the class 3, I’ve never been able to touch my front teeth, I don’t wear my back teeth. I think I am not able to generate a type of forces that wears my teeth. I do have jaw pain though.  On the opposite side, you have the patients who never have jaw pain in in the muscles, and they. Are usually in full occlusion. They have a really heavy bite on and they load all their teeth because they need all their teeth to support that amount of force. I have this one patient who he managed to intrude his teeth. He had a full arch bridge on 11 teeth, and he managed to intrude that bridge into his gums. So that’s an outlier of course, but I think, most patients who wear their teeth, they’re usually in full occlusion. I think having posterior wear, is more a function of consequence of how they function, how they chew, how they eat, how they swallow, how they process food when they take food into the mouth. I think that’s probably more important because I don’t think none of these patient, I think it cry to having a anterior open bite that usually means patient with anterior open bite, usually have a large maxillo mandibular angle. They have usually like a long face like I do, usually more crowding. If you have a tongue thrust, you’re biting on your tongue which kind of stops you from biting too fast.  So the interior open bite cases, those are actually the cases where I don’t recommend doing a modified  DAHL reverse style. If they wear their teeth, they usually, they wear their cusp, the molar cusp, they wear them flack because they, that’s the way they function horizontally. But when they’re worn flack it stops. If you don’t put acid in there, or significant amounts of acid, even with exposed dentine, that where just stops when the cusp are ground down and the patient functions in laterotrusion, then it stops in those patients.  [Jaz]No, no. Definitely. Where when I observe that you find that, yeah, the molars are very flatten, but they stay like that. When you see them year after year, and you could do a time lapse and, see how, how they progress and they stay very stable.  [Hans]Yeah, I definitely do recommend taking photographs, following your patient with wear. It’s always beneficial to have a long-term relationship with your patients, so usually if you could at least observe them for a year or so, that would be nice. If they’re in pain, if you have to do something. Yeah. You don’t have to shy away from that rule and, and treat them of course, but if you can spend some time with them, have a checkup or, or two, take some photographs and sometimes information pops up. That’s really interesting to know.  [Jaz]It is important to have those conversations and plant those seeds. [Hans]Oh boy. But I place a lot of blame on, on diet, but of course, there’s some environmental courses as well. So if you work in industries like smelting, there’s sulfuric acid in the air. If you work in swimming hall, the chlorinated water. Chlorinated it with highly chlorinated water that also may cause erosive wear.  If you’re a farmer, you’re using methyl acid you use it to preserve grass in dairy. Okay. That will also be in the air while you’re working with it so I’ve seen a few farmers having worn their teeth, and I think it’s probably due to that because couldn’t find anything in the diet, couldn’t find anything on reflux, so possibly environmental for them. So it’s a good thing to know your patient and have a conversation that you’ll learn. Surprising stuff once in a while.  [Jaz]So that’s where the occupation history and the social history definitely comes into play in these erosive cases. That’s a hundred percent for sure. In these cases, Hans, have you noticed a pattern of types of occlusion? So do you find that you’re seeing more class 2 people, class 1, class 3 people? Like any traits that you see people with shorter faces, stronger muscles, traits that you see?  [Hans]Yes, definitely. So in the literature it is called Brachy facial Patients, the square faced patients. Those are definitely on the wear list of patient who wears their teeth. You can also see that kind of in the middle, the miso facial patients, and then you’ve got long face patients where you don’t see much wear, but usually you see more TMJ issues. So definitely it’s the Meso facial or the squareish face patient. I usually take pictures of my patient’s face from the front and from the side, and that’s quite informative sometimes.  [Jaz]I think that’s so important for anyone who perhaps doesn’t do that. Sometimes when I was younger, I was only taking photos of the teeth and I was missing that information. And I think the more you appreciate the face and the role of that and the muscles is definitely a great, great idea to start taking that facial photo as well. Let’s imagine that example case that we’ve imagined there are posterior localized wear, and we’ve said that “okay this patient has probably a brachy facial, strong muscles, silent reflux, and they’ve managed to see their GP, and let’s say they’ve controlled it, and now you’re looking to treat and plan this case because this patient’s young. The primary reason to treat here is not aesthetics, it’s far from it, is to preserve their teeth to make sure that they will keep their teeth for as long as possible, right?  [Hans]Preserve the teeth, but ultimately also to preserve aesthetics and functioning. Because if you lose your modus it will inevitably hurt your front teeth over time. [Jaz]Do your patients complain of sensitivity?  [Hans]Yeah. Then usually I do an impression just to have a model so I can have a look at the model and the way I do the reverse or modified  DAHL, it’s a direct technique so after I’ve assessed the models and I’ve checked the curve of speed and check if are there any interferences for the teeth to either erupt or intrude, and we’ll have to have a chat about eruption and intrusion after this one, then I build up to, usually when you worn down to the dentine, you’ve worn about two millimeters off the molar cusps because young molars and young healthy molars, they have about two millimeters of enamel on top of the cusps.  So, if you add back anatomy and use anatomy as your guide, you will add about approximately the right amount of composite to the top of that tooth for the composite to be fairly aware assistant to not break.  [Jaz]The first question I have there, Hans, is it makes sense to use anatomical norms ’cause that will give you not only the right form and function, but also actually gives you the right amount of thickness for your composite anyway, which, like what you said right in the beginning, but just to go back one step, we gotta talk about it, right? Joint position. Right. In these cases, are you using centric relation as your guide or not? How are you recording the joint position before you wax it up on the articulator.  [Hans]Like I said, my occlusal education was very poor, so I usually start from MIP from full maximum inter cuspation. And since after I build this up, the patient rarely hits more than maybe one point on each tooth, maybe on the seventh so I try to kind of divide the forces between 3/ 7 and 4/ 7, for instance, and you’re hitting just two points. It’s really, really, really easy just to make sure the patient hit those two points about the same time just for comfort. But otherwise the occlusion will evolve from there. So the occlusion will evolve from there to what I’m thinking is that, Joint position in these cases doesn’t really matter because you’re working in a system where everything changes. I think we as dentists now, and I think this is part of why occlusion has become such a difficulty, is that we’re thinking of our mouth and our teeth are static because they are firm there’s no cells that change the surface and not like the rest of the body.  But the truth is teeth are living, teeth are moving and they are in place because of all the functional forces that are on them. They’re tongue, lips, cheek, chewing forces, habitual forces are keeping teeth in their place. And so we’re working in a system that that changes all the time. I don’t think really think it matters. What I do think matters if that when you cover that sensitive dentine, the patient will be happy for it and we’ll be able to chew off of that and we’ll be able to have a glass of wine and some shrimps and a shrimp salad sandwich without being in pain, which is from day one after doing that treatment. [Jaz]Okay. Well, in this case, I love the idea of the second molars in equal intensity contacts, but in a typical case that you’ve treated, is it just the second molars that are getting the composite or are you having to do the second molars? The first molars and the second premolars, but actually because you’ve built them up to anatomical form, it’s actually only the second molars because the way the jaw closes that are taking the contact, that will then intrude and then, then the second, the first molars and the premolars will eventually come into contact. Just explain that.  [Hans]That is completely correct way to put it. Just because the function of the jaw, how the jaw functions, you will only be hitting your most poster posterior teeth when you’re doing those buildups. But of course, I take the. Opportunity to build up the rest of the teeth that are worn, but the patient will, of course, only hit on the most posterior teeth. [Jaz]And in this case, would you typically just do, like, obviously I’m sure you’re looking the anatomy of the teeth and you’re thinking, well, both the upper and the lower are destroyed. So let me add in wax on both, or like split the difference or do you tend to have a strategy to preferentially wax up one arch more than the other? Or what have you found? Or is one arch more affected than the other usually?  [Hans]I usually don’t do wax up. To me, this is a direct technique for different reasons, but I’ve been practicing my anatomy for a long time it feels really easy for me. [Jaz]So it’s a free hand technique? [Hans]It’s a free hand technique. [Jaz]That’s so cool.  [Hans]So you don’t need to use technicians or use wax-ups. Those techniques are for the really, really difficult cases where you don’t have. Much anatomy to guide you. So if the teeth are completely destroyed, maybe you lost a third of the occlusal height, completely exposed dentine, then it becomes a lot more difficult to do those buildups because you don’t have any reference points. I find that my technique, I was lucky to be able to see one of Didier Dietschi lectures on interceptive dentistry, and he does that directly in the mouth. And this technique resembles a lot his technique, but he’s of course much more fluent in occlusion than I am. So he takes that into concern but he says the problem is how to get enough space for the most posterior teeth, and this technique, the reverse  DAHL, the modified  DAHL. That’s the answer to that question. You let the teeth move so you build up. So yes, you build up all the teeth that needs to build up.  [Jaz]Yeah. So upper as well as lower, basically  [Hans]If there’s words on the upper. Yes, I treat those as well, perhaps not at the same time. Perhaps we’ll do the lower first and then we’ll wait a few months before we do the uppers, just to make the patient a bit, a little bit more comfortable. But I have treated patient who wanted to have it all done in one go, and of course, they ended up maybe with a 6 millimeter anterior opening afterwards. Yeah, it worked out. But usually I have patients that are close by so we can stage the treatment a little bit more and perhaps make it a little bit more comfortable. Although I haven’t had any patients really complain about discomfort.  [Jaz]Well, we’re gonna unpack about, when you monitor these patients, how long it takes and whatnot. We’re gonna get to that. But just one little thing, which I find amusing is that if I was doing this treatment, like if I’m building up the lowers, I would be looking at the upper and if I’m seeing like a really sharp cusp, I’d be smoothing it down. Do you adapt to that as well? To, to try and get nicer forces? [Hans]If you have a really sharp cup, I, I know about your contracept of Robinhood dentistry, but in this case, we can do more Oprah Winfrey dentistry so you can get a filling and so if you have a really plunging cusp in the upper and you have composites or amalgams, uppers and lowers and you need to, and they kind of born u-shaped. Yeah.  Then I would probably just build up old teeth during a short period and then you’ll be able to lower the Cuspal planes. So that you get the Cuspal plane won’t be as steep anymore. And you can build the cuspal planes so that they’re less steep than the canine planes, and that takes away a lot of those problems. So the patient get more freedom and attrition in and horizontal movements, and you transfer guidance to the anterior or the canines.  [Jaz]Okay. So let’s talk about that. You’ve just done, let’s say the, the lower second molars and the first molar and the second pre-molar. When you deliver this, the contacts equal intensity only on the second molars ’cause the way the jaw closes. Yeah. But at that moment in time, do they still have some canine guidance? [Hans]Well, it depends on how deep your bite is. So if patients with really deep bite, when you open them a millimeter and a half posteriorly, they still can touch with their front teeth. They can still bite off food with their front teeth. So some patients are like that. Some patients have less where you open them up. They don’t have any contact on the front teeth. Doesn’t seem to matter much. Both groups of patients, in my experience, doesn’t really experience much discomfort.  [Jaz]Are you having to adjust the excursions in any way to make sure they’re to a particular liking? [Hans]So that’s what you do on the follow-ups because after doing a full jaw buildups, at least I’m really tied. So I’ll just make sure that they’re hitting those two points. And you’ve made cusps a cost. We’ll have some planes to them. So you can have, sometimes you have to adjust for excursions on the cusp, and sometimes you can use cusps to kind of guide teeth into the right position if you have a pronounced curve of spee for instance, in an older patient, you get most of the tooth movement, I believe, is in the lower jaw you get intrusion in the lower jaw. And that can open contacts and then you can use the cuspal planes to kind of guide those teeth and close those contacts over time.  [Jaz]But the day they leave you, when you fit them, obviously with Tide and stuff, but when they grind left and right, it’s not only the dots on the second molars, but they’re also grinding on these second molars. Right. And, but that’s okay. That’s how you leave them. [Hans]Yeah, I’ll just leave them like that and, but sometimes, of course it’s composite you can adjust it. And like I said, you’re also in a working environment where everything changes. So what might be completely fine on the day you leave them. Might not be fine when they come back after usually I have, I see them after a month to do some adjustments. Hopefully we’ll get to talk about how we do that. I do that, but yes, you can be mindful of excursions. Not too mindful though. Because now you just built up those teeth and everything’s changed for the patient. Nothing works the way it used to. The neurology isn’t there. Reaction patterns aren’t there. So that just needs to settle. Patient just needs a bit of time.  [Jaz]Okay. And the patient then goes away. What’s your review schedule like for these patients? Like how often do you see them and then more importantly, what have you observed, Hans, when you’re seeing them they come back at week one. They’re like this, they come back at week five, and I, I’d love to know. What is an average of what you’ve what you’re seeing and when do they fully establish contact?  [Hans]Yes. I think we have to stop talking about the Curve of Spee in this case, because teeth have a constant width. They don’t change the width unless you, you grind on them or on them. So the curve, it works like a bridge, like the keystone in a bridge. So if you try to compress the curve, compress the teeth into the curve, for instance, for uppers, if you want to intrude uppers, that’s really difficult because. You’re trying to put teeth, trying to compress those teeth into a curve, that means you have, might have to release, do some IPR between those teeth to have them intrude and the same with the lowest, the curve of speed. Usually if you have intrusion, then intrusion is easy, but if, if you want them in a younger patient, if you want them to erupt. That means you might have to release little bit in between the teeth to give the teeth an opportunity to erupt into the curve.  Other than that, you might, sometimes you need the help of an orthodontist if you really don’t want to grind on teeth or there’s no opportunity to grind on fillings or things, and sometimes you can just leave it like that and just be aware of that. It just takes a lot longer when the teeth have to move a little bit horizontally to adjust for that curve of speed.  So when the patient comes back in after a month, they usually see them after one month. They’ve been well informed about this being a bit little bit awkward in the beginning and after a month, they’re well on the way. Usually they’ve closed more than half the way down after a month. [Jaz]Do you think there’s any condylar repositioning happening there? Do you think that very quick change? Like in the anterior  DAHL we say that if you see a lot of change happen very quickly, that’s not necessarily intrusion and dento alveolar compensation, that could be the condyles repositioning. Have you suspected the same in your cases?  [Hans]Why not? Why shouldn’t that happen? Everything else changes. I do think I think in terms of how fast the patient comes back in a rule of thumb is that a tooth can move about a millimeter per month. So to me it seems like that’s approximately the rule that I follow. So that’s why my take is that it’s probably mostly intrusion for those patients. I check with my foil, I check with my contact paper, and also I use a floss. So I check the contacts with the floss. If they’re really hard, that tells me something about how the teeth move. So if you have a really hard contact and it didn’t use to be really hard, that means that, okay, if it’s in the upper jaw, yes this tooth is probably intruding. If it’s in the lower jaw, then yes, this tooth is probably erupting and you have to decide if you want to give, make some space for that. So that’s what I do on normal checkups. But most of the time patient is completely fine. Yeah, it was a bit awkward in the beginning. Feels better and better. Then we do an evaluation. When should I see you again? Perhaps I see you in another month. Perhaps I see you in a couple of months and sometimes patient close the occlusion really fast then, is that, no, I can’t be bothered by coming back. We’ll see you at the next checkup. So, and then they do, and it’s, it’s fine.  [Jaz]Well, a bit like the question I have my mind now is a bit like orthodontics. Like I am imagining at that first review that there will be some increased physiological mobility of those second molars, which is part of the process, a bit like ortho patients, aligner patients, when you take off the aligners, there’s some mobility and for a younger dentist who’s never seen this before, that can be quite worrying, but just it confirmed. Have you observed that? And just to reassure everyone.  [Hans]That definitely happens. And in one case, I built the posterior cuffs, I built them too steep. I was into a pronounced anatomy at the time, and I, of course, had to adjust for excursions on those teeth and they firmed up. And for the next checkup, they were fixed again.  So, yes. Be aware of teeth moving. Sometimes it’s a good thing, so sometimes it’s a bad thing and I’m not sure if me adjusting the occlusion on those teeth helped or contributed to do the case or was irrelevant to the case. It might have just solved by itself without me intervening.  [Jaz]Good point. And in these cases, when you see them again and you follow them up, what percentage, fully established contact, and then how long on average does that take? Does that take like a, a year, two years, you know, quicker on younger patients? Longer and older patients kind of thing?  [Hans]No, I think it depends on how much force the patient is able to put on a teeth. Most people I treat for posterior wear are not young guys. They’re, they’re older people. They’re 35, 40, sometimes 50’s and deruptive potential of the teeth is not, is not really high. In  DAHL study, he said that his patient, his selection of patients, and that’s one of the myth myths of  DAHL, is that it’s about 60% eruption and 40% intrusion, but that’s the average of the selection of the cases that Dahl investigated. But he says in his article that it seems that eruption is more pronounced in younger patients. And intrusion is more pronounced in older patient and he related that to facial growth and facial changes as you age. So it kind of depends on the age of the patients. If you have an old patient, you, most of the changes will probably intrusion and if you have a very young patient , most of it will probably eruption. [Jaz] And at the end, once a teeth established contact. Are there any adjustments you need to do at that point, or do you find that this everything just falls into place nicely and you don’t need to do any adjustments?  [Hans] Yeah, usually I don’t need to do any adjustments. But I do think about occlusion when I do the buildups. Like I said earlier, I prefer to make the cuspal planes less steep than the canine plane, so the patient usually ends up in anterior or canine disclusion canine guidance. Do you need canine guidance to function for most patients, probably not, but it’s a way to possibly save my restorations a little bit longer just to make them it last a little bit longer, to not place them under tensile forces and try to make all the forces on the composite compressor. [Jaz]Very true. And that’s a huge tip right there, guys. You know, Hans said to try and keep your restorations under compression ’cause our materials can handle that much better. And so you mentioned the word longevity to make it all last longer. What do you tell your patients and you know, sometimes we, what we tell our patients is not what actually happens. You know, we actually hopefully undersell it and over deliver. So how long does it take until Hans is gonna recycle a posterior dial case?  [Hans]I’ve haven’t had to recycle many of them so far. I’ve recycled a couple of them and that was like 10 years and 12 years. So last quite a long time. Then I have a couple of patient who crushed their composites. So the composite looks like gravel on top of their tooth. And we had, and then I said, okay, this is, we need ceramics here.  So sometimes that happens, but then you’ve created a space for the ceramics so you can do the ceramics much more minimal and invasive. But I do think that ceramics does have a, apart from being quite expensive doing ceramics, I think they do have a place in the posterior  DAHL, modified  DAHL technique as well. And if you’re really brave and know, think you know what you’re doing, you might go directly to ceramics.  [Jaz]That was just what was I was gonna ask, basically, I mean, I’d only trust you to do that because you know, I think you need a bit of experience when you’re doing these kind of cases I guess. But have you done that then? How many cases you’ve done? Yeah. We’ve just gone to ceramics, especially nowadays with the, I’m recording soon with Pascal Manet on occlusal veneers, right. And you know, 0.4 millimeters zirconia, occlusal veneers, or maybe some thicker lithium di silicate ones, so minimal prep, ’cause you already have the thickness, ’cause you open the bite. There could be some benefit here.  [Hans]But I’m thinking also that you’ve negated the problem so you don’t have to make really thin occlusal veneers. Yes, I’ve read about it and read the some research on it. And it’s quite a favorable prognosis, but you don’t have to make 0.4 millimeter occlusal veneer. You can probably make them for a decent thickness that really make them last because teeth will move and perhaps you can do this, do a temporary in composite, just a quick and dirty one. And then wait for occlusion to settle, and then you can do it in, ceramics to give a very long lasting restoration.  So in a few cases you’ve had to do that because they’re trying to destroy the composites. But in a lot of these cases, you’re seeing ’em last and you’re probably saying, you’re probably just observing and monitoring. Yeah. I think it depends on how much of the damage is caused by the patient’s by attrition, how much of the damage is caused by erosion. So how much just physical and how much is chemical? So I do, I’ve seen patients that have followed up for a long time and which they have mostly erosive wear.  And then you see they undermine the restorations that I’ve done. So the restorations are still there. The enamel around it just kind of disappear and then you have to go back. But then it’s composite so you can go back in and you can put the rubber dam on and you can do some air abrasion and you can, I love my aqua care for that. Do some air abrasion and then you can just bond may highly filled flowable or maybe normal paste composite and just repair those damages and then you can go on for a long time.  [Jaz]Brilliant. And just ’cause we’re wrapping up now, I’d, I’d love to see Hans, if you are able to on the app or on YouTube, have you got maybe a, a before and after when the occlusion was established, just an example case to help the visuals? [Hans]Yeah. Let’s do that.  [Jaz]Okay, so while you are doing that, and, you’ll see the share button at the bottom. I’m gonna ask you, I’m gonna be very naughty and while you are focusing on get finding in case I’m still gonna ask you some questions. Okay. So you have to multitask big time. Okay. Yeah. Contraindications. Are there any contraindications to this technique that you can present to, a very keen young colleague who might say, oh. I’m gonna try this tomorrow. Can you put some shackles on them and suggest some contraindication?  [Hans]Anterior open bites, do not do this in anterior open bites. The diagnosis is the selection, worn posterior teeth. Those patients, when you give them that diagnosis that you have posterior tooth wear, that’s when you can do this type of treatment.  [Jaz]Kind of those tough cases where you’re scratching your head thinking, how do I fix this? Because there’s so much more wear posterior than there is anteriorly, and you’re kind of like scratching your head and then you think, ah, yes, this technique exists.  [Hans]Yeah. So you already selected your patient by having a patient having wear. So, it’s important that there is wear, and also if you can stop the wear by getting the patient to change their habits. Even exposed dentine will last a really, really, really long time without wear. So you might not need to do buildups. And that’s why I said you have to have a proper diagnosis. You have to know why the damage, why is the patient looking like the patient does right now, before you start doing any treatment. So that’s my take on it. And also patients with TMJ, then again, you normally don’t have occlusal wear. Avoid opening the bite on the posterior, it might be quite painful. So let’s see if I can share an image with you from a case of done. This is the posterior doll case, so I’m just gonna describe it for those audio listeners. [Jaz]Right. So those on Spotify and Apple, some beautiful rubber dam dentistry going on here with the beautiful Teflon ligature as well. And it’s a classic erosive case with the wear. You see the cupping, I see some attrition as well on the second molar. So yeah, the kind of like the scenario we described. [Hans]Yeah. So we abrade that, clean it up well, put in some separation between the teeth and then start building up. I usually start a little bit on the marginal ridge then cusp by cusp. Your comms are beautiful man. Yeah, thanks. Thanks, lovely, Nancy. These sessions are quite enjoyable for me. I love building that up. And this patient, you see, that’s him right after, he has quite a deep bite, so it’s a deep bite patient, but with those crowns on the centrals, but rest of the teeth unrestricted. Yeah. So probably a trauma case. Yeah, a trauma case when he was quite young. Those crowns are made by a dentist in London, not by me. He was working there at the time. Really nice crowns in, in my opinion. So that’s right. Straight up, right after I’ve built those teeth up, you can see there’s a little bit of marks on top of the cuffs there that’s not really context, just an abrasive mark from the occlusal paper. And these are pictures.  [Jaz]So lovely shot here. Clearly showing the posterior separation. Yeah. In the premolar region. Right? So obviously anterior we can’t appreciate it ’cause you have someone with like a complete a hundred percent deep bite and now they have like a. 90% deep bite. Whereas on the premolars, you can see how they’re outta the occlusion now because you’ve only treated here second molar, and first molar, and lower only.  [Hans]Yeah, lower only on this guy because well, we’re staging the treatment on, on him, and like you said, he has bit of a plunging cusp on the upper, so perhaps I should have done the upper at the same time, but. I know, well, he’s local here, so I know I’ll have to treat him several times during his lifetime, at least my professional career if he decide to stay with me. And this is about, let’s, I have to check my notes on this one. Sorry. [Jaz]Hey, this makes you so happy. This, this, this is the money shot right here. This makes us happy. So guys, we are seeing the photo right, of the established occlusion and it’s just a thing of beauty. Yeah. Right. Those premolar spaces have been filled in just in a marvelous way. And the intercuspation here on the left especially is really beautiful. Yeah. It’s he’s really back to where he was before we began and he’s got the a hundred percent deep bite again, or maybe the 99% deep bite again.  [Hans]Yeah. It’s back to having a deep bite. He will, think should you really do orthodontics to fix that deep bite perhaps? I don’t know. He seems to work well.  [Jaz]It’s another option, right? You fix the deep bite and you create some space posteriorly. But then that’s, that’s a very tricky case in terms of Anchorage stuff, right? Because you’re trying to intrude the anteriors and intrude the posteriors. And so that’s a very tricky overall case I think. [Hans]I’m really happy to refer orthodontics to an orthodontist, so I’m not doing much of that myself, but that’s two months after on this guy.  [Jaz]Two months. That’s very impressive.  [Hans]Yeah, so like I said, it depends on how much force the patient is putting on on their teeth and how fast they can move them. And I think the case that took the longest, took about three years. I built her up, then she got cancer, got really, really sick, hospitalized for a long time, and of course teeth didn’t move but when I saw her a year ago, she was back to being healthy and then in full occlusion. So something is happening. There are some muscles involved I think. But she was comfortable all the time, even though her bite had hadn’t closed all the way, it just closed partially. She was comfortable, I said, okay, now that you are ill should we just grind away some composite to make you more comfortable? And she goes, no, it doesn’t bother me at all. And when I saw a year ago, she was back in full occlusion. So changing the occlusion doesn’t really matter. And as you said on the lecture, I saw you on you shouldn’t really be touching your teeth. Too much anyway during the day, during the 24 hours of the daytime. [Jaz]Very true. And the only question I have now, ’cause I know someone’s gonna mention the comments, right, is they’re gonna say, I think I know what you’re gonna say as well, and they’re gonna ask you, do you give the patient a guard after they’ve established their occlusion?  [Hans]Yes. Sometimes I’ve tried that. Generally guards are not used for a long time, perhaps maybe a month or two in the beginning. If the patient is still thinking about it and then they forget the guard when they go to their cabin or to on holiday.  [Jaz]To my cabin- [Hans] To my cab. Yeah. Reminds me, yeah, that one was really good. [Jaz]Reminds the performance  [Hans]Maybe to know what the f— says. So I think compliance on night guards to stop where is poor and I’m not always sure that it’s the nighttime where that is the problem. Perhaps it’s the daytime wear and then I’m not wearing a guard anyway, so I usually, I don’t do guards right now. [Jaz]I just still want to see what you are practicing.  [Hans]I don’t do guards. I thought I should tell this will wear and next time we’ll add some composite again. And you’ll wear that away again. I think that is more comfortable for the patient. But of course you have some patients who are really, really conscientious and, and are able to wear a guard during nighttime every night and do that consistently over the years. [Jaz]Hans, you would’ve seen in Didier Dietschi cases that he shows, right? He shows he’s like ridiculously brilliant 30 year follow ups, of anterior resins. The thing he says, which is the same thing that Tony Rotondo said last year when I saw him speak and show his like 22-year-old re recall is. The only reason this patient’s composites look so good is not because I am a master, it’s because she wore her night guard every night, and that literally, that’s what he said in his words. So sometimes when you get that patient who really wants to keep things. Things pristine. Yeah. And if the nocturnal brox has been an ecological factor Yeah. Then that can help longevity. But I completely take your view that it takes a special kind of person to be able to comply as good as those patients. [Hans]Yeah. Like I said, it has to be nocturnal where, and it has to be a really conscientious patient. They do exist, but how many patients, how many night guards do you need to make? To treat that one patient who will actually use it.  [Jaz]Asymptomatic patients ha have got the poorest. If you’ve got symptoms, you’ve got TMD and you’re symptomatic, and then you are, you are willing to wear even the most wackiest of spin. Yeah. But when you give an asymptomatic individual an appliance, then you will definitely get have to accept reduced compliance race. We’ve across the hour you are approaching midnight, but yes, so I wanna make sure that you get to bed,  [Hans]I’m fine. I’m happy, talking with you. I just wanted to make one last point.  [Jaz]Yes, please.  [Hans]Patients that wear their teeth, they don’t have TMJ problems, so they’re asymptomatic in the first place. So that’s a point to you that giving asymptomatic patients splints doesn’t really work well and sometimes if they’re dentists, they might. If they’re dentists, I do treat some dentists as well.  [Jaz]That’s very true actually. And, what, what you mentioned there was just on last point, what you mentioned there was is very true that the patients who have wear on their teeth, they often don’t have stresses on their masticatory system. With those patients whose periodontium. Has taken all the stress. Yeah. They often don’t have the wear the opposite in a way. Right. So, sometimes patients have lots of wear but no jaw issues. Sometimes patients have mobility in their teeth, but no wear.  And so this is all part, like the weakest link theory that is really good paper attached to this episode and it’s like trying to put patients into boxes, just like a stupid little thing to do, but it kind of explains what we see in the real world. Hans, thank you so much for this. Please do tell us about any education you run. I know you’re on the lecture circuit. If you’ve got any education coming up that you’d like our audience to tune into. I’d love for you to talk about that, my friend.  [Hans]Usually I lecture in Norwegian mostly, at least for now. Perhaps this will change after this podcast. You have a, you have a very widespread audience around the world at the moment. I do not have anything coming up. I’m very involved with building a new clinic. So that’s mostly what’s on my mind and we’ll see what opportunities comes later on. Other than that, if you want to see me, I do run the continuing education with the four fellows of mine here in Stavanger in this part of the country. So you, you can come see some of our courses if you like. We have some quite interesting ones-  [Jaz]And your Instagram handle so they can see your lovely photography and–  [Hans]It’s tannlegognedal it’s in Norwegian, my last name, and Tan Legg, which is dentist in Norwegian. So that’s my Instagram handle and you’re free to share that of course, on your video if you like. [Jaz]Amazing. No, I always tag our guests in, in the description. So Hans, thank you so much.  [Hans]Yeah, thanks. If anyone has a question, I’m really happy to answer them. Send me a message on Instagram. I think that’s easiest. No worries.  [Jaz]And send Hans a message on Insta or comment below. And I’ll tell Hans now and again check it and to hopefully see lots and lots of thank yous and honestly, Hans, thank you for covering a topic that is not widely talked about and it’s a really good minimally invasive solution when we’re scratching our head running out of ideas ’cause yeah, classically, yes, gold on Lays or these ways of doing it, but to raise the vertical dimension on posteriors only can be a very scary thing to do.  When you are, you know, let alone doing anterior  DAHL for the first time to do this Reversal  DAHL. And I think you’ve just covered it really well in a really pragmatic way. I like that you’re not using wax up, you’re not using funky stuff, you’re just building them up to anatomical form and you’re letting nature do the rest.  [Hans]And of course scanning has worked wonders. You ask about injection molding at one point, why not? But then you all already has involved some very heavy technology so you can manage the occlusion in a whole another way. This technique, the reverse  DAHL really started as a, as a really hands-on, direct composite way to do it, just to minimize the expenses of having models, having wax ups, doing difficult occlusal stuff.  [Jaz]Hans, appreciate your time and thanks so much for everyone for listening to the end. Jaz’s Outro:Well, there we have it guys. Thanks so much for listening all the way to the end. Now you know about the reverse  DAHL technique. If you’re inspired by this and you wanna learn more about the normal  DAHL technique, then again, I’ve linked it all in the show notes. This episode is eligible for an hour of CPD or CE Credit Suite are a PACE approved provider. Now that you’ve done the hard work of listening to someone talk about teeth for a whole hour, just answer the questions, get 80%, and you get your CE certificate. Our CPD Queen Marie will look after you and just like this, you can gain so many hours. Throughout the year making this one of the most valuable subscriptions that you have. So if you’re interested in joining us and join the nicest and geekiest dentist of the world, check out Protrusive Guidance. It’s an app on iOS, Android, but the best way to sign up is on the laptop. First, go to Protrusive.app. Sign up to your level of subscription, if you go for the ultimate, you get all my master classes as well, including my premium clinical videos. I wanna thank you again for listening. I wanna thank the team of Erica, Gian, Krissel, Julia, Nav, Emma, who at this moment in time is doing her finals, so wishing her all the best. And with that, my friends, thank you so much. I’ll catch you same time, same place next week. Bye for now. Oh, and don’t forget to give this a thumbs up.